Every finding on record at The Pines Healthcare & Rehabilitation Centers Olea

Based on observation, interview, and record review conducted during the Standard survey completed on 3/7/25, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for one (1) (Resident #19) of two (2) residents reviewed for physical restraints. Specifically, Resident #19 did not have a physician's order for the use of a wheelchair trunk restraint and there was no evidence quarterly assessment/evaluation was completed for its use. Additionally, there was no documented evidence the trunk restraint was released every two hours. The finding is: The policy and procedure titled Physical Restraints dated 4/16 documented each physical restraint in use was to be assessed and monitored as a medical necessity using the interdisciplinary approach. Physical restraints are items used to restrict, restrain or prevent movement of a person. Examples may include but not limited to chairs with a latching bar and/or securing strap. The multidisciplinary team will assess the use of the restraints on at least a quarterly basis and to be reviewed at the resident's interdisciplinary quarterly care plan meeting. Options for removal or reduction of restraint were to be considered at that time, documentation of risks, benefits and plan were to be placed in the medical record. A physician order was required for any device considered a restraint and the physician order was to be reviewed and renewed at least every 60 days. Alternatives to restraints must be tried and the effect documented routinely. Nursing staff were to attend to a restrained resident at a minimum of every two hours; restraint was to be released or removed at least every two hours. Resident #19 had diagnoses which included Parkinson's disease, repeated falls, and encephalopathy (disease of both brain and spinal cord). The Minimum Data Set (MDS- a resident assessment tool) dated 1/17/25 documented Resident #19 was understood, understands and had moderate cognitive impairment. Resident #19 required total dependence of staff for dressing and used a trunk restraint daily while in their wheelchair. The comprehensive care plan dated 11/23/23 documented Resident #19 had limited physical mobility related to Parkinson's disease and contractures of bilateral shoulders. Interventions included Certified Nurse Aides were to bring Resident #19 to the Licensed Practical Nurse in the morning to apply the harness (trunk restraint). Licensed Practical Nurses were to release the harness every two hours for ten minutes then reapply; monitor for the ten minutes harness was removed. The Kardex (a guide used by staff to provide care) dated 3/6/25 documented Certified Nurse Aides were to bring Resident #19 to the Licensed Practical Nurse in the morning to apply the harness. Licensed Practical Nurses were to release the harness every two hours for ten minutes then reapply; monitor for the ten minutes harness was removed. Review of the order summary report dated 8/7/24 through 3/5/25 revealed there was no order for the use of a trunk restraint (harness). On 3/6/25 and order was received that documented, Licensed Practical Nurse in morning to apply harness. Licensed Practical Nurses to release harness every two hours for ten minutes then reapply. Monitor for the ten minutes harness was removed every two hours for release harness when up in wheelchair. Review of the Medication Administration Treatment Administration Records dated 1/1/25 through 3/5/25 lacked documented evidence of release of restraint. Review of the Provider Visits dated 8/7/24 through 2/12/25 lacked documented evidence for use of a restraint. Review of the Restraint - Physical Quarterly/Annual Evaluation dated 5/17/24 documented Resident #19 had frequent falls, was sliding out of their wheelchair, had generalized weakness, poor trunk stability and abnormal posture. Additionally, an alternative chair was previously trialed which improved positioning, however the chair style could not be self-propelled by Resident #19. Resident #19 was care planned for a chest strap in the wheelchair for maintenance of independence with wheelchair mobility. Recommendations included continued use of restraint. There were no additional Restraint - Physical Quarterly/Annual Evaluations between 5/17/24 and 3/6/25. Review of the Restraint - Physical Initial Evaluation dated 8/7/24 with a locked date of 2/10/25 documented Resident #19 presented with generalized weakness, poor positioning, and poor trunk stability/ability reposition self in wheelchair. Resident #19 was found tipped forward in the wheelchair due to leaning and shifting weight forward secondary to poor trunk control abilities. The date of the first application of the chest strap was 1/23/23. Additionally, it was documented that a physician order was required and received. There were no additional Resident - Physical Initial Evaluations completed between 5/17/24 and 2/10/25. Review of the nursing progress notes dated 1/1/25 through 3/5/25 lacked documented evidence that the restraint was released every two hours. Review of the Physical Therapy Evaluations and Progress notes dated 8/8/24 through 3/6/25 lacked documented evidence an assessment for the use of a restraint. Review of the Occupational Therapy Evaluations and Progress notes dated 8/8/24 through 3/6/25 lacked documented evidence an assessment for the use of a restraint. During an observation on 3/3/25 at 11:08 AM, Resident #19 was in their room sitting up in their wheelchair. There was a black strap around Resident #19's chest that wrapped around the back of their wheelchair and was secured in the back. During an interview on 3/6/25 at 11:11 AM, Certified Nurse Aide #6 stated Resident #19 reaches for things a lot and leans to one side, so they wear a strap around their them to help them sit up. They stated they did not think that Resident #19 could release the strap themselves and the nurses release the strap every two hours for about 15-20 minutes. During an interview on 3/6/25 at 11:20 AM, Certified Nurse Aide #7 stated Resident #19 wore a holster to keep them from leaning and falling out of their chair. Prior to using the holster, a different type of wheelchair was tried to help Resident #19 with their positioning, but they did not like that wheelchair because they were unable to self-propel in it. They stated they were not sure if anything other than a wheelchair was tried prior to using the holster. They described the holster as a strap that goes around the front of Resident #19 and hooks around the back of their wheelchair. Certified Nurse Aide #7 stated the Certified Nurse Aides were unable to watch and monitor Resident #19 at all times and that was probably why it was being used. During an interview on 3/6/25 at 11:27 AM, Licensed Practical Nurse #5 stated Resident #19 wore a safety strap for positioning. Prior to using the strap, therapy attempted to work with Resident #19 using a different type of wheelchair, but they were unable to self-propel themselves in that chair. Resident #19 was given a grabber to help reach for things, but they would still fall from their chair without wearing the strap. They stated the strap goes around Resident #19's chest, around the back of their chair, and clips in the back of the wheelchair. They stated if Resident #19 spun the strap around they would probably be able to unclip it, but if they were unable to do that, then it would be considered a restraint. They stated it was unclipped every two hours for about 15 minutes. Licensed Practical Nurse #5 stated there used to be a place in the Treatment Administration Record to document that the strap was released but it was no longer there. They stated it should probably be documented to show that Resident #19 wasn't restrained to their chair all the time. They stated Resident #19 had good days and bad days and there should have been an attempt made at some point to reduce the use of the strap. When Resident #19 was out of their room, it was easier for staff to monitor them, but Resident #19 liked to be in their room and staff would not be able to monitor them at those times. During an interview on 3/6/25 at 11:37 AM, Licensed Practical Nurse #4 Unit Manager stated Resident #19 wore a positioning strap across their chest that wrapped around the back of their wheelchair. Resident #19 was unable to self-remove the strap, so in a way it was considered a restraint. Therapy completes restraint assessments. They stated Resident #19 was unable to hold themselves up well and the strap allows them to be more independent by keeping them from slumping over or leaning too far forward. They stated they believed there was not an order or documentation that the strap was removed every two hours because it was listed in the Kardex, but they had to double check with Registered Nurse Supervisor #1. During an interview on 3/6/25 at 11:56 AM, Registered Nurse Supervisor #1 stated they felt it was a gray area if a physician's order was needed for the strap because it was just a strap. They stated the nurses should document when it has been released. They stated because the strap was used for safety, and they did not believe it was a restraint. During an interview on 3/6/25 at 12:37 PM, the Director of Rehabilitation stated they referred to the strap that went around Resident #19 as a lap band and it was to support their trunk. They stated prior to using it, Resident #19 was always leaning forward and having falls. Resident #19 was unable to undo the lap band. The therapy department was responsible for completing restraint evaluations every quarter. They were informed in February 2025 that there was a restraint initial evaluation that was opened for 8/10/24, and it was blank. The form was completed and locked on 2/10/25 by therapy. They stated there should have been a restraint evaluation completed by therapy in August and November of 2024. The Director of Rehabilitation stated in the restraint evaluation that was completed 2/10/25, it was indicated that a physician order was required, and it was the responsibility of the Nursing Supervisors to communicate the need for an order to the Medical Director. During an interview on 3/6/25 at 4:03 PM, Licensed Practical Nurse #6 stated Resident #19 wore a strap that went around their chest and wheelchair. Resident #19 was unable to reach behind the wheelchair to unhook the strap, which would make it a restraint. They stated they have seen Resident #19 moving their torso back and forth while wearing the strap trying to reach and pick stuff off the floor. Resident #19 had a grabber to help reach for items as well but did not always use it. Licensed Practical Nurse #6 stated the documentation in the Medication Administration Record began on 3/6/25 and before that, they did not document anywhere that the strap was released. It should have been documented when it was released so that anyone who read the chart knew that it was released every two hours when they were in their wheelchair. During an observation and interview on 3/7/25 at 8:50 AM, Resident #19 was in their room sitting upright in their wheelchair. Licensed Practical Nurse #4 Unit Manager requested Resident #19 to remove their chest strap. Resident #19 stated, they were unable to remove it because the clip was behind the wheelchair, and they were unable to reach it. They stated the strap keeps them from plopping out of their wheelchair. Licensed Practical Nurse #4 Unit Manager stated they knew that different type of wheelchairs, the grabber and different types of straps and harnesses were trialed with Resident #19, but they were unsure of any recently attempted interventions trialed to reduce the use of the strap between August 2024 and March 2025. During an interview on 3/7/25 at 11:23 AM, the Director of Nursing stated they expected evaluations to be completed quarterly by therapy and for a physician's order to be in place for any restraint. They stated they believed the breakdown in communication occurred when the facility switched therapy companies, and they were unaware that the evaluations needed to be completed quarterly. They stated they 100% believed Resident #19 required the strap to assist with positioning and so they were able to be as independent as possible; without it, they were unable to hold themselves up to complete hygiene or feeding tasks and participate fully in activities. They stated a few steps were missed and they would expect the nurses to document when the strap was released to show that it was released every two hours. During an interview on 3/7/25 at 12:14 PM, the Administrator stated they expected therapy to complete the evaluations for restraints quarterly and if they had missed an evaluation, it was the Minimum Data Set Coordinator's responsibility to notify them of any missed evaluations. The purpose of the evaluations was to ensure the least restrictive interventions were trialed prior to using a restraint. They stated they were not sure if Resident #19 required a physician's order for their strap because it was a positioning device. But they did expect for nursing to document the strap was released every two hours because that was a requirement. The Unit Manager, Nursing Supervisor and ultimately the Assistant Director of Nursing and Director of Nursing were responsible to make sure the nurses were documenting the strap was released every two hours. During a telephone interview on 3/7/25 at 12:34 PM, the Medical Director stated they were somewhat familiar with Resident #19, but they did not recall any straps going around the chest of the resident and clipping behind the back of the wheelchair. They stated that sounded like a restrictive thing and there was no order for that. They stated they were not aware of this, and they expected someone from the facility to notify them that it was being used and for what purpose. They stated it fell under restriction and whoever decided it was necessary at the facility was responsible to let them know about it. During an interview on 3/7/25 at 12:42 PM, the Minimum Data Set Coordinator stated their most recent Minimum Data Set on 1/17/25 indicated Resident #19 used a trunk restraint because they had a restraint that went across their trunk area. They stated they received that information by looking at the therapy documentation and that was when they realized there was a blank restraint evaluation open from last August. They stated they usually let therapy know when there were missing quarterly assessments, but they were late reporting the missing the restraint evaluation to the therapy department. They stated they did not remember if they let anybody in nursing know that there was an order missing for the restraint. 10 NYCRR 415.4(a)(2)(iii)

Based on interview and record review conducted during a Complaint investigation (#NY00343645) during a Standard survey completed on 3/7/25, the facility did not ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #99) of two residents reviewed for abuse. Specifically, facility staff did not immediately, or no later than two hours, report an allegation of verbal abuse to the Administrator. Additionally, once the Administrator was aware of the verbal abuse allegation, it was not reported to the State Survey Agency in the required timeframe. The finding is: The policy titled Abuse Prevention and Reporting last revised 2/25 documented it is the policy to prevent, identify and investigate incidents of resident abuse; treat all residents with kindness, dignity and consideration; ensure all residents are free from verbal abuse; and to comply with all State and Federal Regulations regarding abuse. Verbal abuse was documented to include, but not limited to use of profanity, swearing; sarcasm, threats; teasing or degrading. Employees are required to report any act of resident abuse to their supervisor and/or the facility Director of Nursing and/or Administrator immediately. The New York State Department of Health will be notified by the Nursing Director and/or Administrator/Designee per reporting manual guidelines. Resident #99 had diagnoses that included dementia, stroke affecting right side, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 4/20/24 documented Resident #99 had moderate cognitive impairment was understood and understands. The comprehensive care plan initiated on 4/14/22 documented Resident #99 had an activities of daily living self-performance deficit related to confusion, mild right sided weakness and impaired balance. Approaches included one assist with personal hygiene and toileting hygiene. On 1/29/24, Resident #99 had the potential for mood state/behavior status issues related to anxiety. Approaches included caregivers to provide opportunity for positive interaction and attention. Review of the Department of Health Nursing Home Facility Incident Report submitted successfully on 5/29/24 at 2:55 PM, documented an allegation type of mental/verbal abuse to Resident #99 in the resident's bathroom and unit hallway by Certified Nurse Aide #8. The incident date/time was documented as 5/25/24 at 10:00 AM and the date/time the Administrator was first made aware of the incident was on 5/28/24 at 2:20 PM. The facility investigation submitted on 6/4/24 at 4:29 PM, documented there was a verified finding of abuse toward Resident #99. The facility investigation revealed verbal abuse was not reported to the Assistant Director of Nursing by staff members involved until three days after the incident occurred. During an interview on 3/7/25 at 9:23 AM, Certified Nurse Aide #3 stated they recalled Resident #99 asked Certified Nurse Aide #8 for something and Certified Nurse Aide #8 replied rudely. Certified Nurse Aide #3 stated if they heard verbal abuse, they would report it to their charge nurse or supervisor so no harm came to the residents, and so management could take care of the matter as soon as possible to ensure the safety of all the residents. Certified Nurse Aide #3 reviewed their interview/statement given on 5/28/24 and stated Licensed Practical Nurse #1 was already aware as they witnessed Licensed Practical Nurse #1 advising Certified Nurse Aide #8, they could not say things like hold off, let me think before I strangle you to a resident. During an interview and observation on 3/7/24 at 9:54 AM, Licensed Practical Nurse #1 stated if an aide reported abuse to them, they would immediately make sure the resident was safe and notify the supervisor. Licensed Practical Nurse #1 reviewed their interview/statement given on 5/29/24, and stated they remembered telling Certified Nurse Aide #8 to leave Resident #99's room during care because of how they were speaking to Resident #99, it was verbal abuse. Licensed Practical Nurse #1 stated they called Registered Nurse Supervisor #1 to report what was going on with Resident #99 but could not recall if they reported what Certified Nurse Aide #8 said to Resident #99. They stated they usually reported any abuse concerns immediately but felt they handled it at that time and did not think Registered Nurse Supervisor #1 would have addressed the situation. During an interview on 3/7/25 at 10:24 AM, Registered Nurse Supervisor #1 stated any allegation of abuse was reported to the Director of Nursing as soon as it was reported to them. Registered Nurse Supervisor #1 stated everyone was responsible to report abuse for resident safety. They stated any abuse that has caused injury has to be reported within two hours, if no injury then within twenty-four hours. They stated the Director of Nursing was responsible for reporting abuse to the Department of Health. Registered Nurse Supervisor #1 denied that any abuse allegation regarding Resident #99 was brought to their attention. They stated Certified Nurse Aide #8 was known to be verbally loud, animated, eccentric and residents would indicate they did not like Certified Nurse Aide #8's demeanor. During an interview and observation on 3/7/25 at 10:37 AM, Certified Nurse Aide #4 stated an allegation of verbal abuse was brought to their attention by Certified Nurse Aide #3 regarding Certified Nurse Aide #8. Certified Nurse Aide #4 reviewed their interview statement provided on 5/29/24, during the facility investigation, and stated the verbal abuse allegation was reported to them on 5/28/24 and had occurred over the weekend. Certified Nurse Aide #4 stated the staff should not have waited to report the verbal abuse and should have reported it immediately to the nursing supervisor. During an interview on 3/7/25 at 1:25 PM, the Administrator in the presence of the Director of Nursing Home Deputy of County Administrator, stated staff should have reported the verbal abuse made to Resident #99 immediately and they did not. They stated it was important for abuse to be reported immediately because there was a time constraint on reporting abuse to the Department of Health. They stated they have two hours to report abuse with serious bodily injury and any other abuse would be reported within twenty-four hours. 10 NYCRR 415.4(b)(2)

Based on observation, interview, and record review conducted during the Standard survey completed 3/7/25, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for one (1) (Resident #18) of one (1) resident reviewed for bed rails. Specifically, Resident #18 was not assessed for risk of entrapment from bed rails, the risks and benefits of bed rails were not reviewed with the resident or their representative, and no consents were obtained prior to bed rail use. The finding is: The policy titled Side Rail Policy dated 4/16, documented side rails will be used if requested by a cognitively intact person or activated health care proxy. Such use is facilitated following education of the requestor and a signed risk benefit analysis. All residents will be evaluated for side rail use at admission/re-admission using the Side Rail and Alternative Equipment Decision Tree. Such use is permitted only after educational material and explanation has been provided to the requestor. The policy titled Safety Devices (Bed) dated 9/23 documented the facility maintains the safety of the resident and prevents injury and harm. The resident beds meet the Food and Drug Administration entrapment guidelines. The facility will provide and utilize devices to assist in bed mobility, and/or prevent injury. Such devices may include bed mobility handles. All residents will be evaluated for safety device use at admission/re-admission, and as needed. The User-Service Manual copyright 2017, for the bed series utilized in the facility, documented when assessing the risk for entrapment you need to consider assist devices and other accessories. It is important to review the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk. The State Operations Manual dated 8/8/24 documented examples of bed rails include but are not limited to grab bars and assist bars. Resident #18 had diagnoses that included Alzheimer's disease, vascular dementia, legal blindness and repeated falls. The Minimum Data Set (a resident assessment tool) dated 2/8/25 documented the resident sometimes understands, sometimes understood, had severely impaired vision and had severe cognitive impairment. Resident #18 was dependent with rolling left and right in bed. No bed rail use was indicated on the assessment. The Kardex (guide used by staff to provide care) dated 3/3/25, documented for bed mobility the resident required bilateral bed mobility handles to aid in turning and repositioning in bed. The comprehensive care plan revised on 11/12/23, documented Resident #18 had an activities of daily living self-care performance deficit related to confusion and dementia. Approaches initiated on 12/9/22 documented Resident #18 used mobility handles to maximize independence with turning and repositioning in bed. On 6/20/24 the resident required bilateral bed mobility handles to aid in turning and repositioning while in bed. A revision on 5/25/2024 documented the resident was at high risk for falls related to confusion, vision/hearing problems. The Nursing Admission Screen and History effective 10/21/22, documented Resident #18 required assistance with bed mobility and could not use a side rail to assist with positioning while care was being provided by staff. The Physical Therapy evaluation dated 8/27/24 documented for bed mobility the resident was dependent, they rarely/never had the ability to understand, and their ability to follow one step directions was inconsistent, even with prompts/cues. There was no documented evidence of an evaluation or use of bed mobility handles. During observations on 3/5/25 at 9:53 AM, 3/6/25 at 9:41 AM, 3/7/25 at 9:05 AM Resident #18's bed had bilateral bed rails secured to the bed frame at the head of the bed. During a continual care observation and interview on 3/6/25 from 9:41 AM to 9:55 AM, Resident #18 was in bed with bilateral bed rails at the head of bed in the up position. During turning and repositioning of Resident #18 in bed, Resident #18 did not utilize the bed rails, their bilateral arms were observed crossed over their chest while being turned during care. Certified Nurse Aides #3 and #5 did not offer instruction or encourage the resident to use the bed rails during care. Certified Nurse Aides #3 and #5 both stated that Resident #18 did not usually use the bed mobility handles (bed rails) at the head of bed to assist with turning and repositioning. During an interview on 3/6/25 at 10:03 AM, Certified Nurse Aide #3 stated they would know if a resident had bed mobility handles if they looked in the resident's room and it would be on the residents' care plan. Certified Nurse Aide #3 stated they did not consider Resident #18's bed mobility handles to be a restraint because it was not a full bed rail. Certified Nurse Aide #3 stated Resident #18 would not be able to follow direction for use of the bed mobility handles to assist with their bed mobility. They stated the therapy department determined if a resident received bed mobility handles. During an interview on 3/6/25 at 10:24 AM, Licensed Practical Nurse #3 stated residents have bed mobility handles for positioning and mobility in bed; some residents preferred them for comfort and safety because they thought they were going to fall out of bed. They stated nursing staff were responsible to make sure that the bed mobility handles were present per the care plan and were still needed. They stated nursing staff could notify therapy to evaluate a resident for the use of bed mobility handles if needed. During an interview on 3/6/25 at 5:24 PM, the Director of Rehab stated that therapy evaluated residents for bed mobility handles upon admission, annually and as needed. They stated the therapy department had maintenance install the bed mobility handles to a bed after they felt a resident could utilize them appropriately and safely. They stated bed mobility handles were given to residents to promote more independence with bed mobility. The Director of Rehab did not know whether the bed mobility handles were considered a restraint, or a risk for entrapment and stated they should know for resident safety. The Director of Rehab stated to their knowledge there was not an assessment form, or consent required for the use of the bed mobility handles. During an interview on 3/6/25 at 5:38 PM, the Director of Nursing stated therapy evaluated each resident to see if the use of bed mobility handles was appropriate and able to be used safely. They stated that bed mobility handles were not considered bed rails; they were too short and were used for rolling and repositioning. The Director of Nursing stated no consent forms or bed rail forms were completed for bed mobility handles. The Director of Nursing stated they did not believe the bed mobility handles were a risk for entrapment. They stated if a resident was unable to follow instructions, they would not be appropriate for the use of the bed mobility handles. During an interview on 3/7/25 at 9:10 AM, Registered Nurse #1, Head Nurse, stated they were unaware of any risk, benefit or consents that were needed prior to the installation of the bed mobility handles. They stated they weren't aware of which residents on their unit had bed mobility handles. Registered Nurse #1 stated Resident #18 was not of sound mind, had severe cognitive impairment and did not know they had bed mobility handles. They stated the bed mobility handles were small and did not think they posed an entrapment risk to the residents. During an observation and an interview on 3/7/25 at 9:38 AM, the Superintendent of Buildings and Grounds measured the bed rails attached to Resident #18's bed. They stated the height of the bed rails was fifteen inches and the width was nine and three quarters inches. The Superintendent of Buildings and Grounds stated all residents had to be care planned before installation of bed rails. They stated a mobility handle was a bar that the residents used to be able to move in bed. They stated they always used the most non-restrictive devices as possible. During an interview on 3/7/25 at 11:50 AM, the Minimum Data Set Coordinator stated the bed rail was only supposed to be used to assist the residents in rolling back and forth, these residents should be able to hold on to the rail to support themselves while care was being provided. They stated it did not mean the resident could turn and rotate independently but they would be able to assist in supporting themselves partially while staff provided care. The Minimum Data Set Coordinator stated if Resident #18 was not able to follow instructions to hold on to the bar during care, it would not be appropriate to leave the bar on the bed. They stated that physical therapy did bed mobility assessments yearly and they were required to do quarterly assessments as well. During a follow up interview on 3/7/25 at 1:25 PM, the Director of Rehab stated therapy was responsible to review bed mobility annually or as needed by referral from nursing. They stated they would have expected a physical therapist to have assessed Resident #18's bed mobility handles, bed rails in August 2024 to see if Resident #18 was still capable of using them safely. The Director of Rehab stated if Resident #18 was incapable of using the bed rails, therapy should have documented that, and they should have been removed from the care plan and bed. They stated if Resident #18 could use the bed rails safely, and there was no risk for injury with use that should have been documented. During an interview on 3/7/25 at 1:25 PM, the Administrator stated they were familiar with bed rails regulations and that the facility did not use bed rails. They stated there was not a risk assessment completed for the use of the bed mobility handles. They stated therapy or the head nurse would address the use of the bed mobility handles with family and would expect it to be documented on the evaluation or in a progress note. 10 NYCRR 415.12 (h)(1)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00363844) during a Standard survey completed on 3/7/25, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (1) (Resident #16) of three (3) residents reviewed. Specifically, Resident #16 lacked pressure ulcer assessments that included accurate pressure ulcer staging, and there was the lack of medical provider documentation to include the resident's pressure ulcer and treatment plan. The finding is: The policy and procedure titled Pressure Ulcer/Wound Management and Treatment revised 3/15/23 documented to ensure a resident with a pressure ulcer receives necessary treatment and services to promote healing a Registered Nurse will accurately assess and reassess all pressure ulcers on a weekly basis, document pressure ulcer assessments in the medical record, abide by the National Pressure Ulcer Advisory Panel (NPUAP) publications, Pressure Ulcer Prevention and Treatment Clinical Practice Guideline on staging pressure ulcers and measurement of pressure ulcers. The Wound Evaluation will be completed and documented in the Wound and Skin Module in the electronic medical record weekly. Licensed Practical Nurses may measure and document on established wounds. Description may include when applicable: exudate (fluid released from wound), necrotic (dead) tissue, drainage, tissue type, and stage (only pressure ulcer) per the National Pressure Ulcer Advisory Panel guidelines. Purpose and Function of Wound/Pressure Ulcer Management Team to provide consultation to unit nurses and physicians in the treatment of pressure ulcers; monitor the healing of existing pressure ulcers through weekly team meeting discussions with rounds on units as determined by team. Review of an undated Wound Assessment and Documentation in-service packet provided by the Director of Nursing documented to assess characteristics, amount (document in percentage) and location of tissue types which included: Necrotic Tissue (dead; non-viable, included slough-yellow, green, grey, nonviable (necrotic) tissue, usually lighter in color, thin, wet stringy; and eschar-black, brown, dry, nonviable (necrotic) tissue, usually darker in color, thicker, hard. Staging system- assessment system that classifies pressure ulcers, documented: Stage 2: partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red, pink wound bed, without slough; Stage 3: full thickness tissue loss. Slough may be present but does not obscure the depth of the tissue loss; Un-stageable: full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Further description: until enough slough and/or eschar is removed to expose the base of the wound, the true stage, cannot be determined. Resident #16 had diagnoses which included pressure ulcer of sacral (sacrum) region, type 2 diabetes mellitus, and neuromuscular dysfunction of bladder. The Minimum Data Set (a resident assessment tool) dated 2/1/25, documented Resident #16 was understood, understands and was cognitively intact. Resident #16 had an indwelling catheter, was always incontinent of bowel, was at risk for the development of pressure ulcers and had an unhealed stage 2 present on admission. The comprehensive care plan initiated 3/31/2024 documented Resident #16 had the potential for pressure ulcer/impairment of skin integrity related to fragile skin, and immobility. Interventions included to keep skin clean and dry, report abnormalities, failure to heal, maceration to the Medical Doctor/Nurse Practitioner, turn and reposition every 2-3 hours while in bed. The goal was revised 9/5/2024 and documented the resident would remain free from injury/skin impairment with a target date of 5/6/25. Additionally, nutritional care plan revised 1/21/2025 documented risk altered skin integrity-stage 2 coccyx (tailbone). The Order Summary Report, order date range 7/23/24-3/31/25, documented stage 2 to coccyx (tailbone), cleanse with normal saline, pat dry, apply silver alginate (antimicrobial dressing) and cover with foam dressing every shift and as needed, start date 1/17/25. On 2/5/25 treatment order changed frequency to everyday shift and as needed. Review of Provider Visit progress notes dated 1/22/25 and 2/21/25 revealed there was no documented evidence of pressure ulcers evaluation. On 2/21/25 Nurse Practitioner #1 documented the resident's skin had no rashes or lesions. Review of Skin and Wound Evaluation; and Wound Evaluation (picture) revealed the following: -1/17/25, completed by Registered Nurse Supervisor #1, documented Stage 2 pressure ulcer to coccyx present on admission (1/17/25). Wound measurements 3.9 centimeters length by 0.5 centimeters width, slough (dead tissue) filled 80 percent of the wound bed. -1/22/25, completed by Licensed Practical Nurse #2, Head Nurse, documented Stage 2 pressure ulcer to coccyx. Wound measurements 1.4 centimeters length by 0.8 centimeters width. -1/29/25, completed by Registered Nurse Supervisor #2, documented Stage 2 pressure ulcer to coccyx. Wound measurements 1.2 centimeters length by 0.6 centimeters width. -2/5/25, completed by Licensed Practical Nurse #2, Head Nurse, documented Stage 2 pressure ulcer to coccyx. Wound measurements 2.0 centimeters length by 0.8 centimeters width. -2/12/25, completed by Licensed Practical Nurse #2, Head Nurse, documented Stage 2 pressure ulcer to coccyx. Wound measurements 1.8 centimeters length by 0.8 centimeters width. -2/19/25, completed by Licensed Practical Nurse #2, Head Nurse, documented Stage 2 pressure ulcer to coccyx. Wound measurements 1.2 centimeters length by 0.5 centimeters width. -2/26/25, completed by Licensed Practical Nurse #2, Head Nurse, documented Stage 2 pressure ulcer to coccyx. Wound measurements 1.6 centimeters length by 0.5 centimeters width. -3/5/25, completed by Licensed Practical Nurse #2 Head Nurse, documented Stage 2 pressure ulcer to coccyx. Wound measurements 1.0 centimeters length by 0.3 centimeters width. Review of the wound pictures as documented above revealed slough was visualized to the pressure ulcer wound bed on the following dates: 1/17/25,1/22/25, 1/29/25, 2/5/25, 2/12/25, 2/26/25 and 3/5/25. During an interview on 3/5/25 at 11:46 AM, Resident #16 stated they have a hole on their buttocks that was acquired while in the hospital. They stated treatment to their buttocks was completed daily. Additionally, they stated the hole on their buttock has not been seen by a specialist, or wound provider to their knowledge. During an observation of wound care on 3/6/25 at 12:37 PM revealed Resident #16 had a pressure ulcer to sacral area with full thickness tissue loss, with the base of the ulcer covered by slough in the wound bed (un-stageable). During an interview at the time of the observation Licensed Practical Nurse #1 stated the pressure ulcer was documented as Stage 2 to the coccyx. At this time, Licensed Practical Nurse #1 described the pressure ulcer wound bed as yellow. During an interview and observation on 3/6/25 at 1:07 PM, Licensed Practical Nurse #2 Head Nurse stated a Registered Nurse must initiate a wound/pressure ulcer assessment. They stated once the initial assessment was completed, they complete the weekly wound/pressure ulcer picture and evaluation in the electronic medical record. Licensed Practical Nurse #2, stated they complete their weekly unit skin rounds usually with a Certified Nurse Aide only. They stated every Wednesday the Wound Team, consisting of Head Nurses/Unit Managers, Dietary Technician, Therapy Director, Social Worker, Minimum Data Set Coordinator, and Inservice Coordinator/Infection Preventionist meet to discuss weekly pictures and evaluations. They stated the Wound Team discusses if the wound/pressure ulcer was deteriorating, improving, interventions and need for treatment change. Review of Wound Evaluation picture dated 3/5/25, Licensed Practical Nurse #2, stated Resident #16's base of pressure ulcer to coccyx could not be seen due to the presence of yellow tissue. Additionally, they stated the Registered Nurse determines the staging of pressure ulcers with the initial assessment. LPN #2 stated the wound team meets every Wednesday and reviewed wound pictures from their wound rounds and they discussed if wound was deteriorating, improving, if there was a need to change treatment, or interventions. They stated there was no new recommendations given. During an interview and observation on 3/6/25 at 2:01 PM, Inservice Coordinator/Infection Preventionist/Wound Care Certified Registered Nurse stated a Registered Nurse determines the stage of pressure ulcers. They stated once a pressure ulcer was established, they expected the weekly evaluating nurse to take pictures and document on the condition of the pressure ulcer, drainage, wound bed appearance with percentages, peri wound, signs/symptoms of infection and treatment. They stated this was part of the regulation and was important to see if the treatment, and modalities being utilized were assisting in wound healing. They stated review of pressure ulcer staging by the Wound Team was based on observing of the pictures in the electronic medical record. They stated they do not lay eyes on every wound/pressure ulcer and could not say if they had ever laid eyes on Resident #16's pressure ulcer. Inservice Coordinator/Infection Preventionist/Wound Care Certified Registered Nurse reviewed Resident #16's Wound Evaluation pictures in the electronic medical record from 1/17/25 - 3/5/25 and stated the pressure ulcer should have been staged as a Stage 3, as the wound bed presented with slough/fibrin: narcotic tissue. They stated they would not have staged Resident #16's pressure ulcer as an unstageable pressure ulcer on 1/17/25 as the pressure ulcer was not covered with eschar. After reviewing the Wound Evaluation pictures, they stated there was no improvement to the wound bed of the pressure ulcer and the current treatment was not effective. Additionally, they stated they had no answer as to why Resident #16's pressure ulcer was incorrectly staged but stated it was not a Stage 2 and it should have been staged as a 3. During an interview on 3/7/25 at 11:12 AM, Registered Nurse Supervisor #1 stated they were aware Resident #16 had a pressure ulcer. They stated they were taught if they are unable to see what the wound bed looked like it was staged as unstageable, and a pressure ulcer with yellow slough would be staged as unstageable. Registered Nurse Supervisor #1 reviewed pictures of Resident #16's pressure ulcer to coccyx and stated they would have staged pressure ulcer as unstageable on 1/22/25, 1/29/25, 2/5/25, 2/12/25, 2/19/25, 2/26/25, 3/5/25 based on slough completely covering the wound bed. Additionally, they stated taking a picture of a pressure ulcer may not be the best way to stage a wound, as it could be improperly staged depending on glare, and angle when picture was taken. During a follow up interview on 3/7/25 at 11:35 AM, Inservice Coordinator/Infection Preventionist/Wound Care Certified Registered Nurse stated they would expect the evaluating nurse completing weekly wound rounds to be documenting on the appearance of the pressure ulcer wound bed. They stated a wound bed with 80 percent slough would not be considered a Stage 2 pressure ulcer. They stated any ulcer with slough/fibrin would be a Stage 3 or Unstageable. Additionally, they stated the medical providers do not attend the weekly Wound Team meeting but can look through a resident's electronic medical record to view the Skin and Wound evaluation and pictures. During an interview on 3/7/25 at 11:54 AM, the Director of Nursing stated it was important for pressure ulcers to be staged and wound bed described correctly to determine proper wound care, treatment plan, and monitoring of pressure ulcers. The Director of Nursing stated that a Registered Nurse can be notified to lay eyes (in person) on a wound and assess it if there were any concerns or questions when needed. During a telephone interview on 3/7/25 at 12:35 PM, Medical Director #1 stated they were made aware of resident pressure ulcers when they make rounds by the nurse, and they can review wounds in the computer. They could not say if they had ever assessed Resident #16's pressure ulcer. They stated if a pressure ulcer was improving, they would not expect any communication and they would not review pressure ulcer pictures. They stated the only time they expected communication regarding a pressure ulcer is if there was a concern, otherwise they expected the nursing staff to follow protocol. Medical Director #1 stated if a concern was brought to their attention, they would make a progress note to that affect. Additionally, they stated if slough was covering a wound base, it would have to be removed to see how far the pressure ulcer goes. During an interview on 3/7/25 at 12:52 PM, Nurse Practitioner #1 stated they were aware Resident #16 had a pressure ulcer but was unable to recall for sure if they have physically seen the pressure ulcer. They stated if they had seen a pressure ulcer it would be documented under skin assessment with stage and progress. Upon review of Wound Evaluation dated 3/5/25, Nurse Practitioner #1 stated the wound base could not be seen be seen and staging wound be undetermined/unstageable until it was clean. 10 NYCRR 415.12 (c)(2)

Based on interview, observation, and record review conducted during a Standard survey completed on 3/3/23, the facility did not ensure that resident who use psychotropic drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for two (Residents #14 and #56) of five residents reviewed for unnecessary medications. Specifically, Resident #56 received medication including Zyprexa (an antipsychotic), Lexapro (an antidepressant), and Xanax (anti-anxiety medication) and had symptoms of tardive dyskinesia (a movement disorder with uncontrolled movements of the body and face) that were not monitored or reported to the physician; Resident #14 received Lexapro and Buspar (anti-anxiety medication), did not have a GDR as required, and there was a lack of documentation that a GDR was clinically contraindicated. The findings are: The facility Policy and Procedure (P&P) titled, Change in Resident's Condition dated 2/2013 documented that upon full assessment of a resident, the RN is to make a judgement whether a resident has had a change in condition based on current standards of practice. Further review of the P&P documented that the physician was to be notified if there is a change in condition. The facility P&P titled, Nursing Documentation dated 4/2016 documented that nursing documentation is part of the clinical record written by nurses and is the total written information concerning a resident's health status, nursing needs, nursing care and response to care. Further review of the policy documented that a nurse should document resident's behavior, adverse reactions to medications, and a significant change. The facility P&P titled, Medication, Antipsychotic Drugs/Gradual Dose Reduction dated 10/2007 documented that if a medication irregularity was identified by a professional staff member, a nurse will notify the supervisor of the irregularity and the supervisor will then contact the Director of Nurse (DON) and Medical Director for further evaluation. Further review of the P&P documented that the irregularity will be discussed during the Interdisciplinary Team Meeting. The facility P&P titled, Consultant Pharmacist dated 4/2016 documented that the Consultant Pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Further review of the P&P documented that the MRR included the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 1. Resident #56 had diagnoses of Alzheimer's and type 2 diabetes. A review of the Minimum Data Set (MDS - a resident assessment tool) documented that the resident is severely cognitively impaired, usually understood by others and understands others. A review of the physician orders dated from 9/1/22 to 3/31/23 documented that the resident received Zyprexa 2.5 milligrams (mg) once a day for agitation and anxiety initiated on 9/9/22, Lexapro 20 mg once a day for depression initiated on 11/24/22, and Xanax 0.25mg as needed for increased agitation and anxiety initiated on 2/20/23. A review of the resident's comprehensive care plan (CCP) dated 9/14/22 documented that the resident was ordered Zyprexa related to behavior management and that nursing staff were to monitor for side effects as well as adverse reactions of psychotropic medications including tardive dyskinesia. Further review of the CCP documented that nursing staff were to educate the resident, their family, or caregivers about the risk, benefits, and the side effects and/or the toxic symptoms of Zyprexa. A review of the chronological progress notes dated from 9/9/22 to 3/3/23 documented that the resident was initiated on Zyprexa 2.5 mg daily on 9/9/22 and nurse staff had noted no adverse symptoms from 9/9/22 to 9/21/22. Zyprexa was increased on 10/23/22 to 2.5 mg twice a day and nurse staff had noted no adverse symptoms from 10/23/22 to 11/1/22. Zyprexa was decreased to 2.5 mg to be given at night and nurse staff had noted no adverse symptoms from 11/2/22 to 11/15/22. There were no documented adverse symptoms from 11/15/22 to 3/3/23. Intermittent observations between 3/1/23 to 3/2/23 of the resident revealed: On 3/1/23: -9:18AM, the resident was observed with their mouth closed with their jaw moving right to left, the movement then stopped, then the movement started again. The resident was not eating or speaking at that time. -9:48AM, the resident was observed asleep in their wheelchair in the doorway of their room with their mouth closed with their jaw moving right to left. The resident was not eating or speaking at that time. -11:59AM, the resident was observed in the unit dining room with their jaw moving right to left, the movement stopped for one minute, then the movement started again. The resident was not eating or drinking at that time. -1:17PM, the resident was observed in the doorway of their room speaking with a staff member. Observed the resident's jaw moving back and forth along with their tongue thrusting against their teeth while speaking. On 3/2/23: -7:45AM, the resident was observed in unit dining room with their jaw moving right to left. Observed the resident speaking with slight tongue thrusts against their bottom teeth. During this observation, Licensed Practical Nurse (LPN) #3 stated that they noticed the resident's jaw movement for a little less than a year. They stated that they did not report the jaw movement to their manager or the physician. An interview on 3/1/23 at 9:21 AM, LPN #1 stated that they did not know what tardive dyskinesia was or how it was caused. An interview on 3/2/23 at 8:10 AM, LPN Unit Manager (UM) #4 stated that they never saw the resident's jaw movement. They stated that if they knew about the movement, they would have notified the physician. An interview on 3/2/23 at 11:06 AM, the Physician stated that they were not aware that the resident was having issues with facial movements. They stated that they did not know if the nurses knew about tardive dyskinesia symptoms with psychotropic medications. They also stated that they would expect the nurses to report to them or the DON of changes in condition or if something out of the ordinary happened with the resident. An interview on 3/2/23 at 11:20 AM, the DON stated that they expected their staff to report to them or the unit manager of any changes in condition in a resident. They stated that if there was any kind of tardive dyskinesia symptoms, they would expect them to report it to them or the assistant DON. An interview on 3/2/23 at 11:54 AM, the Consultant Pharmacist stated that they were not aware that the resident had possible tardive dyskinesia symptoms. They stated that antipsychotics can cause facial movements and tongue thrusts. They also stated that antidepressants can also cause facial movements but are less likely than antipsychotics. They stated that they did not see anything documented concerning facial movements or tongue thrusting from the resident. They also stated that they have psychotropic medication meetings every three months and that the facial movements were not discussed or reported to them. 2.Resident #14 had diagnosis including Alzheimer's Disease, Major Depressive Disorder (MDD), and chronic kidney disease. The MDS dated [DATE] documented Resident #14 had severe cognitive impairment, was understood, and understands. The MDS documented Resident #14 had no behaviors exhibited and received anti-anxiety and antidepressant medications. Review of the CCP last revised on 1/18/2020, documented Resident #14 used antidepressant medication Lexapro and anti-anxiety medications Buspar related to (r/t) anxiety disorder. Approaches included nursing staff were to administer medications as ordered. Monitor for side effects and effectiveness every shift. Monitor/document/report as needed adverse reactions to therapy. The CCP documented Resident #14 had an alteration in mood state/behavior status at times r/t diagnosis of dementia with anxiety, history of intermittent episodes of agitation/repetitive verbalizations noted, some refusals of care, with the use of psychotropic medication, revised on 9/26/22. Review of facility Order Summary Report printed 3/3/23 documented an active order for Buspar 5mg two times a day (BID) for anxiety with a start date of 3/12/2021 and Lexapro 20mg every day (QD) for depression with a start date of 4/17/2018. Review of the Medication Regimen Reviews (MRR-completed by the Consultant Pharmacist) dated 1/1/22 to 2/28/23 revealed no recommendations for a GDR or for staff to document why a GDR was clinically contraindicated. Review of the facility Progress Notes dated 3/1/2022-3/1/2023 showed no documented evidence that Resident #14 received a GDR of the psychotropic drugs, Buspar and Lexapro. Review of the facility Provider Visit-MD dated 4/5/21 through 1/31/23 documented the resident had a history of anxiety and depression, with all medications reviewed and approved. There was no documented evidence that a GDR was clinically contraindicated. During an intermittent observation on 3/3/23 from 8:00 AM to 9:49 AM, Resident #14 was sitting up in a wheelchair on the unit, noted with pleasant interaction between staff and other residents, smiling, making needs known. Resident #14 offered no complaints, and no signs or symptoms of depression or anxiety were observed. During an interview on 3/3/23 at 9:49 AM, CNA #2 stated Resident #14 liked to pull hair, pinch during care sometimes and made sexual comments to staff that are inappropriate. CNA #2 stated Resident #14 can be redirected easily, involved them in an activity, and talked to them in a calm voice. CNA #2 stated Resident #14 didn't seem depressed or anxious. During an interview on 3/3/23 at 9:55 AM, LPN #7 Supervisor stated there are meetings held with the Pharmacy Consultant and residents receiving psychotropic medications were reviewed quarterly. During the meeting, psychotropic medications were reviewed for effectiveness, a determination was made if medication can be reduced, kept at current dose, or increased. LPN #7 stated psychotropic medications should be reviewed for dose change, side effects, effectiveness. LPN #7 stated any time there was a change in a resident's behavior, nursing staff should be documenting behavior, letting nurse manager know and monitoring for need of further evaluation. During an interview on 3/3/23 at 10:16 AM, LPN #8 stated some days Resident #14 was more anxious than others. Resident #14 hollers out quite a bit, repeats things all the time, pinches, and hits during hands on care at times; makes inappropriate comments. LPN #8 stated that Resident #14 was easily redirected 90 percent of the time. LPN #8 was unaware that resident #14 received psychotropic medications until they viewed their medications in the electronic medical record (EMR). During an interview on 3/3/23 at 10:29 AM, the DON stated they (DON, Assistant Director of Nursing (ADON), Nursing Supervisors, LPN Unit Managers and Social Work (SW)) had quarterly psychotropic medication meetings to review all psychotropic medications in the building with the pharmacy consultant to review for GDR. Recommendations were then presented to the MD. The DON stated that is an area we are lacking notes in when questioned about meeting notes r/t psychotropic medication meetings. The DON stated they were aware that there was a strict protocol but not sure why GDRs haven't been done at least once a year. The DON stated certain diagnoses were exempt from GDRs and felt that the MD didn't like to mess with Resident #14's psychotropic medication because they were stable. The DON stated they knew Resident #14 had been reviewed quarterly but was unable to provide any psychotropic medication meeting notes that documented Resident #14 had been reviewed for GDR of Lexapro or Buspar. During a telephone interview on 3/3/23 at 10:56 AM, the Consultant Pharmacist stated psychotropic medication meeting were completed separately from monthly medication regime reviews (MRR). The committee was responsible to discuss every resident receiving psychotropic medication and determine a GDR or increase. The Consultant Pharmacist stated they didn't have documentation as to why Resident #14 had not had a GDR recommendation for Lexapro and/or Buspar, but that they must have discussed that Resident #14 was stable and didn't need it. The Consultant Pharmacist stated they knew the regulation regarding GDR reviews but was unable to answer why Resident #14 had not received a recommendation for one. During a telephone interview on 3/3/23 at 12:48 PM, the MD stated there were three different ways to complete a GDR of a psychotropic medication: Pharmacist comes in, indicated the resident was a candidate for a reduction; nursing staff evaluation; and their examination. The MD stated Resident #14 should have had a GDR if it wasn't documented that it would be clinically contraindicated. The MD stated if a resident was stable, they continued with what they were doing, don't want to rock the boat. 10 NYCRR 415.12(l)(2)(i)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/3/23, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for two (Resident's #21 and #27) of three residents reviewed for accidents. Specifically, an extensive assist resident was observed to be in a tilted back, lying position while feeding themselves, and coughing (#21). Additionally, a resident on aspiration precautions (measures to prevent food, liquids, and secretions into the lungs) that was care planned for no straws was observed assisted by staff drinking from straws and coughing (#27). The findings are: The undated facility policy and procedure (P&P) titled Feeding Resident documented staff is to ensure residents are in a comfortable position. If a patient needs some help, have them do as much as they can. Do not feed them for expediency and if swallowing is a difficulty, offer small amounts of food to prevent choking. The facility P&P titled Comprehensive Care Plans dated 6/07 documented each comprehensive care plan is composed of a problem the resident has and approaches that are instructions or directions to staff stating what they will do to help the resident. The facility P&P titled Speech/Language/Swallowing Therapy Screening and Evaluation dated 9/21 documented the Speech Language Pathologist ensures that every resident who exhibits swallowing difficulties and is on an altered textured diet will be placed on the highest texture possible to ensure safety and highest quality of life. 1. Resident #21 had diagnoses including dysphagia (difficulty, chronic obstructive pulmonary disease (COPD), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 2/15/23 documented the resident was understood, understands and severely cognitively impaired. The resident's functional status with eating was extensive assistance with one-person physical assist. No swallowing disorder was indicated. The untitled comprehensive care plan (CCP) with revision date 5/30/22, documented Resident #21 required extensive to total assistance by one staff to eat. Resident can bring finger foods to their mouth when handed to them/ bring drinks to their mouth when handed to them. Provide total assistance for managing food on utensils. General swallowing precautions as necessary: slow rate, small bites/ sips, alternate solids/ liquids. Resident was to have back of Broda (a positioning chair that reclines) chair in upright position for meals. During a breakfast observation on 2/28/23 at 8:51 AM, Resident #21 was sitting in the dining room in a Broda chair. The back of the chair was at an approximate angle of 45-55 (degrees) and was not in an upright position. The breakfast tray was on a tray table and placed in front of the resident. Resident was given a carton of milk with a straw in it by a staff member, who then walked away to assist other residents. The resident started to drink from the milk carton by themselves and then pulled the straw out of the milk carton. The resident then began trying to drink the milk from the carton directly without the straw and began spilling it all over their shirt. The resident asked for help several times and then a staff member came over and attempted to dry the shirt. The staff member put the straw back in the carton and handed it back to the resident. The staff member then left the resident to go sit with another resident. The resident was left there by themselves for approximately 15 minutes to try to feed themselves appearing to be struggling to reach for the food on their tray. The staff member came back over to assist the resident but was rolling in their chair from one table to another assisting several residents at the same time. During an observation on 3/1/23 at 8:50 AM, Resident #21's breakfast tray was placed on the tray table in front of them and the staff member left to assist other residents. Resident was sitting back at an approximately 50-60 angle and the back of chair was not in an upright position. Resident at the time was sleeping. At 8:58 AM, a staff member who was feeding two other residents at a table opposite of Resident #21 rolled over in their chair to Resident #21 to try to assist them. A few minutes later the staff member left and went back to the other resident to assist them. At 9:09 AM, Resident #21 was eating by themselves and began coughing on food. Certified Nurse Aide (CNA) #1 came over and gave the Resident #21 a drink. Resident #21 then stopped coughing for a few minutes and CNA #1 left. Resident #21 was sipping milk with a straw, and they began coughing again. During an observation on 3/2/23 at 9:00 AM, Resident #21 was in the dining room for breakfast. The back of the chair was in a tilted position approximately 55-60 angle and not in an upright position. Breakfast food was on the tray in front of them and the resident attempted to feed themselves while struggling to reach the food. No staff member was assisting the resident. During an observation on 3/2/23 at 12:01 PM, Resident #21 was in the dining room lying reclined back in the chair. When their lunch tray was being served, Licensed Practical Nurse (LPN)#2 Unit Manager (UM) told a staff member to make sure they put Resident #21 in an upright position for eating. Observed resident in the upright position eating lunch by themselves with no assistance from staff. Resident was asked if they liked sitting up better when eating and Resident #21 stated it feels good to be sitting up while eating. Review of the document titled Speech Therapy SLP Discharge Summary dated 9/15/21 revealed discharge recommendations that Resident #21 use the following strategies and/ or maneuvers during oral intake: lingual sweep/ re swallow, alteration of liquids/ solids, bolus size modifications, chin tuck, general swallow techniques/ precautions and second dry swallow upright posture during meals, upright posture for >30 minutes after meals and chin tuck. Review of the document titled Interdisciplinary Rehabilitation Screen dated 5/15/22 revealed Resident #21 was an extensive to total assist for feeding. Review of the document titled Therapy Referral dated 12/30/22, revealed Resident #21's seat of Broda chair (bottom lever) in tilt back position AAT's (at all times), back of chair in upright position for meals. During an interview on 3/1/23 at 12:03 PM, CNA #1 stated Resident #21 eats independently when they can, and staff will assist as needed. It depends on how the resident is at the time. CNA #1 stated the resident coughs more days than others but not always during meals. During meals when the resident coughs it is more with the liquids than the solids. CNA #1 stated the resident's care plan states on the back of the chair the bottom lever should be reclined down AATs (at all times) and the top lever which is for the back they are not to move. They stated the resident has contractures of the hips and is stiff and cannot be up in a sitting position as they may slide down. During an interview on 3/2/23 at 10:04 AM, Certified Occupational Therapy Assistant (COTA) stated when Resident #21 is eating, the back of the chair needs be in an upright position and should not be leaning back during meals. When not eating the chair should be reclined in a tilt back position as the resident cannot maintain their balance sitting up all the time and they slide down. We do not want him laying back or down when eating. During a further interview at 2:03 PM, the COTA stated Resident #21 is an extensive to total assist times one when eating. This means one person should be sitting with the resident AATs. The resident has been declining and has been needing more help with eating. The resident has been spilling or dropping their food more. During an interview on 3/2/23 at 12:27 PM, LPN #2 UM stated Resident #21 should be sitting in an upright position during meals and should not be lying back. The position they are in right now is the correct position (observation showed resident to be at a 90-degree angle sitting upright). LPN #2 UM stated the resident is care planned to be in an upright position at meals. When the resident is not at meals, they should have them lay back AAT's as they tend to slide. LPN #2 UM stated the resident does not need assist with eating as they feed themselves. Occasionally they may need to go help the resident. LPN #2 UM stated the recommendations from the Speech Language Pathologist (SLP) on the care plan are recommendations that were taught to the resident themselves to use while eating, like alternating solids/ liquids. They are not recommendations for staff to do with the resident as the resident does not need staff to be with them when eating. During an interview on 3/2/23 at 1:26 PM, the SLP stated they have not personally worked with Resident #21. The last time the resident was seen by a SLP was in 2021. At that time, the discharge recommendations were moist puree consistency and thin liquids. It was recommended to alternate solids and liquids while eating. They stated the resident should be sitting at a 90-degree angle or as close to 90 degrees when eating. If the resident was in a position where they are lying back, they would be at risk for aspiration. They stated staff should be following the recommendations made by the SLP. The SLP stated per the COTA, the resident has been needing more assist with eating. The SLP stated they were unaware that the resident has been coughing as nursing staff has not addressed this with them. During an interview on 3/2/23 at 3:30 PM, the Director of Nursing (DON) stated We like to encourage (Resident #21) to do as much for themselves when eating. If the resident was not doing well, they would expect staff to do it for them. With this resident it depends on the day. Staff should definitely be next to the resident when they are eating and encouraging them. Resident #21 definitely should not be alone when eating. This resident should be sitting upright as much as they are capable of. The DON stated, I would expect the CNAs to keep a closer eye on this resident and follow the SLP recommendations when assisting them. During an interview on 3/3/23 at 8:12 AM, the Physical Therapist (PT) stated that the resident cannot sit at a 90-degree angle due to their contractures but at meals they should put the back of the chair up to the resident's tolerance. The resident should not be in a lying position while eating. 2. Resident #27 had diagnoses including dysphagia, Alzheimer's disease, and history of cerebral infarction (stroke). The MDS dated [DATE] documented Resident #27 had short term and long- term memory impairments and required extensive assist with eating. The CCP revised on 8/17/22, documented Resident #27 was an extensive assist for eating and had interventions of no straws, and aspiration precautions in place. The Kardex (a guide used by staff to provide care) Report dated 2/1/23, documented no straws, and aspiration precautions. Review of a Speech Therapy Discharge Summary dated 8/25/22 at 7:04 AM, documented to facilitate safety and efficiency, it was recommended the patient use the following strategies and/or maneuvers during oral intake: rate modification, alternation of liquid/solids, bolus size modifications, no straws and general swallow techniques/precautions, upright posture during meals and upright posture for greater than 30 minutes after meals; aspiration precautions. The resident's meal ticket dated 3/2/23 documented an alert which included no straws. During a lunch meal observation on 2/27/23 at 12:10 PM, Resident #27 was sitting in their wheelchair at a dining table. A staff member placed a straw in a carton of boost (a protein supplement drink) and fed the resident, alternating bites of food and drinks from a straw in a carton of boost. At 12:24 PM, the resident began to cough. At 12:27 PM, the staff member added a straw to a coffee cup and placed the straw up to the resident's mouth. The staff member encouraged Resident #27 to drink from the straw. The resident's meal ticket was observed to document an alert for no straws. During an interview on 3/2/23 at 10:29 AM, CNA #2 stated sometimes Resident #27 drinks best using a straw. During an interview on 3/2/23 at 10:51 AM, CNA #3 stated Resident #27 used a straw during meals to drink all their boost. CNA #3 stated other staff members had told them, Resident #27 drinks better from a straw. During an interview on 3/2/23 at 11:03 AM, CNA #5 stated Resident #27 will drink from the boost carton or with a straw; sometimes the resident coughs to clear their throat. During an interview on 3/2/23 at 11:06 AM, LPN #6 stated when giving Resident #27 medications, sometimes a straw is put in a cup of water out of habit. During an interview on 3/2/23 at 11:35 AM, LPN #9 stated who ever gives the meal tray to the resident was responsible to make sure the meal tray matches the meal ticket. LPN #9 stated Resident #27's Kardex documented no straws. LPN #9 stated speech therapy would recommend no straws; sometimes residents will drink too much with straws causing aspiration. During an interview on 3/2/23 at 1:36 PM, the SLP stated Resident #27 was evaluated in August for difficulty swallowing. The SLP stated Resident #27 was recommended no straws due to potential for aspiration. The SLP stated no straws is documented on the Kardex and on the meal ticket. The SLP stated staff used straws with Resident #27 in the past; at that time, the staff was counseled about aspiration precautions and reminded Resident #27 should not use straws. The SLP stated they were unaware staff was currently using straws with the resident. During an interview on 3/3/23 at 9:35 AM, the DON stated the SLP determines if a resident should use straws and determines the risk for aspiration. The DON stated it was the responsibility of the CNAs to ensure the tray matches the meal ticket. The DON stated it was expected that the nursing staff follow the recommendations of the SLP. The DON stated the LPNs were ultimately responsible for the CNAs in the dining room. 10 NYCRR 415.12(h)(2)

Based on observation, interview and record review conducted during a Complaint Investigation (NY00286248 and NY00283680) completed during the Standard survey completed 3/3/23, the facility did not ensure the resident's right to be free from abuse for three (Resident #30, #34 and #77) of four residents reviewed for abuse. Specifically, Licensed Practical Nurse (LPN) #5 verbally abused Resident #34 in the presence of their roommate (Resident #77). The incident was witnessed by a Certified Nurse Aide (CNA) who did not immediately report the abuse to facility staff; Resident #30 had an allegation of abuse against CNA #3, who had multiple disciplinary notices for neglect and abuse allegations and continued to work with residents. The findings are: The policy and procedure titled Abuse Prevention and Reporting signed and dated 6/28/22 documented it is the policy of the facility to prevent and investigate incidents of resident abuse; treat all residents with kindness, dignity and consideration; ensure all residents are free from physical, verbal, mental, financial and sexual abuse or neglect; comply with all State and Federal Regulations with regard to abuse and neglect. Physical abuse is any act or omission which may cause or causes physical pain, harm or injury to the resident or where it is reasonable to believe that pain, harm or injury would result. Verbal abuse is any act or omission which may cause or causes emotional harm, psychological harm, mental harm, mental distress or humiliation or where it is reasonable to believe that harm would result regardless of the cognitive or sensory level of the resident. If the investigation supports disciplinary action, appropriate disciplinary action will be taken which may include the following: reinstatement without pay; suspension without pay between three and ten days in addition to the lost investigation time; immediate termination. The State Operations Manual Appendix PP dated 10/21/22 documented neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. 1a. Resident #34 had diagnoses including major depressive disorder, psychosis, hypertension (HTN-high blood pressure) and type 2 diabetes mellitus (DM). The Minimum Data Set (MDS- a resident assessment tool) dated 10/28/21 and 12/20/22 documented the resident was understood, understands and cognitively intact. Review of the untitled comprehensive care plan (CCP) revision date 1/18/23 revealed Resident #34 has potential for alteration in mood state r/t (related to) dx (diagnoses) of major depressive disorder, anxiety and psychosis, with use of psychotropic medication; history of incident involving staff, support give, resident venting feelings well. During an interview and observation on 2/28/23 at 9:39 AM, Resident #34 stated they vaguely remembered the incident with a staff member, and it happened a while ago and the incident happened on another unit and in a different room. They stated they felt like the facility has taken care of the situation and have not seen or even remember who that LPN was. They stated they did not feel afraid and felt safe here at the facility. The resident appeared calm and comfortable talking about the incident. Review of the progress note titled RN (Registered Nurse) Note dated 11/10/21 at 10:01 AM, revealed Resident #34 requested this writer come to their room after breakfast today, stated they are very upset due to the incident during the night. Resident stated the night shift LPN was mean to them, yelling at them and their roommate during the night. Resident reported they were unable to sleep after the incident. 1b. Resident # 77 had diagnoses including schizophrenia, acute embolism (obstruction of an artery) and thrombosis (clotting within a blood vessel), and nutritional and metabolic disease. The MDS dated [DATE] documented the resident was understood, understands and moderately impaired. The MDS dated [DATE] documented the resident was understood, understands and cognitively intact. Review of the untitled CCP revision date 11/6/20 revealed Resident #77 has diagnosis schizophrenia, potential for alteration in mood and behavior status. During an interview and observation on 2/27/23 at 1:30 PM, Resident #77 stated they did not remember the incident. They stated, It was not me it must have been somebody else. The resident stated they feel safe at the facility and had no issues with any of the staff. Resident was smiling and appeared to be calm and comfortable when discussing the incident. Review of the progress notes titled Psychosocial Note completed by the Social Work on 11/10/21 at 10:53 AM revealed they visited Resident #77 today regarding incident involving roommate and staff. Information given to Administration. Resident stated they feel safe there and said, I just didn't want to get involved. Support given with effect noted. On 11/12/21 at 10:14 AM visited with Resident #77 today. They were calm and pleasant. The resident shook their head yes to question Are you alright after the other day? and Have you been sleeping? The resident shook their head no to the question Is the incident still bothering you? No verbalizations noted. Resident did make eye contact and smiled at this worker. Support given and they were assured of future visits to which they shook their head yes. Review of an unsigned, undated document in the facility's investigation folder revealed: On 11/10/21 Resident #34 reported that the prior night (11/9) they rang their call bell three times. When LPN #5 answered the bell, the resident asked for a fan. It was reported that the LPN #5 responded and said, How the hell do I know, I got that fan for you, and I can take it away. It was also reported that LPN #5 grabbed the neck pillow from the roommate's bed and began to hit the bed with it, loudly saying get up. LPN #5 told the resident See, I can do what I please, you don't tell me what to do. The resident and the roommate indicated to the SW that they were frightened by this interaction. The resident indicated that they were not able to sleep following the interaction. The resident claims that LPN #5 has done things like this before, but not as bad (these were not reported or investigated prior). When conducting the investigation with staff that worked that unit the same night, a statement was received that they overheard the altercation from outside of the room. They did not report the altercation and was disciplined for that. They indicated that LPN #5 has spoken this way to residents before. Both the resident and the roommate are alert and oriented. Once the report was received the facility began an internal investigation. The punishment that was proposed via the NOD (Notice of Discipline) was a 6-month unpaid suspension. This punishment was derived based upon a hearing officer's finding earlier this year in a case of reported abuse. The County's position is that resident abuse was a severe offense, and cannot be tolerated, which is why it was not logical to start this discipline with a warning or a reprimand. The county has a moral and legal obligation to protect residents. Review of an untitled statement dated 11/11/21, written by CNA #10, revealed they witnessed LPN #5 being verbally abusive with Resident #34. Review of the Notice of Discipline dated 12/10/21, revealed LPN #5 was guilty of misconduct and unacceptable professional performance for lack of providing quality care. On the morning of November 10,2021, a resident reported that during the night of November 9, 2021, into November 10, 2021, (overnight shift), LPN #5 was verbally abusive to them. The investigation found these allegations to be substantiated. During an interview on 3/3/23 at 6:37 AM, LPN #5 stated at around 12:30- 12:45 AM they came back from their break and heard Resident #34 yelling, you need to get off your high horse and help me to an agency aide. They went over to Resident #34 and asked what they needed, and the resident stated they needed help fixing a fan. LPN #5 stated they and Resident #34 went to the resident's room and fixed the fan. As they were trying to leave the resident was blocking their way out and there was only a small area to get around and out. They tried to walk around them and tripped on the walker and fell to the bed of the roommate with their right hand on top of the foot board and the other hand landing on the roommate's leg. They stated, I was afraid to go in the resident's room to give them their medications in the morning because of what had happened that evening. LPN #5 stated they received in-servicing on abuse yearly. They stated they were found guilty by the facility and placed on a 6-month suspension with no pay. Since they have been back, they have been in-serviced on abuse and are on a different unit from where the two residents are located and has had no contact with them. During an interview on 3/3/23 at 10:51 AM, the DON stated LPN #5 was placed on a 6-month suspension without pay and then was able to come back. They stated LPN #5 was currently working at the facility on another unit and kept off the units that these two residents are on. They stated LPN #5 was required to do some education when they came back. They stated what LPN #5 did was highly inappropriate and the residents were upset over it and residents should not be treated like that. They stated, I feel it could definitely cross the line of verbal abuse. During an interview on 3/3/23 at 11:45 AM, the Administrator stated they recalled the incident, and that the facility went for termination as they felt at that time there was an issue. They stated LPN #5 was placed on 6-month leave without pay. They stated they did not know who wrote the untitled, unsigned document in the investigation folder and that the Social Worker was on vacation and there was no way to contact them for an interview. The Administrator stated based on the resident statements and the witness there were some verbally abusive things said. 2a. Resident #30 was admitted to the facility with diagnoses of Alzheimer's and anxiety. A review of the MDS dated [DATE] documented the resident is mildly cognitively impaired, understands others, and is understood by others. The resident's CCP dated 3/17/21 documented that the resident has limited physical mobility related to weakness. Further review of the CCP documented that the resident has a potential for alteration in behavior or mood state related to anxiety with interventions that include give time for the resident to understand the situation and be able to express feelings. Additional interventions for the resident on the CCP included to analyze what triggers and what de-escalates the resident's anxiety. A review of a facility investigation dated 9/22/21 at 12:15 PM, documented that LPN Unit Manager (UM) #2 walked by Resident #30's room and saw the resident crying and shaking. The resident stated that CNA #3 was mean and rough during care and threw their belongings on the floor. The resident stated they asked CNA #3 to pick up their belongings and CNA #3 replied, pick them up yourself. Further review of the facility investigation documented that the resident appeared psychologically upset. The investigation also documented that CNA #3 was removed from the building and put on administrative leave pending the outcome of the investigation. A review of a witness statement dated 9/22/21, completed by LPN UM #2 documented that they saw the resident crying and shaking. Further review of the statement documented that the resident's belongings were on the floor and that the resident's bed was not made. LPN UM #2 stated that they picked up the resident's belongings off the floor and made the resident's bed. A review of an undated witness statement from CNA #3, completed by CNA #3, documented that the resident wanted their back scratcher, but the CNA had dirty linens in their hand and would be back to give the resident their back scratcher. The witness statement documented that CNA #3 saw that the breakfast cart had arrived on the unit and decided to pass meal trays. The witness statement documented that by the time CNA #3 returned to the resident's room, the resident's back scratcher was on the over the bed table, so they left the resident's room. Further review of the personnel file revealed that CNA #3 received training in prevention of elder abuse; recognizing, reporting, and preventing resident abuse; spotting the signs of elder abuse; understanding abuse and neglect; abuse prevention policy; and It's all in your approach after the incident with Resident #30. Review of the New York State Department of Health (NYS DOH) Automated Complaint Tracking System (ACTS) Facility Summary dated 9/22/21 at 1:55 PM, the facility documented that there was a reasonable cause to believe that abuse, neglect, or mistreatment occurred. 2b. A review of the personnel record of CNA #3 revealed that the staff member received 52 disciplinary actions from 11/23/14 to 7/12/22 including written warnings, counseling, and notices of discipline (a notice with the alleged charges and details of infractions). Further review of the personnel file documented that those disciplinary actions included but were not limited to: 1. Failed to follow the care plan by not putting floor mats next to the bed and the resident fell out of bed. 2. Failed to place call light button next to resident and left resident in a wet bed for an hour. 3. Ignored a resident's call light to be toileted multiple times. 4. Failed to replace a bed alarm for a resident's and the resident fell out of bed not alerting staff. 5. Did not perform incontinence care as care planned for two residents. 6. Failed to follow care plan and resident slid out of wheelchair. 7. Failed to follow direction of their nurse and delayed toileting a resident. 8. Failed to follow care plan and left resident in an unsafe position and not in a low bed. 9. Failed to follow care plan as they ambulated resident without a wheelchair following behind them. Also, asked a family member to hold a gait belt (an assistive device used to help a resident walk or transfer) while they left to get a wheelchair. 10. Failed to wear the proper personal protective equipment when they provided care to a resident, specifically a gown. 11. Failed to follow care plan and left resident in bed in an unsafe position. 12. Cursed and yelled in front of residents on their unit. 13. Failed to change resident's brief (on 2/6/22). 14. Refused to do walking unit rounds (to observe residents to ensure safety and care measures are implement) for their residents at the beginning of their shift (on 3/10/22). Review of the Other Investigation allegation summary dated 8/29/22 documented that CNA #3 was being rough with a resident causing them pain. This allegation was unsubstantiated by the facility. Review of an Employee Risk assessment dated [DATE] conducted by the County Risk Management Office, documented that the employee has a significant history of unprofessionalism and concerns with the care they provided to residents. The recommendation was that CNA #3 should be supervised to ensure that they are responsible for their residents in their care. A review of a Notice of Discipline dated 2/23/23 documented that CNA #3 received a notice of discipline for failure to sign mandatory supervision sheets for care of their residents. During an interview on 3/3/23 at 8:34 AM, LPN UM #2 stated that they walked by the resident's room and saw the resident upset, crying, and shaking. They stated that the resident told them that CNA #3 opened the curtain quickly and knocked the resident's belongings off the over the bed table and onto the floor. They also stated that CNA #3 would not pick up the items off the floor per the resident's request. They stated that the resident was particularly upset about their phone on the floor and always wants her phone with her. They stated that the resident would not be able to physically pick up anything that fell to the floor. They also stated that CNA #3 can be rough with residents. During an interview on 3/3/23 at 9:13 AM, CNA #3 stated that they couldn't pick up the items on the floor because they had dirty linen in their hands. They stated that they told the resident they would be back after they put away the dirty linen. They stated that the resident swore at them and when CNA #3 came back to the resident's room, LPN UM #2 was already in the room. During an interview on 3/3/23 at 9:47 AM, with the Director of Nursing (DON) present, the Administrator stated that discipline at their facility is done on a progressive level. The Administrator stated that staff members start with counseling memos to written warnings to notice of disciplines. The Administrator stated that the infractions to progress to a level of terminating a staff member's position must be for the same exact infraction thing including care plan violations and abuse. The DON stated that CNA #3 would behave for awhile and then go back to their behavior of unprofessionalism and insubordination. The Administrator stated that this particular incident had gone to a hearing officer, and they wanted to wait to decide after the outcome of the state investigation. During an interview on 3/3/23 at 10:41 AM, the Risk Management Investigator stated that they do an investigation when there is an allegation of abuse. They stated that they interview the resident, the alleged perpetrator, and anyone staff who worked with the resident up to 72 hours prior to the incident. They stated that the county does progressive discipline from counseling to notice of discipline to termination. They stated they were not sure why CNA #3 has so many disciplinary actions but that the policy is that the employee has to commit the exact same offense multiple times in order to be terminated. 10 NYCRR 415.4(b)(1)(i)

Based on interview and observation conducted during a Standard survey completed on 3/3/23, the facility did not ensure that only authorized personnel have access to medication keys. Specifically, one (Unit B) of three units reviewed for medication storage had issues with a nurse giving their medication cart, medication room, and narcotic cabinet keys to another nurse without reconciling the medications. The finding is: The facility Policy and Procedure titled Controlled Substances dated 4/2016 documented that at no time are keys given to another nurse unless there is a count and records completed. 1.During an observation of wound care on 3/2/23 at 9:38 AM, Licensed Practical Nurse (LPN) #1 asked LPN #2 Unit Manager (UM) for supplies for the wound treatment. LPN #2 UM asked LPN #1 if they could have their keys to the treatment cart. LPN #1 stated, they're in my pocket and LPN #2 UM reached into LPN #1's scrub top pocket and retrieved the medication cart keys. LPN #2 UM left the room for approximately five minutes and returned to the room. LPN #2 UM then gave the keys back to LPN #1. An interview on 3/2/23 at 11:45 AM, LPN #1 stated that they should not have given their medication cart keys to another nurse. They stated that the keys that were given to LPN #2 UM were for the medication cart, the treatment cart, the medication room, and the narcotic medication cabinets. They also stated that they should have had LPN #2 UM stay with the resident while they went to the treatment cart for wound treatment supplies. During an interview on 3/2/23 at 12:57 PM, LPN #2 UM stated that they should have not asked for keys from another nurse. They also stated that they should have stayed with the resident while LPN #1 went to go get the wound care supplies. An interview on 3/2/23 at 1:10 PM, the Director of Nursing (DON) stated that under no circumstances a nurse should ask another nurse for their medication keys. They also stated that nurses should not give their keys to another nurse. 10 NYCRR 415.18(e)(1)

Based on observation, interview, and record review conducted during an Infection Control Focus Survey (Complaint #NY 156) completed on 6/25/20 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (A, B and C Wings) of 3 units reviewed. Specifically, the facility did not ensure all staff and visitors were adequately screened for respiratory related symptoms and illness upon entrance to the facility. This is evidenced by: The Executive Order 202.11 dated March 27, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The Health Advisory from New York State Department of Health (NYSDOH) Bureau of Healthcare Associated Infections (BHAI) Memorandum dated March 13, 2020 to all Nursing Homes and Adult care Facilities, provided: Immediately implement health checks for all HCP (Health Care Personnel) and other facility staff at the beginning of each shift. HCP and other facility staff with symptoms or with T greater than 100.0 F should be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility should immediately go home. Any (permissible) visitors shall be checked as if they are staff. The Centers for Medicare & Medicaid Services (CMS) memo (Ref: QSO-20-14-NH) titled Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) dated 3/13/2020, documented guidance to facilities to implement active screening of residents and staff for fever and respiratory symptoms; to screen all staff at the beginning of their shift for fever and respiratory symptoms; and to actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. The findings are: Review of facility policy and procedure (P&P) COVID - 19 revised 5/18/20 included the following: - Non-facility staff that must enter receive health screening and a mask at the front door prior to entry. - All staff are screened for the following health related items upon entry and every 8 hours afterwards, into the building effective 3/13/20. a. Known contact with someone with a known COVID-19 infection. b. Fever above 100.0 c. Travel to known COVID-19 hotspots. d. Cough/shortness of breath. On 6/24/20 at 8:51 AM the facility Receptionist was observed screening staff in the vestibule of the main entrance. The Receptionist obtained the temperatures of six staff (employee #s 1,2,3,4,5 and housekeeper #1). The staff were not screened for symptoms of respiratory illness or COVID-19 symptoms. Review of the employee COVID-19 Check List dated 6/24/20, prepared by the Receptionist during the screenings, documented employee #s 1,2,3,4,5 and housekeeper #1 had no respiratory related symptoms and illness. During an interview on 6/24/20 at 8:59 AM the Receptionist stated the staff was just coming in for the day. Additionally, the Receptionist stated, essentially the training I got was how to operate the thermometer. We were asking questions in the beginning, but we don't anymore because if they (staff) aren't feeling well they (staff) would tell us. During an interview on 6/24/20 at 8:42 AM the Registered Nurse (RN) Infection Control Preventionist (ICP) stated there was no questionnaire upon entry to facility. She stated the person performing the screen should be asking staff if they have any signs and symptoms of illness when entering the facility. During an interview on 6/24/20 at 10:20 AM the RN Director of Nursing (DON) stated it is the expectation to ask health screening questions to everyone that comes into the facility. During an interview on 6/24/20 at 8:29 AM, the Administrator stated the process for screening visitors and staff was to obtain their temperature, instruct them to sanitize their hands, and they should report any signs and symptoms of respiratory illness. Additionally, questions are supposed to be asked of anyone entering the building, but the Administrator was unsure if the questionnaire was available at the facility screening area. 415.19(b)(1)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 141) during the Standard survey completed on 3/6/20, the facility did not ensure the residents environment remains as free of accident hazards as is possible for one (Resident #35) of five residents reviewed for accidents. Specifically, the facility did not ensure the shower chair preventative maintenance was completed per the manufacturers' safety/ maintenance information. The shower chair collapsed from beneath Resident #35 resulting in Resident #35 falling to the floor. The finding is: Review of the undated policy and procedure entitled Cleaning and Disinfection of Resident Care Equipment included the purpose to maintain a safe and clean resident environment, that housekeeping will clean and disinfect shower chairs on a daily basis, and any noted defects will be reported to maintenance. 1. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 12/14/19 documented Resident #35 was understood, understands, and was totally dependent on one staff member for bathing. Review of the facility Witnessed Fall dated 11/14/19 documented Resident #35 was being showered in the shower room, the PVC ([MEDICATION NAME] chloride) shower chair broke and Resident #35 fell to the floor. Review of an email dated 11/15/19 from the Administrator to Maintenance revealed the following: I know that you all have a lot of preventative maintenance (PM) to do throughout the building; however, due to a recent event with a shower chair, we will now have to do a monthly PM log on all shower chairs in the facility. For the PM they will need to be visually inspected for cracks and any other signs of wear and replaced when necessary. According to the supplier, these chairs have a 2-year wheels and back warranty, a 5-year frame warranty, and a life use of [AGE] years. Each chair has a sticker on them to check these specs (specifications). Review of the manufacturers Operation Instructions included the following under Safety/ Maintenance Information: - Check pipe and fittings for hairline fractures monthly. - Check all junctures to make certain the pipe and fittings do not pull apart. Review of the shower chair manufacturers sticker included a Serial number of 02/10/2010. During an interview on 3/5/20 at 1:13 PM, the Superintendent of Buildings and Grounds stated, part of our plan of correction for this incident was to start a check of the shower chair/ equipment. Prior to this we didn't have anything in place for the checking of the shower chairs. We relied upon staff to report to us if there were any issues. During an interview on 3/6/20 at 9:41 AM, the Administrator stated the facility should always follow the manufacturers' recommendation for preventative maintenance, and prior to the incident with Resident #35 on 11/14/19 there was no evidence of a routine preventative maintenance schedule. 415.12(h)(1)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaints #NY 025 & NY 386) completed on 11/21/19, the facility did not ensure the resident's right to be free from abuse and neglect for one (Resident #1) of three residents reviewed for abuse and neglect. Specifically, the Certified Nurse Aide (CNA) roughly handled the resident while providing care; and provided care alone when the plan of care required two assist. The finding is: Review of the facility policy and procedure titled Abuse Prevention and Reporting revised 10/19 revealed physical abuse is any act or remission which may cause or causes physical pain, harm or injury to the resident or where it is reasonable to believe that pain, harm or injury would result. Physical abuse may include but is not limited to: slapping, pinching, kicking; pushing or rough handling, unnecessary restraints, failure to intervene in a resident altercation that results in physical harm to a resident. Verbal abuse may include but is not limited to: use of profanity, swearing; sarcasm, threats, teasing or degrading, discussing employee personal matters which are offensive, sensitive, loud, lewd or embarrassing to resident. Neglect is an act or omission which causes or may cause emotional or physical pain, harm or injury to a resident or which violates the resident's rights done carelessly, recklessly or unintentionally which falls below reasonable standards of conduct expected of employees in performing their jobs. Neglect may include but is not limited to: not providing care as stated on care plan. 1. Resident #1 was severely cognitively impaired with a [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 5/8/17 documented the resident is a total 2-assist with incontinence care in bed, 2-assist with a mechanical lift for transfers and required extensive 2-assist to turn and reposition in bed every two hours and as necessary. Review of a facility investigation dated 4/11/19 documented the (former) Administrator was made aware that a CNA provided incontinent care and repositioning for Resident #1 alone instead of using a two person assist for care. There was no accident or injury from this care plan violation. The CNA was placed on investigatory suspension on 4/11/19 and given a written warning on 4/12/19. The CNA was placed on close supervision and spot checked by her charge nurse and shift Registered Nurse (RN) Supervisor. Review of a Counseling Form Nursing Department dated 4/12/19 documented a care plan violation due to the CNA performed incontinent and repositioning care by herself when the resident's care plan called for 2-assist. The form also documented rough handling and using the f word. Review of a facility investigation documented that on 5/28/19 at approxiamtely 4:00 PM the current Administrator observed camera footage provided by Resident #1's family taken on 4/8/19 which the family had placed, without informing management, to observe resident treatment. The camera shows the accused CNA verbally abuse the resident and grab her leg up in the air and slam it down. The resident cries out and says help me. Review of a Notice of Discipline dated 5/30/19 documented the CNA was terminated due to mistreated/abused a resident by carelessly yanking and throwing her legs to the bed while transferring her against care-planned assistance-levels. The CNA was accused of using foul language and making derogatory statements in the resident's presence. Observation on 11/21/19 at 10:00 AM of the camera footage dated 4/8/19 at 1:08:58, revealed the CNA provided Resident #1 care alone while the resident was in bed instead of with 2-assist with bed mobility, toileting and positioning per the care plan. The CNA is heard telling the resident, chill out, you're gonna get it all over me in a sarcastic tone and repeatedly tells the resident to chill out. At 1:10:38 the CNA is observed to roughly pick the resident's leg up and roughly drop it with an audible sound as it hit the bed. The resident is heard crying out throughout care. During an interview on 11/14/19 at 2:30 PM, the current DON stated that the former DON and Administrator saw the video on 4/12/19 after the family brought it to their attention. The current DON stated that the following should have been done: the CNA immediately terminated; a full RN assessment documented; Social Worker involvement; staff interviewed that worked that night, and alert and oriented residents who were cared for by the CNA interviewed. The Interdisciplinary Team would have discussed the resident's care further to determine any changes. During an interview on 11/14/19 at 2:35 PM, the current Administrator stated if she had seen the camera footage on 4/12/19, she would have terminated the CNA immediately and determined if other residents were affected. 415.4(b)(1)(i)

Based on interview and record review conducted during an Abbreviated survey (Complaints #NY 025 & NY 386) completed on 11/21/19, the facility did not ensure that all alleged violations involving abuse, are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #1) of three residents reviewed for abuse. Specifically, the Certified Nurse Aide (CNA) that roughly handled the resident while providing care was not reported to the New York State (NYS) Department of Health (DOH) as required. The finding is: Review of a facility policy and procedure (P&P) titled Abuse Prevention and Reporting revised 10/19 revealed there was no P&P regarding when allegations of abuse should be reported to the administrator of the facility and when the facility is required to notify the NYS DOH. 1. Resident #1 was severely cognitively impaired with a [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 5/8/17 documented the resident is a total 2-assist with incontinence care in bed, a 2-assist with a mechanical lift for transfers and required extensive 2-assist to turn and reposition in bed every two hours and as necessary. Review of a facility investigation dated 4/11/19 documented the (former) Administrator was made aware that a CNA provided incontinent care and repositioning for Resident #1 alone instead of using a 2-assist for care. There was no accident or injury from this care plan violation. The CNA was placed on investigatory suspension on 4/11/19 and given a written warning on 4/12/19. The CNA was placed on close supervision and spot checked by her charge nurse and shift Registered Nurse (RN) Supervisor. Review of a Counseling Form Nursing Department dated 4/12/19 documented a care plan violation due to the CNA performed incontinent and repositioning care by herself when the resident's care plan called for 2-assist. The form also documented rough handling and using the f word. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/Incident Investigation Report revealed the Date/time of occurrence: 4/8/18 at 10:45 PM. Submitted by the by the facility: 4/12/19 at 8:56 AM. During an interview on 11/14/19 at 2:35 PM, the current Administrator stated she was aware of the 2-hour reporting regulation for alleged abuse but was not employed by the facility when the incident occurred. 415.4(b)(4)

Based on interview and record review conducted during an Abbreviated survey (Complaints #NY 025 & NY 386) completed on 11/21/19, the facility did not have evidence that all alleged violations are thoroughly investigated for one (Resident #1) of three residents reviewed for abuse and neglect. Specifically, the resident's bruises above the left eye along the full length of the eyelid and to the left side of her forehead were not thoroughly investigated to include written statements from staff that cared for the resident within the 24-hour period. The finding is: Review of the facility policy and procedure titled Abuse Prevention and Reporting revised 10/19 included physical abuse is any act or remission which may cause or causes physical pain, harm or injury to the resident or where it is reasonable to believe that pain, harm or injury would result. Physical abuse may include but is not limited to: slapping, pinching, kicking; pushing or rough handling, unnecessary restraints, failure to intervene in a resident altercation that results in physical harm to a resident. Neglect is an act or omission which causes or may cause emotional or physical pain, harm or injury to a resident or which violates the resident's rights done carelessly, recklessly or unintentionally which falls below reasonable standards of conduct expected of employees in performing their jobs. Neglect may include but is not limited to: not providing care as stated on care plan. If there is suspected resident abuse, the administrator or his/her designee will conduct an in-depth investigation. The investigation may include but not limited to: Interview all potential witnesses written statements obtained from each witness; interview of resident; chronology of events, including time, place, person. The facility will ensure that employees suspected of abuse will be directed to refrain from all contact with the resident involved in the allegation pending investigation. The intent of the procedure is to protect residents while the investigation is pending. 1. Resident #1 was severely cognitively impaired with a [DIAGNOSES REDACTED]. Review of an Accident and Incident (A&I) Report dated 4/6/19 at 3:45 AM documented the resident was found on the inside of the bed on the floor and sustained a large lump on the back of the head and a red area on the coccyx. The resident was sent to the emergency room and returned that day. Review of Nurse's Notes and A&I Reports dated 4/7/19 through 4/12/19 revealed no documented evidence of further falls or incidents. Review of a Nurse's Note dated 4/13/19 at 11:22 by a Registered Nurse (RN) documented the resident was found with a bruise along the eyelid of the left eye and another on the left side of the forehead of unknown cause. Review of a Nurse's Note dated 4/13/19 at 12:52 by a RN documented the resident's spouse was notified and stated he already knew about the bruises because they have been there for a few days. Review of a Nurse's Note dated 4/13/19 at 23:23 by a RN documented the resident had dark purple bruising to left upper eyelid and [MEDICAL CONDITION] and faint bruising on the forehead above the left eye. Family expressed concern that the cause of injury is unknown. Review of an Accident and Incident (A&I) Report dated for 4/13/19 at 6:20 AM documented Resident #1 was found with a deep purple bruise above the left eye along the full length of the eyelid measuring 4.0 centimeters (cm) by 1.0 cm. She also had a bruise to the left side of her forehead 2.0 cm by 0.5 cm light purple and reddish in color. Further review revealed there were no written statements from staff that cared for the resident within the 24-hour period. Review of a Report of Events dated 4/13/19 at 7:20 PM documented the Personnel Officer in charge of Human Resources, Civil Service and Risk Management received a call from family notifying her of an injury to Resident #1. The daughter had visited the resident on 4/12/19 until 10:00 PM. On 4/13/19 the family was told by a RN the resident was doing good, had slept well and was calm when they called to inquire about her. On 4/13/19 at approximately 11:30 AM a RN called the family to report Resident #1 had bruises. The family believed the bruises they were being informed of were the result of a previous incident. Family visited on 4/13/19 at 7:15 PM and found the resident with a black eye on the left side and a goose egg bump on her forehead. On 4/15/19 the Personnel Officer met with the Director of Nursing (DON) to review steps for a complete investigation and injuries and lack of any documentation of the occurrence of these injuries. Questioning of staff was initiated on 4/17/19. During an interview on 11/14/19 at 2:00 PM, RN #1 stated the bruising on Resident #1's eye and forehead had been reported by night shift CNA's that morning. Staff speculated that the bruising could have occurred when Resident #1 tried to push her glasses up onto her face. RN #1 notified the resident's husband and he stated it had already been reported to him. The night nurse started the A&I Report. RN #1 thought the investigation to the cause of the bruise had been in progress. 415.4(b)(3)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 972) completed on 7/16/19, the facility did not ensure the resident environment remains as free from accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. Specifically, Resident #1 was not transferred per the plan of care, to include a gait belt (transfer belt), which resulted in the resident falling to the ground and sustaining two abrasions. The finding is: Review of the undated facility policy and procedure titled Transfers and Lifting included the following: Ensure the residents move from one surface to another safely with the degree of assistance required. Communicate the appropriate method of transfer/ lift to all caregivers. One person assist, and two persons assist mode include use of gait belt and/ or assistive devices. 1. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 5/16/19 documented the resident was moderately cognitively impaired, required extensive assistance of one person to transfer, and had one fall with injury (except major) since last assessment. The Care Plan Detail documented the resident required the transfer status of one person assist with gait belt and rolling walker in and out of bed 11/13/18 through 5/17/18. Review of a facility Witnessed Fall report dated 5/17/19 included the following: -Incident Description: Upon entering room resident was seated on his bottom on the floor with WC (wheelchair) parked behind him. CNA (Certified Nurse's Aide) was standing next to the resident. Resident was being transferred out of bed 1 assist with rolling walker, no gait belt in place, after resident stood up and turned, he began to sit without WC behind him and lost his balance and fell to floor without hitting his head. Resident denies pain at this time, has two abrasions on left flank (area between upper abdomen and back) measuring 6.5 cm (centimeter) x (by) 0.5 cm the other 3 cm x 2 cm. During an interview on 7/16/19 at 2:03 PM CNA #1 stated, I was going in his room (Resident #1) getting him up to go to dinner. I got him on the edge of the bed, got him set up to stand at the walker when his knees buckled, and he went down to the ground. I did check the care plan and he needed a gait belt. I don't recall if I put a gait belt on, but I don't think so. During an interview on 7/16/19 at 10:00 AM the Acting Administrator stated, I expect staff to follow the care plan. If the care plan has gait belt on it, then a gait belt should be used. 415.12 (h)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 750) completed on 12/7/18, the facility did not ensure that each resident receives adequate supervision to prevent accidents. One (Resident #1) of three residents reviewed for accidents, the resident care planned not be left alone on the toilet was not supervised which resulted in a fall while on the toilet. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS - a resident assessment tool) dated 7/5/18 documented the resident was severely cognitively impaired, understands others, is understood by others, and required extensive assist of two people for toileting and transferring. An undated facility policy and procedure entitled Resident Accident and Incident Reports documented that the facility will ensure that each resident receives adequate supervision and assistive devices to prevent accidents. An Interdisciplinary Rehabilitation Screen dated 7/6/18 documented that the resident transfers with a two assist and the standing lift (a mechanical lift used to transfer a patient between seated surfaces) due to a limitation in function and was non-ambulatory (did not walk or self-propel his wheelchair). The Mini Care Plan dated (MONTH) (YEAR) documented the resident was not to be left alone on the toilet. Review of a facility self-reported complaint intake via the New York State Department of Health Central Complaint Intake Program dated 7/12/18 documented that on 7/10/18 at 8:20 AM two CNAs (Certified Nurse Aide) got up Resident #1 by a standing lift to bring to the toilet and to be washed. Resident was positioned safely sitting. While the lift was being pulled out of the bathroom, resident leaned forward and fell on his face and down on the floor. CNA tried to catch him but he had fell . RN (Registered Nurse) assessment was performed, 911 called, and resident immediately transferred to the hospital. MD (medical doctor) and family notified. Resident was sent back to the facility the same day with [DIAGNOSES REDACTED]. During an interview on 11/29/18 at 1:52 PM, CNA #1 revealed that during the 7/10/18 incident the resident was seated on the toilet and CNA #2 left the bathroom to get a shirt to dress him. As CNA #1 pulled the standing lift out of the bathroom the resident started to lean forward while seated on the toilet. At that point the resident was by himself in the bathroom. CNA #1 tried to get around the lift to catch him but was not in time. During an interview on 11/29/18 at 3:56 PM, CNA #2 revealed that during the 7/10/18 incident she assisted CNA #1 with the transfer and knew Resident #1 was not to be left alone on the toilet. CNA #1 had the standing lift in her hands and the resident was seated completely on the toilet. CNA #2 expected CNA #1 to stay in the bathroom with the resident since she was in the bathroom with the lift. CNA #2 thought she heard the resident say, I'm falling and ran to bathroom. When she arrived from the resident's bed she saw CNA #1 standing outside of the bathroom with her back against the wall with the standing lift in front of her. CNA #2 stated that by the time she got to the bathroom the resident was already on the floor. During an interview on 11/30/18 at 7:18 AM, the Physical Therapist revealed that she did an evaluation on 7/12/18 after the fall and the resident remained a standing lift but that someone should be in the bathroom at all times. This meant the resident was not a contact guard (standing and holding a resident while they are on the toilet) but that the resident should be within reach at all times while in the bathroom. She stated that do not leave alone on the toilet on a Mini Care Plan meant that she expected the CNA to not leave the resident alone in the bathroom. During an interview on 11/30/18 at 8:58 AM, the Director of Therapy revealed that he expected a CNA not to leave a resident alone while on the toilet because there is a safety risk related to mental or physical issues. The intervention on the Mini Care Plan not to leave a resident on the toilet was from nursing and not a therapy intervention. During an interview on 11/30/18 at 9:04 AM, RN #1 revealed that she expects her staff to stay in the bathroom with a resident who is care-planned do not leave alone on the toilet. Resident #1 was weak at the time and was constantly leaning while on the toilet. CNA staff came to her about him in (MONTH) and she changed the Mini Care Plan. RN #1 stated that she should have notified therapy and documented the reason in the Nursing Progress Notes but did not. 415.12 (h)(1)

Based on interview and record review during a Standard Survey completed on 11/30/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct or complete a Legionella risk assessment of the facility to identify where Legionella and other opportunistic pathogens could grow and spread in the facility's potable water system and the facility did not have a water management plan in place for the facility to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building's potable water system. This affected the entire building including three (A, B, and C Wings) of three resident use wings and one (D Wing) of one non-resident use wing. The finding is: Review of the Centers for Medicare & Medicaid Services Survey and Certification Letter S & C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 revised 6/9/17 with an effective date of Immediately on 1/16/18 revealed: Healthcare Facilities must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. Healthcare Facilities must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. During an interview on 11/27/18 at 9:33 AM, the Administrator and Superintendent of Building and Grounds stated the facility had no documentation that a Legionella risk assessment had been conducted for the building's potable water system and the facility had no documentation a Legionella water management program was in place for the building's potable water supply. A Legionella risk assessment had not been conducted for the building's potable water system and a Legionella water management program was not in place for the building's potable water supply. Record review of the facility's Legionella Infection Surveillance, Investigation and Management policy dated 11/27/18 revealed the facility tests water systems for Legionella as per regulation, and follows the water management plan. 415.19(a)(1)

Based on interview and record review conducted during the Standard survey completed on 11/30/18, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized. Five (Residents #32, 70, 105, 111, 116) of 27 residents reviewed for medical records had issues involving the lack of written physician orders [REDACTED].#111), antianxiety medication (#32), chest x-rays, and laboratory tests (#70); lack of documentation of a physician discharge summary (#116); lack of a re-admission note and a physician progress notes [REDACTED].#105). The findings include but are not limited to: 1. Resident #111 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The order was to be discontinued on 6/19/17. There was no new order for the blood glucose fingersticks to be initiated. Medication Administration Records (MARs) dated (MONTH) (YEAR) to (MONTH) (YEAR) revealed that nursing staff obtained fingerstick glucose levels two times daily from (MONTH) (YEAR) to (MONTH) (YEAR), and four times a day from (MONTH) (YEAR) to (MONTH) (YEAR). An interview on 11/28/18 at 6:18 AM with Licensed Practical Nurse (LPN) #2 revealed that there should be a physician's orders [REDACTED]. Interview with a Registered Nurse (RN #2) on 11/29/18 at 8:13 AM revealed that Resident #111 should have an order for [REDACTED].>During an interview on 11/30/18 at 10:18 AM, the Director of Nursing (DON) stated that she expects staff to obtain orders for fingersticks. She also expects nursing staff to check for physician orders [REDACTED]., before they give a medication or another treatment. An undated facility policy and procedure (P&P) entitled Prescriber Medication Orders, Medication Administration Records, Treatment Administration Records, and Pre-Printed Physician order [REDACTED]. 2. Resident #32 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the chronological medical record revealed a Behavior Nursing Progress Note dated 11/25/18 documented the resident received a dose of [MEDICATION NAME] (anti-anxiety medication) for agitation prior to a shower. Physician order [REDACTED]. Review of the Controlled Substance E-Kit Administration Record dated 11/25/18 revealed the resident received the dose of [MEDICATION NAME] from the facility's emergency medication box. Interview with RN #1 on 11/29/18 at 7:05AM revealed that the RN's enter the order in the computer and then it is put on the MAR. LPN's should be checking to see if there is an order for [REDACTED].>Interview with the Physician on 11/29/18 at 7:20 AM revealed that he could not remember if there was a telephone order for [MEDICATION NAME] called in for Resident #32. During an interview on 11/29/18 at 7:35 AM, LPN #5 stated that she administered the medication ([MEDICATION NAME]) after the RN gave it to her, however she could not document the administration in the MAR because there was no order for it. The LPN documented the [MEDICATION NAME] in the Behavior Note because she couldn't document it in the MAR. The LPN did not remember why she didn't tell the RN about there not being an order. Interview with RN #4 on 11/29/18 at 10:36 AM revealed that she spoke with the resident's wife on 11/25/18 and the wife stated that he received [MEDICATION NAME] last week prior to his shower. RN #4 spoke with the Physician on 11/25/18 and obtained a verbal order for the [MEDICATION NAME]. The issue was that she did not enter the medication as a one-time order and she should have. She would expect the LPN to come and let her know that the order was not in the system. RN #4 could not recall why she did not update the Nursing Progress Notes. Interview with the DON on 11/30/18 at 10:18 AM revealed that she expects nursing staff to check orders prior to administrating medication. Review of a facility P&P entitled Prescriber Medication Orders, Medication Administration Records, Treatment Administration Records, and Preprinted Physician order [REDACTED]. 3. Resident #70 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was severely cognitively impaired, understands, was understood, and received antipsychotic medications on a routine basis. The resident exhibited verbal behaviors directed towards others and had no delusions or hallucinations. a.) Review of a Nursing Progress Note dated 9/7/18 revealed the resident was readmitted to the facility. Review of the entire electronic medical record and the medical chart (hard copy) which included but was not limited to Interdisciplinary Progress Notes, Evaluations, scanned documents, Consultations, Therapy Evaluations, and physician progress notes [REDACTED]. Continued review of the medical record on 11/29/18 revealed there was no documented evidence the resident was seen by any provider from the facility since her readmission on 9/7/18. During an interview on 11/29/18 at 10:38 AM, the Unit Clerk stated when residents are admitted or readmitted to the facility, the physician should see the resident every 30, 60 and 90 days unless the physician discharged the resident from the hospital. The Unit Clerk stated that she did not have any notes from the provider since the resident's readmission but would contact his office to see if they could send anything over. Review of the Hospital Discharge Summary dated 9/7/18 revealed Resident #70 was not discharged from the hospital by Physician #1. During an interview on 11/29/18 at 12:10 PM, the Director of Nursing (DON) stated she contacted the Physician, and his office was supposed to send over all his progress notes. She would expect the Physician's Progress Notes to be available and, in the resident's medical record. Review of a fax provided by the DON dated 11/30/18 at 10:06 AM revealed an attached physician progress notes [REDACTED]. During a telephone interview on 11/30/18 at 10:50 AM, the Physician stated he believed he saw the resident a few times since her readmission but would have to look further for his notes. During an interview on 11/30/18 at 12:07 PM, the DON stated they had not received any additional progress notes from the provider to account for his visits. Review of a document provided by the facility entitled A- Wing MD Progress Notes Needed revealed the following Physician Notes were still lacking. - 9/7/18 (Readmission), 10/7/18 (30 day) and 11/7/18 (60 day). b.) Review of Interdisciplinary Progress Notes dated 11/5/18 completed by Registered Nurse (RN #6) revealed orders were given by the Physician Assistant (PA) to obtain a UA/ C&S (urinalysis /culture and sensitivity), CBC (complete blood count), CMP (comprehensive metabolic profile, blood chemistries), chest x-ray and to start [MEDICATION NAME] (antibiotic). Review of the Clinical Physician order [REDACTED]. During an interview on 11/29/18 at 9:55 AM, Registered Nurse Unit Manager (RN #1) stated that orders should have been written (completed in the computer system) for the UA/ C&S, CBC, CMP and the chest x-ray that were received from the PA on 11/5/18. 4. Resident #105 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was severely cognitively impaired, was understood and understands. Review of a document entitled Pneumococcal Vaccine Consent for Resident Without Capacity dated 9/19/18 revealed the resident's responsible party declined to have the Pneumococcal vaccine administered and signed the declination. Review of Interdisciplinary Progress Notes dated 9/18/18 through 11/28/19 revealed there was no documented evidence that staff spoke to the primary responsible party and that consent was obtained to administer the Pneumococcal vaccine. Review of Clinical Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 11/29/18 at 11:10 AM, RN #4 Supervisor reviewed Resident #70's medical chart (hard copy) and electronic medical record and stated that the resident did not have a consent for the Pneumococcal vaccine to be administered. During an interview on 11/29/18 at 1:58 PM, RN #5 In-service Nurse stated he wrote the order but it's not jiving because he does not have a consent. The nurse administering the vaccination would not check for the consent because they would have trusted the individual who wrote the order. At 2:45 PM, RN #5 stated the consent had been missed placed. He contacted the responsible party and she recalled changing her mind and giving consent for the Pneumococcal vaccine to be given. Review of a written statement provided by the facility dated 11/29/18 revealed that RN #4 wrote that she recalled having a phone conversation on 10/4/18 with the resident's responsible party regarding the Pneumococcal vaccination; she provided her with education and the responsible party gave consent for it to be administered. 5. Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired, was understood and understands. Review of Discharge Instructions for Resident #116 revealed the resident was discharged from the facility on 9/5/18 to the community. Review of the entire electronic medical record and the medical chart (hard copy) which included but was not limited to Interdisciplinary Progress Notes, Evaluations, scanned documents, Consultations, Therapy Evaluations, and physician progress notes [REDACTED]. There was no documented Physician Discharge Summary available in the medical record. During an interview on 11/29/18 at 12:10 PM, the DON stated she contacted the Physician, and his office was supposed to be sending over all his notes. She would expect the physician's notes, including Discharge Summaries, to be available and in the resident's medical record. During an interview on 11/30/18 at 12:07 PM, the DON stated that they had not received any additional notes from the provider to account for his visits. 415.22(a)(1-3)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/30/18, the facility did not ensure that each resident's drug regime was free of unnecessary medications. Specifically, one (Resident #70) of five residents reviewed for unnecessary medications had issues involving the lack of adequate indications for the use of an antipsychotic medication ([MEDICATION NAME]). The finding is: An undated policy and procedure (P&P) entitled Behavior Problems/ Psychoactive Medication Assessments documented that residents will not be given routine psychoactive drugs unless a full assessment by appropriate professionals reveals the need to treat a specific condition. 1. Resident #70 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 10/6/18 documented the resident was severely cognitively impaired, understands and was understood. The MDS revealed the resident received antipsychotic medications on a routine basis. The resident had no delusions or hallucinations and exhibited verbal behaviors directed towards others. The undated, current comprehensive care plan documented identified problems including impaired cognitive function, impaired thought process related to Alzheimer's dementia, alteration in behavior status related to hollering out negative comments, and the use of the [MEDICAL CONDITION] medication [MEDICATION NAME] for behavior management. Interventions included plans to administer medications as ordered; monitor and document effectiveness and side effects; anticipate the resident's needs; divert the resident attention; intervene as necessary; assist the resident to develop more appropriate methods of coping and interacting; and present one thought, idea, question at a time. The Mini Care Plan (guide used by staff to provide care) dated 11/1/18 did not provide instructions or interventions to address the resident's behavior. A physician's Progress Note dated 10/26/18 the resident had a past medical history of [REDACTED]. She has a lot of anxiety [MEDICAL CONDITION]/worsening dementia. She gets very upset and starts screaming. We increased her benzo (Benzodiazepines - central nervous system depressants that are used to treat anxiety and variety of mood disorders) however this did not help. Review of interdisciplinary Progress Notes dated 11/1/18 through 11/22/18 revealed the resident had periods of yelling out for care needs and made negative statements about facility and staff. Clinical Physician order [REDACTED]. Review of a Progress Note dated 11/23/18 at 9:40 PM revealed the resident slept the whole shift and continued sleeping. The MD (medical doctor) was updated and an order was received to decrease the [MEDICATION NAME] to daily. Clinical Physician order [REDACTED]. Intermittent observations on 11/26/18 between the hours of 6:00 PM and 10:00 PM revealed the resident was sitting in a recliner chair in the hallway, listening to music. There were no observed negative behaviors and the resident was talking to staff in an appropriate manner. Progress Notes dated 11/26/18 documented the resident got out of bed at 10:00 AM, only accepted bites for breakfast, was lethargic after breakfast, and was difficult to keep awake. Klonopin (benzodiazepine - used to treat certain types of [MEDICAL CONDITION] and used to treat panic disorder) was held due to being unarousable and continued to sleep until 7:30 PM. The resident got up yelled a few times, took all her meds, went back to bed at 9:30 PM and stayed in. A Progress Note dated 11/27/18 at 9:50 PM documented the resident slept most of the shift, was aroused for about a half hour and fell back to sleep. Intermittent observations on 11/27/18 and 11/28/18 between the hours of 8:00 AM and 4:00 PM revealed the resident was in bed sleeping or in the hallway sitting in the recliner. There were no negative behaviors or yelling out. During intermittent observations on 11/29/18 and 11/30/18 between 8:00 AM and 4:30 PM, the resident was in bed sleeping. During an interview on 11/29/18 at 9:55 AM, the Registered Nurse (RN #1) Unit Manager stated the resident was started on [MEDICATION NAME] because of her yelling out and nothing seemed to help. However, when her family visits, she had no behaviors. The RN further stated the resident did not exhibit any paranoia, [MEDICAL CONDITION], hallucinations, delusions or physically aggressive behaviors During an interview on 11/29/18 at 11:49 AM, RN #6 stated the resident was not well and was sleeping a lot. The resident has dementia, yells out and was angry about being at the facility. RN #6 stated the resident was not a harm to herself or others and had no physical aggression, delusions, hallucinations or paranoia. During an interview on 11/29/18 at 11:54 AM, a Certified Nurse Aide (CNA #7) stated the resident sleeps all morning and does not want to get up. She stated the resident yells out at times but has never tried to hit anyone. During an interview on 11/29/18 at 11:56 AM, CNA #1 stated she was very familiar with the resident. The resident yells out and is directed towards staff. The resident never gets physical and she did not feel the resident was a danger to herself or others because she only yells. The resident does not yell out when the family visits. During an interview on 11/29/18 at 1:00 PM, a Licensed Practical Nurse (LPN #1) stated the resident was a demanding person and yells out a lot. The resident had mostly verbal behaviors directed toward staff and has not had any delusions, physical aggress, hallucinations or paranoia. She reported that the resident was sleeping a lot more and she believed changes had been made because she (the LPN) no longer gives the medication on her shift. During a telephone interview on 11/30/18 at 8:25 AM, the Pharmacy Consultant stated he was made aware that the resident was started on [MEDICATION NAME]. He stated that yelling out and making derogatory statements would not be an adequate indication for the use of an antipsychotic medication particularly without signs of [MEDICAL CONDITION] or physical aggression. During a telephone interview on 11/20/18 at 10:50 AM, Physician #1 stated that he prefers to use antipsychotic medications over benzos. He gets calls from the nurses that the resident yells and screams and he tries to make the best decisions based on what the nurses tell him. During an interview on 11/30/18 at 11:00 AM, the Director of Nursing (DON) stated the use of an antipsychotic medication needs to have an adequate justification and need to be documented, including what non-pharmacological approaches were used. The DON further stated that yelling out, in her opinion was not an adequate justification. 415.12(2)(i)(a-d)

Based on observation, interview, and record review conducted during the Standard survey completed 11/30/18, the facility did not ensure that residents were free from physical restraints for one (Resident #87) of one resident reviewed for physical restraints. Specifically, a thorough assessment and re-evaluation were not conducted to address the use of a self-release seatbelt while in the wheelchair that may restrict the resident's movement, and a physician's orders [REDACTED]. The finding is: The facility policy and procedure (P&P) entitled Physical Restraints, revised on 4/16, documented the policy of the facility is to assess and monitor the use of physical restraints as a medical necessity using an interdisciplinary (IDT) approach. The P&P instructed to assess the risks and the benefits for use of a physical restraint, and to monitor and assess the ongoing use of a physical restraint. The IDT team may consider the use of a restraint in situations to enhance the quality of life of a resident, emergent situations, and the Physical Therapist/ Occupational Therapist may consider a restraint for positioning. The assessment will be documented in the medical record and the IDT will assess the use of restraints at least quarterly. 1. Resident #87 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 10/18/18 documented the resident had severely impaired cognitive skills; required total assistance of two people for transfers, personal hygiene, toilet use, and was non- ambulatory. The resident had two or more falls with injury. The MDS revealed the resident used a bed alarm daily and there were no physical restraints used. The undated, current comprehensive care plan (CCP) with a print date of 11/29/18 documented the resident was at high risk for falls with interventions that included the use of a bed alarm, low bed and a positioning belt (self-release seatbelt) when seated in the care foam chair (specialty wheel chair) and to release the belt every two hours for 15 minutes. The Mini Care plan dated 10/31/18 documented safety devices included the use of a positioning belt on in chair with instructions to release every two hours and a bed alarm. Physician order [REDACTED]. There was no documented evidence a physician's orders [REDACTED]. Review of the entire electronic medical record and the medical chart (hard copy), including but not limited to Interdisciplinary Progress Notes, Evaluations, scanned documents, Consultations, Therapy Evaluations, and physician progress notes [REDACTED]. There was no documented medical symptom for the use of the belt and there were no on-going re-assessments for the continued use of the seatbelt. During intermittent observations on 11/26/18 between 6:30 PM and 9:00 PM, the resident was sitting in the hallway by the Nurses' Station in a specialty wheel chair utilizing a self-release seatbelt. The resident did at times have involuntary movements of the upper and lower extremities. Intermittent observations from 11/27/18 thorough 11/29/18, between the hours of 7:00 AM and 4:30 PM, revealed the resident was seated in the specialty wheelchair utilizing the self-release seat belt. The resident was observed to sit for short periods without involuntary movements. During meals, staff were seated directly at the resident's side. The observations revealed the belt was not released every two hours as planned. At times, the resident was observed to slouch down in the wheelchair and the belt would rise upward towards the resident's trunk and chest area. During an interview on 11/29/18 at 12:05 PM, the Director of Therapy stated in this resident's case the seatbelt would be considered a restraint because the resident was not able to self- release it. The facility ordered a special wheel chair for the resident back at the beginning of the year and the chair came with the seatbelt attached. Nursing should have completed an assessment regarding the use of the belt initially, quarterly and annually. The Director reviewed the electronic medical record and stated the only restraint assessment in the system was for the use of a bed alarm dated 2/7/18. During an interview on 11/29/18 at 12:22 PM, the Director of Nursing (DON) stated If the resident can't release the belt on command it's a restraint or we need to justify that it is for positioning. There should be a documented assessment and a plan for the use of the seatbelt. During an interview on 11/29/18 at 1:22 PM, the DON stated he did not have any documented justification for the use of the restraint. They have spoken to the family and they will do a trial reduction. During an interview on 11/30/18 at 7:59 AM, the Registered Nurse (RN #3) Unit Manager stated she did not do an assessment as she did not consider the seatbelt a restraint, because the resident did not always have control over her movements. The seatbelt should be released every two hours and the staff should be monitoring the seatbelt to ensure it is properly positioned. The use of the belt was not assessed by the team and there were no documented identified medical symptoms. 415.4(a)(2)(i-vi)(3-5)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 547) completed on 5/24/18, the facility did not consult with the resident's physician or notify the resident's family when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, one (Resident #1) of three residents reviewed for notification of change lacked timely physician and family notification of when the resident sustained [REDACTED]. The finding is: Review of the facility policy and procedure entitled Resident Accident and Incident Reports dated 4/18/18 revealed the report is to be completed electronically within the Electronic Medical Record (EMR) by the RN (Registered Nurse) Head Nurse or RN Supervisor. The RN must notify the attending physician (if appropriate) and must notify the Responsible Party of all injuries within 24 hours of occurrence. 1. Resident #1's most recent admitted to the facility was 9/3/15 and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/29/18 revealed the resident is moderately impaired for decision making and has short term memory problems. Review of the Minicare Plan dated (MONTH) (YEAR) and used by the certified nurse aides (CNA) to provide resident care revealed the resident was non-ambulatory, a mechanical lift for transfers, and dependent on staff for wheelchair mobility and utilized a calf board (device used for support/comfort) on the wheelchair. Review of an incident report dated 4/17/18 at 6:23 AM revealed a 3-centimeter (cm) x 3 cm light purple hematoma on left shin was observed in the morning. The resident stated, my foot fell off the pillow and they smashed it into the doorway coming back from the dining room after supper. Review of the documentation of Agency/ People Notified revealed the resident's responsible party was notified on 4/18/18 at 13:21 (1:21 PM). Review of the Progress notes from 4/17/18 through 4/19/18 revealed the following: - 4/17/18 at 6:37 AM, RN #2 documented that a 3 cm x 3 cm light purple hematoma (collection of blood under the skin) was noted on the left shin. The resident's pain level was documented as 5/10 (scale for determination of pain with 10 representing the highest level of pain). - 4/17/18 at 13:17 (1:17 PM), RN #3 documented the hematoma to the lower shin remained light purple in color and the surrounding skin was pink. There was no advanced swelling or deformities. - 4/18/18 at 3:15 AM, RN #5 documented the light purple hematoma continued to left-lower shin. There were no sign of [MEDICAL CONDITION] (swelling). Skin around it was pink and would continue to monitor. - 4/18/18 at 13:25 (1:25 PM), RN #4 documented the resident was alert and pleasant. The hematoma to the left shin was noted to remain, area was raised, and discoloration was not noted. Resident complained of pain when area was palpated (touched). The resident stated, I hit it in a doorway. The son was notified. The Licensed Practical Nurse (LPN) aware of resident's discomfort. The resident was up in the wheelchair in hallway at this time and they would continue to monitor. - 4/18/18 at 13:43 (1:43 PM), RN #4 documented the daughter reported the resident had a fracture of left ankle in (MONTH) of (YEAR). The physician was updated and ordered an x-ray of the ankle and lower leg. - 4/18/18 at 21:00 (9:00 PM), RN #6 documented the x-ray results impression was a spiral fracture to left tibia with soft tissue swelling. The physician and son were made aware of the report. The physician ordered a splint, ice, and to the leg elevated. The resident was medicated with Tylenol for pain. - 4/19/18 at 10:32 AM, the Interim DON documented the resident was sent to the hospital for further x-ray and proper splinting. Review of the Patient Report (x-ray results) dated 4/18/18 documented a spiral [MEDICAL CONDITION] tibia, and associated soft tissue swelling. Interview with CNA #1 on 5/21/18 at approximately 1:45 PM revealed she was transporting the resident back to the unit from the main dining room. She had to pass double doors to get to the unit. The right hand side of the door was closed, as she pushed the resident through the open left door the residents foot slipped off the foot board. CNA #1 stated she did not see the resident hit her foot but heard a sound, that sounded like something hitting the door. She stated she thought it was the residents right foot that hit the right door. However, when she reported the incident to LPN #1, the LPN asked her if the resident hit her affected side (the left side) and the aide answered yes without thinking about which side that was. She stated she did immediately report the incident to the LPN and that was the last she knew about it that evening. Interview with LPN #1 on 5/21/18 at 3:00 PM revealed CNA #1 reported the resident's affected side had hit the doorway on the way back from the dining room on 4/16/18. LPN #1 stated she assessed the left leg area and found no injury. She believed the CNA #1 was reporting the incident to the RN Supervisor (RN #1) because the two of them were working together in the Main Dining Room. The LPN stated the evening was very busy and she did not think about the incident again that evening because she thought the RN Supervisor was informed of the incident. Interview with RN #1 Evening Shift Supervisor on 5/22/18 at 2:00 PM revealed she did not know about the resident hitting her foot the evening of 4/16/18 and did not know about the resident's injury until after it had been investigated. Interview with RN #2 Night Shift Supervisor on 5/24/18 at 8:15 AM revealed she was told by the night staff that the resident had a bruise on her shin. RN #2 stated that she assessed the area and found a small bruise. She stated the resident reported that her leg was hit in the doorway. She stated she started the incident report and informed the next shift of the bruise. RN#2 stated she would call the family and physician if the incident was an emergency but otherwise, the next shift would make phone calls later in the day. Interview with RN #3 Day Supervisor on 5/21/18 at 2:00 PM revealed the incident report had been initiated on the night shift. She stated she was aware the resident had bumped her foot. The bruise was small and very light in color and it was possible it didn't rise to the level of calling the physician. The resident was not complaining of pain at that time. Interview with the Interim Director of Nurses (DON) on 5/21/18 at 2:55 PM revealed the resident's leg should have been assessed by the evening RN Supervisor (RN #1) and the incident report should have been started after the RN Supervisor (RN #1) assessed the resident's leg on 4/16/18. Interview with RN #4 Unit Manager on 5/22/18 at 10:45 AM revealed there should have been an incident report filled out by the RN Supervisor (RN #1) on 4/16/18 after the resident was assessed in case injuries appeared later. The family should have been notified on that day as well. The night shift RN #2 started the Accident and Incident Report and she could have called the family in the morning to inform them of the bruise. If staff had known the resident bumped her foot the physician should have been called in the AM. If staff did not know that the resident bumped her foot, the physician might be told if he came into the facility 415.3(e)(2)(ii)(b)(c)

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 249) completed on 2/23/18, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee effectively developed and implemented appropriate plans of action to correct identified quality deficiencies with the potential to cause serious harm to residents. Specifically, the facility QAA failed to implement a plan to prevent residents from elopement when the facility identified their door alarm system was not compatible with a newly installed VOIP (Voice Over Internet Protocol) telephone system. One (Resident #1) of six cognitively impaired residents identified at risk to wander and/or elope was able to exit the building through an exterior door. This had the potential to affect 13 residents identified as at risk for unsafe wandering, and seven residents identified at risk for elopement. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 2/23/18, prior to the completion of the Partial Extended survey The findings are: REFER TO: F 689 - Free of Accident Hazards/ Supervision/ Devices - scope/severity = K F 835 - Administration - scope/ severity = K 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/6/17 revealed the resident has severe cognitive impairment, understands, is understood, and has a history of falls. Review of an undated facility policy and procedure (P&P) entitled Elopement, Risk Prevention, and Management of Missing Residents revealed it is the policy of the facility to provide a safe and secure environment for all residents; identify elopement as when a resident successfully leaves the facility undetected, unsupervised, and enters into harm's way; and initiate procedures to prevent further elopement. The P&P documented that with each attempt to elope, an elopement of unusual wandering, or a resident statement regarding exiting, the Quality Improvement Team will assess, review and document the following: - The reasons for elopement/unsafe wandering (Root Cause Analysis) - The environmental factors pre/ post event - The assessment/ care planning pre/post for the resident(s) involved - The facility's policies and procedures for resident safety/ elopement enactment - The staff training needed and - The facility's overall recommendation/plan. The undated, unsigned Quality Assurance policy and procedure included the following: - Plan: Identification of concerns; Formulation of Quality Improvement Projects; Change in Process/ Activity with an Improvement in Quality Control or Quality of Life; Ongoing monitoring of changes three to six months. A Progress Note, written by the Registered Nurse (RN #1) evening shift Nurse Supervisor dated 9/10/17 at 9:18 PM documented Writer found resident's wheelchair inside at exit door and resident on hands and knees at 8:30 PM. Resident stated How am I supposed to get home now? I was looking for my car. Where did my purse go? Where am I now? The RN Supervisor documented that the resident was brought inside, toileted, changed into night clothes and assessed for injury. The daughter was notified and wanted to meet with the MD if possible. Hematoma (collection of blood under the skin) to right forehead remains. New injuries right knee bruise 4.0 x 2.0 cm (centimeter) purple in color. Left knee purple in color 3.0 x 2.5 cm. Resident performed ROM (range of motion - full movement potential of a joint) without pain or difficulty. Denies headache, nausea, dizziness. Denies pain or discomfort. No other apparent injuries noted at this time. Elopement band put on. Neuros (neuro checks - assessment to evaluate an individual's neurological function and level of consciousness) initiated. Will monitor. An undated, unsigned summary of events, provided by the Director of Nursing (DON) documented the following: - Resident #1 - Elopement 9/10/17 - Resident with anxiety and receiving PRN (as needed) [MEDICATION NAME] (antianxiety medication) and routine [MEDICATION NAME]. Resident had not expressed desire to go home and was not independently mobile therefore a wander bracelet (electronic wander management system) was not provided. - On the night of 9/10/17, Resident #1 was last observed near A wing (Aspen Lodge) Nurses' Station at 2000 (8:00 PM). The last CNA (Certified Nurse Aide) that spoke with Resident #1 had done so around (YEAR) (8:15 PM) at which time Resident #1 declined wanting to go to bed. Resident #1 opened the A-wing low side door at 2013 (8:13 PM) and exited the building. Resident #1 was found at 2030 (8:30 PM) by the RN supervisor on her hands and knees on the cement pad outside the door. Resident #1 was taken into her room and fully assessed by the RN Supervisor. Injuries noted at that time as well as next shift were bruising to both knees. There were no complaints of pain with ROM or palpation to pelvic area. Family was notified at 2130 (9:30 PM) about incident. - Upon opening the door, an alarm was triggered to the supervisors' computer which was accepted after Resident #1 was assessed. - Resident #1 was admitted to a local hospital on [DATE] with a fractured pelvis. The original X-ray stated a possible fracture and a CT scan (computerized axial tomography - specialized X-ray test that produces cross-sectional images of the body using X-rays and a computer) was performed to verify fracture. Physician's documentation stated that there was no pain with deep palpation of pelvic region. Resident #1 did sustain a fall while hospitalized . - Son and daughter have been updated on all findings. During an interview on 2/22/18 at 11:08 AM, the RN (#1) Nurse Supervisor stated while she was walking down the corridor on the low side of the Aspen Lodge Unit on 9/10/17, she saw something that didn't look right outside the doors at the end of the corridor and realized it was a person on the ground. The RN Nurse Supervisor stated We've had a problem with the doors not locking. It is well known that there was an issue with the doors. We used to have phones that we carried that would tell us when the doors opened. The receptionist has a computer that alerts for opened doors by displaying the location of the door. The Nursing Supervisor's office has a computer that also alerts for open doors. If the Receptionist is not here or no one is in the Supervisor's office, all the doors in the facility could be open and you would not know. There's a box (alarm annunciator panel - a system that displays the status of an alarm signal using light and sound features) down near the breakroom in the service corridor and one (box) outside the Supervisor's office that alarms when a door opens, but unless you're right near the box, you can't hear the alarm. The RN Nurse Supervisor stated she did not recall hearing the alarm on 9/10/17 when Resident #1 was found outside the building, she just happened to be walking down the hallway and saw the resident outside. During an interview on 2/22/18 at 3:08 PM, the Director of Nursing (DON) stated that in (MONTH) (YEAR) the facility switched to a VOIP telephone system. Prior to the switch, the Nursing Supervisors were carrying phones at all times and would be alerted via the phone if any resident with an Electronic Wander Management System bracelet was near an exit door. In addition, if anyone opened an exit door the supervisor would be alerted. The Electronic Wander Management System and the door alarms no longer communicate through the phones and are not compatible with the VOIP system. The DON stated that since the change to the VOIP telephone system, there is a computer at the front desk and a computer in the Nursing Supervisor's office that will alert when an exterior door is opened. There are also boxes located directly outside the Nursing Supervisor's office and in the service corridor that alarm when an exterior door is opened. During an interview on 2/22/18 at 5:53 PM, the DON stated that staff are only able to hear the alarm located outside the Nursing Supervisor's office when they are at the front of the nursing units but not at the farther ends of the halls. She stated this was identified while investigating the 9/10/17 elopement of Resident #1. She stated herself, the Administrator, and the Building and Grounds Supervisor had a discussion of the inability of staff to hear the alarm at the Nursing Supervisor's office when an exterior door is opened. She stated the facility is in the process of obtaining a new alert system that will interact with the VOIP telephone system. During an interview on 2/22/18 at 6:00 PM, the Administrator stated that since the facility switched to the VOIP system, the door alarm alert system has not been working properly. The facility identified the issue when investigating the elopement of Resident #1 in 9/2017. The Administrator, DON, and Building and Grounds Supervisor tested the door alarm box after Resident #1 had eloped and identified the alarm was audible but distant on the units, unable to hear at the ends of the hallways, probably unable to hear behind closed doors, and could not distinguish if the sound was actually the alarm at the Supervisor's office. The facility met with IT (Information Technology) and discussed options to establish a new alert system using VOIP. The facility was thinking the solution would be sooner. The original estimate was a couple of months but there has been a problem with the vendor being overbooked. The Administrator was unaware of any measures that were put into place when it was identified the door alarm alert system was not working properly. During an interview on 2/23/18 at 2:24 PM, the Administrator stated the incompatibility of the door alarm alert system with the VOIP telephones was discussed in QAA meetings. The facility determined the door alarm alert system was integrated into the old telephone system and did not work with the VOIP system. The Administrator did not think it was an urgent matter as there was a new door alarm alert system in the works that is compatible with the VOIP system. The Administrator stated he was told by the Building and Grounds Supervisor the facility was within regulation while awaiting the new system. Review of written documentation provided by the Administrator dated 2/23/18 at 2:20 PM revealed the facility implemented the following measures to remove the Immediate Jeopardy: - Local alarms were installed on each of the nursing units' exit doors which, when the door is opened and the contact is broken, will provide an auditory siren at 120 decibels. - Sixty-six percent of staff, including contracted service providers, received inservice training regarding the alarms and the proper response to assure residents are safe. Employees who are not scheduled or expected to be on duty over the next five days will be sent a letter detailing the changes in the facility's security procedures. Observation of the following exterior doors on 2/23/18 between 2:20 PM and 3:30 PM revealed local alarms were installed on the doors, the alarms were functioning, and the alarms were audible: - Aspen Lodge - low side - Aspen Lodge - high side - Aspen Lodge - alcove - Butterfly Lane - low side - Butterfly Lane - high side - Butterfly Lane - alcove - Cherry Blossom - low side - Cherry Blossom - high side - Cherry Blossom - alcove - Door located between Occupational Therapy and Main Dining Room The following employees were interviewed on 2/23/18 between 2:20 PM and 4:15 PM and verified that they had received inservice training regarding the alarms and proper response to assure residents are safe: - Aspen Lodge - one LPN, two CNA's - Butterfly Lane - one LPN, two CNA's - Cherry Blossom - one LPN, two CNA's - one housekeeper - one unit secretary - one RN Supervisor - one Occupational Therapist 415.27(c)(3)(v)

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 249) completed on 2/23/18, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure a safe environment for cognitively impaired residents who wander and/or are at risk for elopement. Specifically, the facility failed to ensure that the exterior door alarm system was audible to facility staff in all locations of the building, in the event a resident exited the building through exterior doors. One (Resident #1) of six cognitively impaired residents identified at risk to wander and/or elope was able to exit the building through an exterior door. This had the potential to affect thirteen residents identified as at risk for unsafe wandering and seven residents identified at risk for elopement. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 2/23/18, prior to the completion of the Partial Extended survey. The findings are: REFER TO: F 689 - Free of Accident Hazards/ Supervision/ Devices - scope/ severity = K F 867 - QAA Committee - scope/ severity = K 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/6/17 revealed the resident has severe cognitive impairment, understands, is understood, and has a history of falls. Review of the facility Nursing Home Administrator job description dated 11/20/08 revealed the following: - This is an administrative position involving responsibility for planning, organizing, directing, managing the operation, and implementing the policies of a nursing facility. This includes making operating decisions, providing general supervision, employing and discharging staff, programming, and where appropriate, integrating the services of the nursing home with the community's health resources. Work is performed in accordance with established policies with wide leeway permitted for the exercise of independent judgement. The work is carried out under the general direction of the Director of the Department of Nursing Homes (A county position held by the facility Administrator). A Nursing Home Administrator does related work as required. An undated facility Policy and Procedure entitled Elopement, Risk Prevention, and Management of Missing Residents documented the following: - It is the facility policy to provide a safe and secure environment for all residents; identify elopement as when a resident successfully leaves the facility undetected, unsupervised, and enters into harm's way; and initiate procedures to prevent further elopement. - With each attempt to elope, an elopement of unusual wandering, or a resident statement regarding exiting, the Quality Improvement Team will assess, review and document the following: the reasons for elopement/ unsafe wandering (Root Cause Analysis); the environmental factors pre/ post event; the assessment/ care planning pre/post for the resident(s) involved; the facility's policies and procedures for resident safety/ elopement enactment; the staff training needed; and the facility's overall recommendations/ plan. A Progress Note, written by the Registered Nurse (RN #1) evening shift Nurse Supervisor dated 9/10/17 at 9:18 PM documented Writer found resident's wheelchair inside at exit door and resident on hands and knees at 8:30 PM. Resident stated How am I supposed to get home now? I was looking for my car. Where did my purse go? Where am I now? The RN Supervisor documented that the resident was brought inside, toileted, changed into night clothes and assessed for injury. The daughter was notified and wanted to meet with the MD if possible. Hematoma (collection of blood under the skin) to right forehead remains. New injuries right knee bruise 4.0 x 2.0 cm (centimeter) purple in color. Left knee purple in color 3.0 x 2.5 cm. Resident performed ROM (range of motion - full movement potential of a joint) without pain or difficulty. Denies headache, nausea, dizziness. Denies pain or discomfort. No other apparent injuries noted at this time. Elopement band put on. Neuros (neuro checks - assessment to evaluate an individual's neurological function and level of consciousness) initiated. Will monitor. An undated, unsigned summary of events, provided by the Director of Nursing (DON), documented the following: - Resident #1 - Elopement 9/10/17 - Resident with anxiety and receiving PRN (as needed) [MEDICATION NAME] (antianxiety medication) and routine [MEDICATION NAME]. Resident had not expressed desire to go home and was not independently mobile therefore a wander bracelet (electronic wander management system) was not provided. - On the night of 9/10/17, Resident #1 was last observed near the A wing (Aspen Lodge) Nurses' Station at 2000 (8:00 PM). The last CNA (Certified Nurse Aide) that spoke with Resident #1 had done so around (YEAR) (8:15 PM) at which time Resident #1 declined wanting to go to bed. Resident #1 opened the A-wing low side door at 2013 (8:13 PM) and exited the building. Resident #1 was found at 2030 (8:30 PM), by the RN Supervisor, on her hands and knees on the cement pad outside the door. Resident #1 was then taken into her room and fully assessed by the RN Supervisor. Injuries noted at that time as well as next shift were bruising to both knees. There were no complaints of pain with ROM or palpation to the pelvic area. Family was notified at 2130 (9:30 PM) about incident. - Upon opening the door, an alarm was triggered to the Supervisor's computer which was accepted after Resident #1 was assessed. - Resident #1 was admitted to a local hospital on [DATE] with a fractured pelvis. The original X-ray stated a possible fracture and a CT scan (computerized axial tomography - specialized X-ray test that produces cross-sectional images of the body using X-rays and a computer) was performed to verify fracture. Physician's documentation stated that there was no pain with deep palpation of the pelvic region. Resident #1 did sustain a fall while hospitalized . - Son and daughter have been updated on all findings. During an interview on 2/22/18 at 11:08 AM, the RN (#1) Nurse Supervisor stated while she was walking down the corridor on the low side of the Aspen Lodge Unit on 9/10/17 at 9:18 PM, she saw something that didn't look right outside the doors at the end of the corridor and realized it was a person on the ground. The RN Nurse Supervisor stated We've had a problem with the doors not locking. It is well known that there was an issue with the doors. We used to have phones that we carried that would tell us when the doors opened. The receptionist has a computer that alerts for opened doors by displaying the location of the door. The Nursing Supervisor's office has a computer that also alerts for open doors. If the Receptionist is not here or no one is in the Supervisor's office, all the doors in the facility could be open and you would not know. There's a box (alarm annunciator panel - a system that displays the status of an alarm signal using light and sound features) down near the breakroom in the service corridor and one (box) outside the Supervisor's office that alarms when a door opens, but unless you're right near the box, you can't hear the alarm. The RN Nurse Supervisor stated she did not recall hearing the alarm on 9/10/17 when Resident #1 was found outside the building, she just happened to be walking down the hallway and saw the resident outside. During an interview on 2/22/18 at 3:08 PM, the Director of Nursing (DON) stated that in (MONTH) (YEAR) the facility switched to a VOIP (Voice Over Internet Protocol) telephone system. Prior to the switch, the Nursing Supervisors were carrying phones at all times and would be alerted via the phone if any resident with an Electronic Wander Management System bracelet was near an exit door. In addition, if anyone opened an exit door the Supervisor would be alerted. The Electronic Wander Management System and the door alarms no longer communicate through the phones and are not compatible with the VOIP system. The DON stated that since the change to the VOIP telephone system, there is a computer at the front desk and a computer in the Nursing Supervisor's office that will alert when an exterior door is opened. There are also boxes located directly outside the Nursing Supervisor's office and in the service corridor that alarm when an exterior door is opened. During an interview on 2/22/18 at 5:53 PM, the DON stated that staff are only able to hear the alarm located outside the Nursing Supervisor's office when they are at the front of the nursing units but not at the farther ends of the halls. She stated this was identified while investigating the 9/10/17 elopement of Resident #1. She stated herself, the Administrator, and the Building and Grounds Supervisor had a discussion of the inability of staff to hear the alarm at the Nursing Supervisor's office when an exterior door is opened. She stated the facility is in the process of obtaining a new alert system that will interact with the VOIP telephone system. During an interview on 2/22/18 at 6:00 PM, the Administrator stated that since the facility switched to the VOIP system, the door alarm alert system has not been working properly. The facility identified the issue when investigating the elopement of Resident #1 in 9/2017. The Administrator, DON, and Building and Grounds Supervisor tested the door alarm box after Resident #1 had eloped and identified the alarm was audible but distant on the units, unable to hear at the ends of the hallways, probably unable to hear behind closed doors, and could not distinguish if the sound was actually the alarm at the supervisor's office. The facility met with IT (Information Technology) and discussed options to establish a new alert system using VOIP. The facility was thinking the solution would be sooner. The original estimate was a couple of months but there has been a problem with the vendor being overbooked. The Administrator was unaware of any measures that were put into place when it was identified the door alarm alert system was not working properly. During an interview on 2/23/18 at 2:24 PM, the Administrator stated he did not think the incompatibility of door alarm alert system with the new VOIP system was an urgent matter due to there was a new system in the works. Review of written documentation provided by the Administrator dated 2/23/18 at 2:20 PM revealed the facility implemented the following measures to remove the Immediate Jeopardy: - Local alarms were installed on each of the nursing units' exit doors which, when the door is opened and the contact is broken, will provide an auditory siren at 120 decibels. - Sixty-six percent of staff, including contracted service providers, received inservice training regarding the alarms and the proper response to assure residents are safe. Employees who are not scheduled or expected to be on duty over the next five days will be sent a letter detailing the changes in the facility's security procedures. Observation of the following exterior doors on 2/23/18 between 2:20 PM and 3:30 PM revealed local alarms were installed on the doors, the alarms were functioning, and the alarms were audible: - Aspen Lodge - low side - Aspen Lodge - high side - Aspen Lodge - alcove - Butterfly Lane - low side - Butterfly Lane - high side - Butterfly Lane - alcove - Cherry Blossom - low side - Cherry Blossom - high side - Cherry Blossom - alcove - Door located between Occupational Therapy and Main Dining Room The following employees that were interviewed on 2/23/18 between 2:20 PM and 4:15 PM had received inservice training regarding the alarms and proper response to assure residents are safe: - Aspen Lodge - one LPN, two CNA's - Butterfly Lane - one LPN, two CNA's - Cherry Blossom - one LPN, two CNA's - one housekeeper - one unit secretary - one RN Supervisor - one Occupational Therapist 415.26

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 249) completed on 2/23/18, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. The facility failed to ensure that the exterior alarm system was audible to facility staff in all locations of the building, in the event a resident exited the building through the exterior doors. One (Resident #1) of six cognitively impaired residents identified at risk to wander and/or elope was able to exit the building through an exterior door. This had the potential to affect 13 residents identified as at risk for unsafe wandering and seven residents identified at risk for elopement. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 2/23/18, prior to the completion of the survey. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/6/17 revealed the resident has severe cognitive impairment, understands, is understood, and has a history of falls. Review of an undated facility policy and procedure (P&P) entitled Elopement, Risk Prevention, and Management of Missing Residents revealed it is the policy of the facility to provide a safe and secure environment for all residents; identify elopement as when a resident successfully leaves the facility undetected, unsupervised, and enters into harm's way; and initiate procedures to prevent further elopement. The P&P documented that with each attempt to elope, an elopement of unusual wandering, or a resident statement regarding exiting, the Quality Improvement Team will assess, review and document the following: - The reasons for elopement/unsafe wandering (Root Cause Analysis) - The environmental factors pre/ post event - The assessment/ care planning pre/post for the resident(s) involved - The facility's policies and procedures for resident safety/ elopement enactment - The staff training needed and - The facility's overall recommendation/plan. Review of a Morse Fall Scale (a tool used to assess a resident's likelihood of falling) completed for Resident #1 dated 8/29/17 revealed a score of 80.0 indicating the resident was at High Risk for Falling. A Wandering Risk Scale (a tool used to assess a resident's likelihood of wandering), completed for Resident #1, dated 8/29/17 documented a score of 9.0 indicating the resident was identified At Risk to Wander. Review of the Careplan (used by staff to provide care) dated (MONTH) (YEAR) revealed the section for Locomotion documented a plan to provide one assist with a gait belt (transfer belt) and a rolling walker for (distances) up to 100 feet and one assist with a gait belt and rolling walker for Transferring. A Progress Note, written by the Registered Nurse (RN #1) evening shift Nurse Supervisor dated 9/10/17 at 9:18 PM documented Writer found resident's wheelchair inside at exit door and resident on hands and knees at 8:30 PM. Resident stated How am I supposed to get home now? I was looking for my car. Where did my purse go? Where am I now? The RN Supervisor documented that the resident was brought inside, toileted, changed into night clothes and assessed for injury. The daughter was notified and wanted to meet with the MD if possible. Hematoma (collection of blood under the skin) to right forehead remains. New injuries right knee bruise 4.0 x 2.0 cm (centimeter) purple in color. Left knee purple in color 3.0 x 2.5 cm. Resident performed ROM (range of motion - full movement potential of a joint) without pain or difficulty. Denies headache, nausea, dizziness. Denies pain or discomfort. No other apparent injuries noted at this time. Elopement band put on. Neuros (neuro checks - assessment to evaluate an individual's neurological function and level of consciousness) initiated. Will monitor. An undated, unsigned summary of events, provided by the Director of Nursing (DON), documented the following: - Resident #1 - Elopement 9/10/17 - Resident with anxiety and receiving PRN (as needed) [MEDICATION NAME] (antianxiety medication) and routine [MEDICATION NAME]. Resident had not expressed desire to go home and was not independently mobile therefore a wander bracelet (electronic wander management system) was not provided. - On the night of 9/10/17, Resident #1 was last observed near the A wing (Aspen Lodge) Nurses' Station at 2000 (8:00 PM). The last CNA (Certified Nurse Aide) that spoke with Resident #1 had done so around (YEAR) (8:15 PM) at which time Resident #1 declined wanting to go to bed. Resident #1 opened the A-wing low side door at 2013 (8:13 PM) and exited the building. Resident #1 was found at 2030 (8:30 PM), by the RN Supervisor, on her hands and knees on the cement pad outside the door. Resident #1 was then taken into her room and fully assessed by the RN Supervisor. Injuries noted at that time as well as next shift were bruising to both knees. There were no complaints of pain with ROM or palpation to the pelvic area. Family was notified at 2130 (9:30 PM) about incident. - Upon opening the door, an alarm was triggered to the Supervisor's computer which was accepted after Resident #1 was assessed. - Resident #1 was admitted to a local hospital on [DATE] with a fractured pelvis. The original X-ray stated a possible fracture and a CT scan (computerized axial tomography - specialized X-ray test that produces cross-sectional images of the body using X-rays and a computer) was performed to verify fracture. Physician's documentation stated that there was no pain with deep palpation of the pelvic region. Resident #1 did sustain a fall while hospitalized . - Son and daughter have been updated on all findings. During an interview on 2/22/18 at 11:08 AM, the RN (#1) Nurse Supervisor stated while she was walking down the corridor on the low side of the Aspen Lodge Unit on 9/10/17 at 9:18 PM, she saw something that didn't look right outside the doors at the end of the corridor and realized it was a person on the ground. The RN Nurse Supervisor stated We've had a problem with the doors not locking. It is well known that there was an issue with the doors. We used to have phones that we carried that would tell us when the doors opened. The receptionist has a computer that alerts for opened doors by displaying the location of the door. The Nursing Supervisor's office has a computer that also alerts for open doors. If the Receptionist is not here or no one is in the Supervisor's office, all the doors in the facility could be open and you would not know. There's a box (alarm annunciator panel - a system that displays the status of an alarm signal using light and sound features) down near the breakroom in the service corridor and one (box) outside the Supervisor's office that alarms when a door opens, but unless you're right near the box, you can't hear the alarm. The RN Nurse Supervisor stated she did not recall hearing the alarm on 9/10/17 when Resident #1 was found outside the building, she just happened to be walking down the hallway and saw the resident outside. Observations of the exterior doors on the Aspen Lodge Unit with the Maintenance Shop Mechanic on 2/22/18 revealed the Mechanic opened the doors and no audible alarm sounded: - 11:46 AM - Aspen Lodge - low side - 1:53 PM - Aspen Lodge - high side During an interview on 2/22/18 at 12:11 PM, the Receptionist stated that the Front Desk is staffed Monday through Friday from 8:30 AM to 6:30 PM and on Saturday and Sunday from 10:30 AM to 5:30 PM. During an interview on 2/22/18 at 1:15 PM, RN #3 the day shift Nurse Supervisor stated that if she is on a unit, she would have to depend on staff in the area of the Nursing Supervisor's office to hear the door alarm box and notify her because she is unable to hear the door alarm box when on the nursing units. During an interview on 2/22/18 at 3:08 PM, the Director of Nursing (DON) stated that in (MONTH) (YEAR) the facility switched to a VOIP (Voice Over Internet Protocol) telephone system. Prior to the switch, the Nursing Supervisors were carrying phones at all times and would be alerted via the phone if any resident with an electronic wander management system bracelet was near an exit door. In addition, if anyone opened an exit door the supervisor would be alerted. The electronic wander management system and the door alarms no longer communicate through the phones and are not compatible with the VOIP system. The DON stated that since the change to the VOIP telephone system, there is a computer at the front desk and a computer in the Nursing Supervisor's office that will alert when an exterior door is opened. There are also boxes located directly outside the Nursing Supervisor's office and in the service corridor that alarm when an exterior door is opened. During an interview on 2/22/18 at 3:39 PM, RN #2 a per diem evening/ night shift Nurse Supervisor stated there is an alarm box located outside the Nursing Supervisor's office that beeps when an exterior door is opened. She also stated that when on the nursing units, she is unable to hear the alarm. During an interview on 2/22/18 at 3:59 PM, an evening shift Certified Nurse Aide (CNA #5) stated she cannot hear the alarm from the Nursing Supervisor's office when she is on the unit, and if she is in a room you cannot hear much with the door closed. Interview with the DON on 2/22/18 at approximately 4:15 PM revealed 119 residents currently reside in the facility and 13 residents were identified at risk for wandering and seven residents were at risk for elopement Interviews on 2/22/18 with four evening shift CNAs (#6, 7, 8, and 9) between 4:52 PM and 5:15 PM revealed none of the CNAs were able to hear the alarm box located outside the Nursing Supervisor's office when they are on the units. Interviews with two evening shift Licensed Practical Nurses (LPNs #4 and 5) on 2/22/18 between 4:47 PM and 5:00 PM revealed the LPNs were unable to hear the alarm box located outside the Nursing Supervisor's office when they are on the units. During an interview on 2/22/18 at 5:53 PM, the DON stated that staff are only able to hear the alarm located outside the Nursing Supervisor's office when they are at the front of the nursing units but not at the farther ends of the halls. She stated this was identified while investigating the 9/10/17 elopement of Resident #1. She stated herself, the Administrator, and the Building and Grounds Supervisor had a discussion of the inability of staff to hear the alarm at the Nursing Supervisor's office when an exterior door is opened. She stated the facility is in the process of obtaining a new alert system that will interact with the VOIP telephone system. During an interview on 2/22/18 at 6:00 PM, the Administrator stated that since the facility switched to the VOIP system, the door alarm alert system has not been working properly. The facility identified the issue when investigating the elopement of Resident #1 in 9/2017. The Administrator, DON, and Building and Grounds Supervisor tested the door alarm box after Resident #1 had eloped and identified the alarm was audible but distant on the units, unable to hear at the ends of the hallways, probably unable to hear behind closed doors, and could not distinguish if the sound was actually the alarm at the supervisor's office. The facility met with IT (Information Technology) and discussed options to establish a new alert system using VOIP. The facility was thinking the solution would be sooner. The original estimate was a couple of months but there has been a problem with the vendor being overbooked. Observation of the exterior doors on the Butterfly and Cherry Blossom Units with the Administrator and the DON on 2/22/18 at approximately 6:15 PM revealed the Administrator opened the high side door on each of the units and no audible alarm was heard. Review of written documentation provided by the Administrator dated 2/23/18 at 2:20 PM revealed the facility implemented the following measures to remove the Immediate Jeopardy: - Local alarms were installed on each of the nursing units' exit doors which, when the door is opened and the contact is broken, will provide an auditory siren at 120 decibels. - Sixty-six percent of staff, including contracted service providers, received inservice training regarding the alarms and the proper response to assure residents are safe. Employees who are not scheduled or expected to be on duty over the next five days will be sent a letter detailing the changes in the facility's security procedures. Observation of the following exterior doors on 2/23/18 between 2:20 PM and 3:30 PM revealed local alarms were installed on the doors, the alarms were functioning, and the alarms were audible: - Aspen Lodge - low side - Aspen Lodge - high side - Aspen Lodge - alcove - Butterfly Lane - low side - Butterfly Lane - high side - Butterfly Lane - alcove - Cherry Blossom - low side - Cherry Blossom - high side - Cherry Blossom - alcove - Door located between Occupational Therapy and Main Dining Room The following employees were interviewed on 2/23/18 between 2:20 PM and 4:15 PM and verified that they received inservice training regarding the alarms and proper response to assure residents are safe: - Aspen Lodge - one LPN, two CNA's - Butterfly Lane - one LPN, two CNA's - Cherry Blossom - one LPN, two CNA's - one housekeeper - one unit secretary - one RN Supervisor - one Occupational Therapist 415.12(h)(1)(2)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 3/27/15. Based on interview and record review conducted during the standard Survey completed on 5/27/16, the facility did not inform the resident's Physician of a change in the resident's physical condition following a fall that resulted in a head injury. One (Resident #93) of three residents reviewed for notification of change had issues with a delay of Physician notification regarding a resident on [MEDICATION NAME] (anticoagulant medication used to prevent blood from clotting) that fell on [DATE] and complained of daily headaches for five days following the fall. The Physican was notified of the headaches on 5/24/16 and the resident was hospitalized with an extra-axil subdural hematoma (bleeding that occurs within the skull but outside of the brain tissue) and emergently received [MEDICATION NAME] reversal. The finding is: 1. Resident #93 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/28/16 revealed the resident is moderately impaired for decision making. Interview with the Registered Nurse (RN) Head Nurse (HN) on 5/23/16 at 11:15 AM revealed the resident had a fall last week. She was found on the floor in her room and sustained a laceration of her right forehead. It was V shaped that did not require sutures. Review of an Accident/ Incident Report dated 5/19/16 revealed the resident was found on the floor following a fall. The resident sustained [REDACTED]. Ecchymotic (purplish patch caused by blood under the skin) area noted left zygomatic bone (cheekbone) 2 cm x 3 cm. Additionally, a red line over the left eyebrow 2 cm x 0.5 cm. The area was cleansed with Normal Saline, TAO (triple antibiotic ointment), Band-Aid and ice applied, on 20 minutes off 20 minutes. The resident is on [MEDICATION NAME] 4 milligrams (mg). INR (international normalizing ration-standardized normalized blood coagulating values) on 5/19/16 was 2.16 (normal range 0.9-1.1). Physician and family notified. Twenty-four hour follow up by the Nursing Supervisor revealed on the day shift no c/o (complaints) of pain and no headaches. The evening shift no c/o of pain, no headaches. The night shift follow up revealed neuro checks normal. APAP (Tylenol-pain medication) given for c/o headaches with positive effect. Review of a physician's orders [REDACTED]. Review of the Nursing 24-Hour Report dated 5/19/16 revealed the resident was found on floor on the afternoon shift, neuro (neurological) checks WNL (within normal limits). The evening shift; resident was medicated with Tylenol for c/o headaches with increased confusion. Question UTI (urinary tract infection). Review of the Nursing 24-Hour Report dated 5/20/16 revealed the resident was demanding [MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) on the day shift. Demanding [MEDICATION NAME] on afternoon shift before it is due and on the evening shift neuro checks WNL. On 5/21/16 on the morning shift [MEDICATION NAME] given x 1 and Tylenol given x 1. Afternoon shift neuro checks WNL and evenings yelling at staff using foul language, slamming doors, and very agitated. Review of May 2016 Progress Notes revealed the following: -5/20 c/o head hurting in that area. Requesting and receiving [MEDICATION NAME] x 2 today. Very demanding and forgetful that the [MEDICATION NAME] order is for every 6 hours. -5/20 Physician notified of increased confusion and (urinary)frequency, urinalysis (urine test) ordered. -5/20 demanding [MEDICATION NAME] before it's due. Better after received. -5/21 some confusion, c/o headache. [MEDICATION NAME] given at 11:30 AM, Tylenol 650 mg given. -5/22 Tylenol given for c/o headache. -5/23 c/o headache, Tylenol given with effect. [MEDICATION NAME] given for c/o headache. -5/24 Physician notified of c/o constant headaches. Resident had a fall on 5/19/16, new order for CT (computerized axial tomography). Interview with the resident on 5/24/16 at 9:55 AM revealed she had experienced head pain after the fall that was not resolved with medication. The resident stated, I fell and hit my head a few days ago, there was blood everywhere, and now I have awful headaches. The resident stated the nurses do give her something for the headaches but she has to wait so many hours in between and the headaches are getting worse. Review of a Hospital Transfer Form dated 5/24/16 revealed the resident fell on [DATE] and has increased headaches and confusion. Medical Doctor (MD) wants resident sent to the emergency room for a CT scan of the head. Interview with the RN Director of Nursing (DON) on 5/25/16 at 11:50 AM revealed staff should monitor the resident's status for three days after a fall. During an interview on 5/25/16 at 12:35 PM, the RN HN stated, I wasn't aware the resident was c/o headache pain. She seemed like her usual self. Neuro checks had been fine. During an interview on 5/25/16 at 12:45 PM, the Physician stated that staff did notify him of the fall. He did not recall if the resident was on [MEDICATION NAME] and stated he would have wanted to be notified of the daily headaches she was having. The Physician stated he did order the CT scan when they called on 5/24/16 but he had not heard anything on the results yet. Review of the hospital History and Physical dated 5/25/16 revealed the resident had an extra-axil subdural hematoma in the right parietal and inferior right temporal region, 6 millimeters. INR 2.56 on 5/24/16. The patient emergently received [MEDICATION NAME] reversal. She will be transferred for a higher level of care and require a neurologic evaluation. Review of the MDS Entry Tracking Record revealed the resident was re-admitted to the facility on [DATE]. Interview on 5/27/16 at 8:45 AM, the RN HN stated, I would've expected the LPNs (Licensed Practical Nurse) to notify me of the constant daily headaches. I would've thought outside the box so to speak, as her neuro checks were ok. 415.3(e)(2)(ii)(b)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 3/27/15. Based on interview, and record review conducted during the Standard survey completed on 5/27/16, the facility did not ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #93) of three residents reviewed for quality of care had issues involving the lack of addressing a resident's complaints of daily headaches for five days following a fall with a head injury on 5/19/16 while on [MEDICATION NAME] (anticoagulant medication used to prevent blood from clotting) therapy. The resident was hospitalized with an extra-axil subdural hematoma (bleeding that occurs within the skull but outside of the brain tissue) and emergently received [MEDICATION NAME] reversal. (Resident #93) This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #93 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/28/16 revealed the resident is moderately impaired for decision making. Interview with the Registered Nurse (RN) Head Nurse (HN) on 5/23/16 at 11:15 AM revealed the resident had a fall last week. She was found on the floor in her room and sustained a laceration of her right forehead. It was V shaped and did not require sutures. Review of the Nursing 24-Hour Report dated 5/19/16 revealed the resident was found on floor on the afternoon shift, neuro (neurological) checks WNL (within normal limits). The evening shift; resident was medicated with Tylenol (pain medication) for c/o (complaints of) headaches with increased confusion. Question UTI (urinary tract infection). Review of a physician's orders [REDACTED]. Review of the Nursing 24-Hour Report dated 5/20/16 revealed the resident was demanding [MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) on the day shift. Demanding [MEDICATION NAME] on afternoon shift before it is due and on the evening shift neuro checks WNL. On 5/21/16 on the morning shift [MEDICATION NAME] given x 1 and Tylenol given x 1. Afternoon shift neuro checks WNL and evenings yelling at staff using foul language, slamming doors, and very agitated. Review of a physician's orders [REDACTED]. Tylenol (pain medication) 325 mg take two tablets (650 mg) every four hours PRN for pain. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] was given on 5/20/16, 5/21/16, and 5/23/16 for headaches. Review of May 2016 Progress Notes revealed the following: -5/20 c/o head hurting in that area. Requesting and receiving [MEDICATION NAME] x 2 today. Very demanding and forgetful that the [MEDICATION NAME] order is for every 6 hours. -5/20 Physician notified of increased confusion and (urinary)frequency, urinalysis (urine test) ordered. -5/20 demanding [MEDICATION NAME] before it's due. Better after received. -5/21 some confusion, c/o headache. [MEDICATION NAME] given at 11:30 AM, Tylenol 650 mg given. -5/22 Tylenol given for c/o headache. -5/23 c/o headache, Tylenol given with effect. [MEDICATION NAME] given for c/o headache. -5/24 Physician notified of c/o constant headaches. Resident had a fall on 5/19/16, new order for CT (computerized axial tomography). Interview with the resident on 5/24/16 at 9:55 AM revealed she had experienced head pain after the fall that was not resolved with medication. The resident stated, I fell and hit my head a few days ago, there was blood everywhere, and now I have awful headaches. The resident stated the nurses do give her something for the headaches but she has to wait so many hours in between and the headaches are getting worse. Review of a Hospital Transfer Form dated 5/24/16 revealed the resident fell on [DATE] and has increased headaches and confusion. Medical Doctor (MD) wants resident sent to the emergency room for a CT scan of the head. Interview with the Registered Nurse (RN) Director of Nursing (DON) on 5/25/16 at 11:50 AM revealed staff should monitor the resident's status for three days after a fall. During an interview on 5/25/16 at 12:35 PM, the RN HN stated, I wasn't aware the resident was c/o headache pain. She seemed like her usual self. Neuro checks had been fine. During an interview on 5/25/16 at 12:45 PM, the Physician stated that staff did notify him of the fall. He did not recall if the resident was on [MEDICATION NAME] and stated he would have wanted to be notified of the daily headaches she was having. The Physician stated he did order the CT scan when they called on 5/24/16 but he had not heard anything on the results yet. Review of the hospital History and Physical dated 5/25/16 revealed the resident had an extra-axil subdural hematoma in the right parietal and inferior right temporal region, 6 millimeters. INR (international normalizing ration-standardized normalized blood coagulating values) on 5/24/16 was 2.56 (normal range 0.9-1.1). The patient emergently received [MEDICATION NAME] reversal. She will be transferred for a higher level of care and require a neurologic evaluation. Review of a MDS Entry Tracking Record revealed the resident was re-admitted to the facility on [DATE]. Interview on 5/27/16 at 8:45 AM, the RN HN stated, I would've expected the LPNs (Licensed Practical Nurse) to notify me of the constant daily headaches. I would've thought outside the box so to speak, as her neuro checks were ok. 415.12

Based on interview and record review conducted during the Standard survey completed on [DATE], the facility did not consult with the resident's Physician when there is a significant change in the resident's physical, mental or psychosocial status or a need to alter the resident's treatment significantly due to adverse consequences. One (Resident #101) of one resident reviewed for a significant change in physical condition had a lack of communication between nursing staff that resulted in a failure to notify the Physician of a nosebleed on [DATE] for the resident recieving aspirin (anticoagulant medication used to prevent blood clotting), and had a lowered blood pressure from the resident's baseline for two shifts and blood in the stool on [DATE] that occurred prior to the resident's death on [DATE]. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #101 was admitted to the facility on [DATE] with a readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Psychosocial History Assessment and Social Work (SW) note dated [DATE] revealed the resident's mood is anxious and the resident is alert with periods of confusion. Review of the initial Care Plan dated [DATE] revealed the resident is non ambulatory and requires a mechanical lift to transfer. Review of the SW notes dated [DATE] revealed the resident is confused and unable to understand information given. Review of a nursing Progress Note dated [DATE] at 6:30 AM revealed the resident had a nosebleed from the L (left) nares (nostril). Oxygen was applied after the bleeding stopped. Further review revealed no documentation that a pulse oximetry (pulse ox-90 to 100% (percent) -oxygen saturation level-amount of oxygen in blood) was obtained. Review of the 24-hour Report Sheet dated [DATE] revealed the night shift reported the resident was awake and yelling out often. The resident had a nosebleed from the L nares that the nursing staff was able to stop. Review of the Medication Administration Record [REDACTED]. Additional review revealed the resident's BP is to be checked every shift for two weeks then weekly thereafter. Review of the MAR indicated [REDACTED]. Resident's baseline was ,[DATE]. Both shifts documented no further nosebleed. Review of a nursing Progress Note dated [DATE] revealed the 7:00 AM-3:00 PM shift documented the resident's "VSS" (vital signs stable). Review of a nursing Progress Note dated [DATE] at 10:50 PM revealed a late entry was added that documented the CNA (certified nursing assistant) reported dark "brick colored blood" on the resident's stool with dark red blood in the toilet. Staff will continue to monitor. Review of the entire 24-hour Report Sheet dated [DATE] for the 7:00 AM-3:00 PM shift revealed the resident's VSS and the resident asking for help from her daughter all day. Review of the entire 24-hour Report Sheet dated [DATE] for the 3:00 PM-11:00 PM shift revealed the resident's BP was ,[DATE], the resident was calling out all shift and received antianxiety and pain medications. Review of the back page of the report sheet revealed an entry was written documenting the CNA reported dark brick colored blood in stool and dark red blood in the toilet. There is no documentation on the 24-hour Report Sheet that the Physician was notified. Review of the 24-hour Report Sheet dated [DATE] for the 11:00 PM-7:00 AM shift revealed the resident was anxious and calling out, and is a new admission with a rectal bleed. Review of a nursing Progress Note dated [DATE] at 7:41 AM revealed the resident was not breathing, had no pulse or BP and the resident was deceased . The family members and Physician were notified. Review of all nursing Progress Notes dated [DATE] through [DATE] revealed the Physician was not notified regarding the resident's nosebleed, lowered BP or blood in the stool and toilet water. During an interview on [DATE] at 1:30 PM with the Registered Nurse (RN) (RN #1) Supervisor, RN#1 reviewed all nursing Progress Notes and 24-hour Report Sheets for the period of [DATE] through [DATE]. RN #1 stated there is no documentation that the RN in charge each shift was informed of the resident's condition or Physician notification of the resident's condition. Interview with the Licensed Practical Nurse (LPN) (LPN #1) on [DATE] at approximately 11: 25 AM revealed LPN #1 worked the night the resident had the nosebleed. LPN #1 stated she applied a cool compress to the resident's nose and along with pressure, the nosebleed stopped. She stated she told the RN Supervisor but the RN did not notify the Physician. During an interview with the RN (#2) Supervisor on [DATE] at approximately 11:25 AM, RN #2 stated that on [DATE] LPN #1 had not informed her during change of shift report of the resident's nosebleed, or was she asked to notify the resident's Physician. Interview via telephone with the Physician on [DATE] at approximately 11:35 AM revealed the Physician easily recalled the resident and her primary health problems. The Physician stated that he called the facility the morning of the resident's death " to see what happened. " The Physician was updated by the RN Head Nurse (HN) that " the resident had been doing well right up until that morning. " This writer then read to the Physician the resident's Progress Notes for [DATE] through [DATE]. The Physician stated that he was not informed or aware of the resident having a lowered BP, nosebleed or regarding the bloody stool and bloody water in the toilet. The Physician stated that " if he had been aware, I would have put a hold on the resident's aspirin and ordered labs to be done right away. I expect that when there is a change in a resident's condition that the staff informs the RN, an assessment of the resident's status is completed such as review of medications, performing vital signs and a physical exam then to call me with that information. " Interview with the RN #1 Supervisor on [DATE] at approximately 1:30 PM, that evaluated the resident the morning of [DATE], RN #1 stated she was just starting the facility report with the night supervisor and received a call that the resident had expired. She had not been aware of any episodes of rectal or nasal bleeding. She went to the resident's room where she found the resident with a very pale color, her skin was warm to touch and the resident had no respirations, BP or pulse. The family, Physician and the funeral home were called by RN #1. Interview with the RN Director of Nursing (DON) on [DATE] at approximately 2:00 PM revealed the DON was not aware of the resident's episode of nasal and rectal bleeding. The DON stated that she would expect that if a resident had a nosebleed the LPN would obtain a BP and then notify the RN Supervisor or Head Nurse (HN). If a resident that is on an anticoagulant,was to pass blood in the stool with red blood in the toilet water, she would expect the RN Supervisor or HN to be informed and to notify the Physician. Interview with the LPN (LPN #2) on [DATE] at approximately 2:34 PM that worked on the resident's unit the evening of [DATE], LPN #2 stated the CNAs assisted the resident with her bedtime care between 8:00 PM to 9:00 PM. She stated that when the CNAs took the resident to the toilet, the resident passed a bowel movement (BM) that was a red brick color as well as blood noted in the toilet water. LPN #2 stated that she did her charting on the resident then after the charting was completed, she remembered that she did not include the episode regarding the BM. LPN #2 added it to the record as a late note. When asked if she notified the RN Supervisor, LPN #2 replied " yes" but stated she did not inform the RN of the low BP. Interview with the RN (RN #4) Supervisor on [DATE] at approximately 4:39 PM, RN #4 stated she was the night shift Supervisor on [DATE]. RN #4 stated she was not notified or aware the resident had a bloody stool. She was not aware of the resident's recent vital signs and was not asked to assess the resident. RN #4 stated she depends on the staff to keep her updated on the status change in residents and to inform her when there are concerns or changes in a resident. Interview with the RN HN (RN #6) on the resident's unit on [DATE] at approximately 9:19 AM revealed the RN HN (RN #6) was not asked to assess the resident or informed of a low BP stating if she was aware, she would have completed a physical assessment and informed the Physician. Interview with RN #1 on [DATE] at approximately 9:20 AM revealed the she was orienting the RN HN (RN #6) on [DATE] and [DATE]. RN #1 was "off and on the unit" as needed, and was not informed of any changes in the resident's condition. During an interview on [DATE] at approximately 9:22 AM with the LPN (LPN #3), that worked the 7:00 AM-3:00 PM shift on [DATE], LPN #3 stated " I do not know why I did not pick up on the fact that the BP on [DATE] was low for the resident. My documentation on the 24-hour Report Sheet is not correct because "VSS" was not accurate as they were not stable. As a rule for a low BP I would inform the RN HN or Supervisor but in this case I did not. " Review of the policy and procedure (P&P) entitled TPR (temperature, pulse and respiration), BP, Accuchecks (portable device used to test blood glucose levels by using a fingerstick blood sample) dated ,[DATE] revealed routine TPRs and BPs are taken to formulate baseline information and ensure abnormal increases or decreases are recognized, monitored or treated appropriately. Review of a P&P entitled Change in Resident ' s Condition dated ,[DATE] revealed upon full assessment of a resident, the RN is to make a judgement whether a resident has had a change in condition based on current standards of practice. Based on this assessment the RN is to judge the significance of the change. If he/she deems necessary, notification of MD (medical doctor) and the resident ' s responsible party must be made. 415.3 (e)(2) (ii) (b)

Based on interview and record review conducted during the Standard survey completed on [DATE], the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #101) of three residents reviewed for quality of care had an issue with the lack of communication between nursing staff that resulted in a failure of a Registered Nurse (RN) to perform a physical assessment for a resident with a significant change in physical condition. Specifically, for a nosebleed on [DATE] for the resident recieving aspirin (anticoagulant medication used to prevent blood clotting), and had a lowered blood pressure from the resident's baseline for two shifts and blood in the stool on [DATE] that occurred prior to the resident's death on [DATE]. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #101 was admitted to the facility on [DATE] with a readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Psychosocial History Assessment and Social Work (SW) note dated [DATE] revealed the resident's mood is anxious and the resident is alert with periods of confusion. Review of the initial Care Plan dated [DATE] revealed the resident is non ambulatory and requires a mechanical lift to transfer. Review of the SW notes dated [DATE] revealed the resident is confused and unable to understand information given. Review of a nursing Progress Note dated [DATE] at 6:30 AM revealed the resident had a nosebleed from the L (left) nares (nostril). Oxygen was applied after the bleeding stopped. Further review revealed no documentation that a pulse oximetry (pulse ox-90 to 100% (percent) -oxygen saturation level-amount of oxygen in blood) was obtained. Review of the 24-hour Report Sheet dated [DATE] revealed the night shift reported the resident was awake and yelling out often. The resident had a nosebleed from the L nares that the nursing staff was able to stop. Review of the Medication Administration Record [REDACTED]. Additional review revealed the resident's BP is to be checked every shift for two weeks then weekly thereafter. Review of the MAR indicated [REDACTED]. Resident's baseline was ,[DATE]. Both shifts documented no further nosebleed. Review of a nursing Progress Note dated [DATE] revealed the 7:00 AM-3:00 PM shift documented the resident's "VSS" (vital signs stable). Review of a nursing Progress Note dated [DATE] at 10:50 PM revealed a late entry was added that documented the CNA (certified nursing assistant) reported dark "brick colored blood" on the resident's stool with dark red blood in the toilet. Staff will continue to monitor. Review of the entire 24-hour Report Sheet dated [DATE] for the 7:00 AM-3:00 PM shift revealed the resident's VSS and the resident asking for help from her daughter all day. Review of the entire 24-hour Report Sheet dated [DATE] for the 3:00 PM-11:00 PM shift revealed the resident's BP was ,[DATE], the resident was calling out all shift and received antianxiety and pain medications. Review of the back page of the report sheet revealed an entry was written documenting the CNA reported dark brick colored blood in stool and dark red blood in the toilet. There is no documentation on the 24-hour Report Sheet that a Registered Nurse (RN) was notified. Review of the 24-hour Report Sheet dated [DATE] for the 11:00 PM-7:00 AM shift revealed the resident was anxious and calling out, and is a new admission with a rectal bleed. Review of a nursing Progress Note dated [DATE] at 7:41 AM revealed the resident was not breathing, had no pulse or BP and the resident was deceased . The family members and Physician were notified. Review of all nursing Progress Notes dated [DATE] through [DATE] revealed an RN did not assess the resident's nose bleed or blood in the stool and toilet water. During an interview on [DATE] at 1:30 PM with the Registered Nurse (RN) (RN #1) Supervisor, RN#1 reviewed all nursing Progress Notes and 24-hour Report Sheets for the period of [DATE] through [DATE]. RN #1 stated there is no documentation that the RN in charge each shift was informed of the resident's condition, or performed a physical assessment of the resident's change in condition. Interview with the Licensed Practical Nurse (LPN) (LPN #1) on [DATE] at approximately 11: 25 AM revealed LPN #1 worked the night the resident had the nosebleed. LPN #1 stated she applied a cool compress to the resident's nose and along with pressure, the nosebleed stopped. She stated she told the RN Supervisor but the RN did not come to assess the resident. During an interview with the RN (#2) Supervisor on [DATE] at approximately 11:25 AM, RN #2 stated that on [DATE] LPN #1 had not informed her during change of shift report of the resident's nosebleed, or was she asked to assess the resident. Interview via telephone with the Physician on [DATE] at approximately 11:35 AM revealed the Physician easily recalled the resident and her primary health problems. The Physician stated that he called the facility the morning of the resident's death " to see what happened. " The Physician was updated by the RN Head Nurse (HN) that " the resident had been doing well right up until that morning. " This writer then read to the Physician the resident's Progress Notes for [DATE] through [DATE]. The Physician stated that he was not informed or aware of the resident having a lowered BP, nosebleed or regarding the bloody stool and bloody water in the toilet. The Physician stated that " if he had been aware, I would have put a hold on the resident's aspirin and ordered labs to be done right away. I expect that when there is a change in a resident's condition that the staff informs the RN, an assessment of the resident's status is completed such as review of medications, performing vital signs and a physical exam then to call me with that information. " Interview with the RN #1 Supervisor on [DATE] at approximately 1:30 PM, that evaluated the resident the morning of [DATE], RN #1 stated she was just starting the facility report with the night supervisor and received a call that the resident had expired. She had not been aware of any episodes of rectal or nasal bleeding. She went to the resident's room where she found the resident with a very pale color, her skin was warm to touch and the resident had no respirations, BP or pulse. The family, Physician and the funeral home were called by RN #1. Interview with the RN Director of Nursing (DON) on [DATE] at approximately 2:00 PM revealed the DON was not aware of the resident's episode of nasal and rectal bleeding. The DON stated that she would expect that if a resident had a nosebleed the LPN would obtain a BP and then notify the RN Supervisor or Head Nurse (HN). An RN assessment would include vital signs, evaluation of the medication regime if any medications may need consideration for change such as an anticoagulant. Interview with the LPN (LPN #2) on [DATE] at approximately 2:34 PM that worked on the resident's unit the evening of [DATE], LPN #2 stated the CNAs assisted the resident with her bedtime care between 8:00 PM to 9:00 PM. She stated that when the CNAs took the resident to the toilet, the resident passed a bowel movement (BM) that was a red brick color as well as blood noted in the toilet water. LPN #2 stated that she did her charting on the resident then after the charting was completed, she remembered that she did not include the episode regarding the BM. LPN #2 added it to the record as a late note. When asked if she notified the RN Supervisor, LPN #2 replied " yes" but stated she did not inform the RN of the low BP. Interview with the RN (RN #4) Supervisor on [DATE] at approximately 4:39 PM, RN #4 stated she was the night shift Supervisor on [DATE]. RN #4 stated she was not notified or aware the resident had a bloody stool. She was not aware of the resident's recent vital signs and was not asked to assess the resident. RN #4 stated she depends on the staff to keep her updated on the status change in residents and to inform her when there are concerns or changes in a resident. Interview with the RN HN (RN #6) on the resident's unit on [DATE] at approximately 9:19 AM revealed the RN HN (RN #6) was not asked to assess the resident or informed of a low BP stating if she was aware, she would have completed a physical assessment and informed the Physician. Interview with RN #1 on [DATE] at approximately 9:20 AM revealed the she was orienting the RN HN (RN #6) on [DATE] and [DATE]. RN #1 was "off and on the unit" as needed, and was not informed of any changes in the resident's condition or requested to assess the resident by the HN or any other staff member. During an interview on [DATE] at approximately 9:22 AM with the LPN (LPN #3), that worked the 7:00 AM-3:00 PM shift on [DATE], LPN #3 stated " I do not know why I did not pick up on the fact that the BP on [DATE] was low for the resident. My documentation on the 24-hour Report Sheet is not correct because "VSS" was not accurate as they were not stable. As a rule for a low BP I would inform the RN HN or Supervisor but in this case I did not. " Review of the policy and procedure (P&P) entitled TPR (temperature, pulse and respiration), BP, Accuchecks (portable device used to test blood glucose levels by using a fingerstick blood sample) dated ,[DATE] revealed routine TPRs and BPs are taken to formulate baseline information and ensure abnormal increases or decreases are recognized, monitored or treated appropriately. Review of a P&P entitled Change in Resident's Condition dated ,[DATE] revealed upon full assessment of a resident, the RN is to make a judgement whether a resident has had a change in condition based on current standards of practice. Based on this assessment the RN is to judge the significance of the change. If he/she deems necessary, notification of MD (medical doctor) and the resident ' s responsible party must be made. Review of a P&P entitled Responsibilities of the Head Nurse dated ,[DATE] revealed the nurse is responsible for documentation of all changes in resident ' s physical and emotional status, reporting resident condition changes to the Nursing Supervisor and Physician and responsible to give a complete informative report to the next shift. 415.12