Every finding on record at Townhouse Center for Rehabilitation & Nursing

Based on observation, record review, and interviews during an abbreviated survey (2631774), the facility did not ensure that all alleged incidents of a staff-to-resident abuse was reported immediately, but not later than 2 hours if there were serious bodily injuries or not later than 24 hours if there were no serious bodily injuries. This was identified for one (Resident #1) of three residents reviewed for abuse. Specifically, on 08/27/2025 Family Member #1 reported to the facility that Resident #1 alleged Certified Nursing Assistant #2 was rough with them and pulled their arms. The facility did not report the alleged abuse to the New York State Department of Health (NYSDOH).Findings include:Facility Policy titled Abuse Prohibition Policy dated 10/2025 documented All Residents will be protected from Abuse, Neglect, Mistreatment, Exploitation, or Misappropriation of property in accordance with State and Federal Regulations. All alleged or suspected incidents of Abuse, Neglect, Mistreatment, Exploitation or Misappropriation of Residents property will be reported to New York State Department of Health, thoroughly investigated, and findings documented.Resident #1 was admitted with diagnosis that include Type II diabetes, bipolar disorder, and chronic obstructive pulmonary disease. On 03/14/2026 a Minimum Data Set Brief Interview of Mental Status was completed for Resident #1 and documented a score of 09 indicating moderate cognitive impairment.The Progress Notes for Resident #1 were reviewed from 08/01/2025 through 10/01/2025, and there was no documentation of the reported allegations in the progress notes.Comprehensive Care Plan for Resident #1 dated 01/04/2021 documented Resident #1 had a care plan for behaviors related to their diagnosis of bipolar disorder. Behaviors of accusatory behavior, screaming at others; puts the resident at significant risk for physical illness or injury; significantly interferes with resident's care (essential nursing, medical, rehabilitation, personal care); significantly interferes with the resident's participation in activities or social interaction. Interventions include assess for unrecognized needs; preferences or illness; analyze key times; place, circumstances; triggers and what de-escalates behaviors; intervene before resident's agitation escalates. Grievance Reporting Form dated 08/27/2025 documented Family Member #1 & Resident #1's account of August 27th incident. Resident #1 expressed that the aide was physical with them and described the aide grabbing on to Resident #1's arms and pushing and pulling their arms while they argued about using (or not using) the bathroom. Resident #1 stated that they felt like they needed to call 911.The investigation concluded that no abuse had occurred and was signed by Administrator, Director of Nursing, and Registered Nurse Risk Manager on 08/28/2025.There was no documentation the facility reported the allegation to the New York State Department of Health within required twenty-four (24) hour timeframe.During an interview with Administrator on 04/01/2026 at 12:27 PM, the Administrator stated they are responsible for reporting allegations of abuse to the New York State Department of Health. They acknowledged the incident was an allegation of abuse but was not reported to the New York State Department of Health due to Resident #1's history of making false allegations. They stated they were aware that all allegations of abuse must be reported to the New York State Department of Health. The facility investigated the incident and found no evidence of abuse. NYCRR 415.4(b)(1)(i)

Based on record review and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development, and transmission of communicable diseases and infections. This was identified during the Infection Control Task. Specifically, the facility did not provide documented evidence of testing of the potable water system for Legionnaires' and other Waterborne pathogens. The facility did not provide documented evidence of a Flow Diagram to indicate a description of the building's water systems as per the facility's policy. The finding is: The facility's Legionella Water Mgmt. Plan (WMP) policy dated 2/06/2017 last reviewed on 10/17/2024 documented the Water Management Plan including but not limited to Flow Diagram and tables for each Water System The Laboratory Certificate of Analysis documented a water sample was collected from the Cooling Tower on 6/7/2024 and results were reported on 6/21/2024 with no Legionella isolates. There was no documented evidence that the facility performed testing of the potable water system in other areas of the building where there was a high probability of opportunistic pathogens in the building water system. The facility did not provide a Flow Diagram and tables for each Water System as indicated in the facility's policy. During an interview on 1/17/2025 at 2:30 PM the Director of Environmental Services stated they recently took over the Maintenance Department responsibilities and were still learning about the building systems. The Director of Environmental Services was notified to provide records of the Legionella testing and results of the potable water system, the design description of the potable water system identifying potential points of Legionnaires and other waterborne pathogens. The requested records were not provided at the conclusion of the survey. During an interview on 1/17/2025 at 2:30 PM, the Administrator stated it is the Director of Environmental Services' responsibility to maintain an updated Water Management Plan. The Administrator stated the Director of Environmental Services was recently assigned to the Maintenance Department and was still learning about the building systems. 10 NYCRR 415.19(a)(1-3)

Based on record review and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development, and transmission of communicable diseases and infections. This was identified during the Infection Control Task. Specifically, the facility did not provide documented evidence of testing of the potable water system for Legionnaires' and other Waterborne pathogens. The facility did not provide documented evidence of a Flow Diagram to indicate a description of the building's water systems as per the facility's policy. The finding is: The facility's Legionella Water Mgmt. Plan (WMP) policy dated 2/06/2017 last reviewed on 10/17/2024 documented the Water Management Plan including but not limited to Flow Diagram and tables for each Water System The Laboratory Certificate of Analysis documented a water sample was collected from the Cooling Tower on 6/7/2024 and results were reported on 6/21/2024 with no Legionella isolates. There was no documented evidence that the facility performed testing of the potable water system in other areas of the building where there was a high probability of opportunistic pathogens in the building water system. The facility did not provide a Flow Diagram and tables for each Water System as indicated in the facility's policy. During an interview on 1/17/2025 at 2:30 PM the Director of Environmental Services stated they recently took over the Maintenance Department responsibilities and were still learning about the building systems. The Director of Environmental Services was notified to provide records of the Legionella testing and results of the potable water system, the design description of the potable water system identifying potential points of Legionnaires and other waterborne pathogens. The requested records were not provided at the conclusion of the survey. During an interview on 1/17/2025 at 2:30 PM, the Administrator stated it is the Director of Environmental Services' responsibility to maintain an updated Water Management Plan. The Administrator stated the Director of Environmental Services was recently assigned to the Maintenance Department and was still learning about the building systems. 10 NYCRR 415.19(a)(1-3)

Based on observations, record review, and staff interviews during the Recertification and Abbreviated Survey (NY 00347071) initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure that each resident's comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #146) of one resident reviewed for Skin Condition. Specifically, Resident #146 had a diagnosis of Hyperkeratosis (a condition that causes thick, rough, patches of skin) of the bilateral feet; however, there was no care plan developed for the Hyperkeratosis until 1/21/2025. The finding is: The facility's policy titled Care Planning Policy, last revised on 1/2025 documented the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights, measurable objectives, and time frames to meet the resident's medical, nursing, mental and psychosocial needs that are identified in their assessment. Resident #146 was admitted with diagnoses including Pressure Ulcers, Type 2 Diabetes, and Schizophrenia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #146 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #146 had unhealed pressure ulcers and utilized a pressure-reducing device for the chair. A review of Resident #146's Comprehensive Care Plan (CCP) revealed that the facility had archived (stored, no longer in effect a care plan for Hyperkeratosis of bilateral feet on 3/5/2024 and was not renewed until 1/21/2025. A Progress Note dated 5/13/2024, from Dermatology Nurse Practioner#1, documented that Resident #146 was seen for a consultation due to Hyperkeratosis and Resident #146 had dry cracked skin on both feet. Dermatology Nurse Practitioner#1 recommended continuing Ammonium Lactate lotion to bilateral feet twice daily. A Physician's Order dated 5/31/2024 last renewed on 1/13/2025 documented Ammonium Lactate 12 percent lotion applied to arms, legs, and feet twice daily for Hyperkeratosis. A Progress note dated 1/20/2025, from Dermatology Nurse Practioner #1, documented that Resident #146 was seen for a consultation due to Hyperkeratosis. The resident had dry cracked skin on bilateral feet. Dermatology Nurse Practitioner #1 recommended continuing Ammonium Lactate lotion to bilateral feet twice daily. During an interview on 1/21/2025 at 8:16 AM, the Wound Care Nurse stated care plans are initiated by the Unit Registered Nurses. The Wound Care Nurse stated Resident #146 had a care plan for Hyperkeratosis in the past. The Wound Care Nurse stated they were not aware that the care plan was archived and was never renewed. The Wound Care Nurse stated that a care plan for Hyperkeratosis should continue due to Resident #146 chronic (long-lasting) diagnosis of Hyperkeratosis. During an interview on 1/21/2025 at 1:27 PM, Registered Nurse #6, the Unit Manager, stated they and the other Registered Nurses were responsible for initiating care plans. Registered Nurse #6 stated that Resident#146's care plan for Hyperkeratosis was not renewed when Resident #146 was readmitted from the Hospital. Registered Nurse #6 stated they should have renewed the care plan because the resident has chronic Hyperkeratosis. During an interview on 1/22/2025 at 8:52 AM, the Director of Nursing Services stated that the care plan for Hyperkeratosis should have been initiated and they expected the Registered Nurses to evaluate, update, and initiate the required care plans. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for two (Resident #223 and Resident #171) of two residents reviewed for the Resident Assessment Task. Specifically, Resident #223's Discharge Minimum Data Set assessment was not submitted within 14 days from the completion of the Minimum Data Set assessment. Resident #171's quarterly Minimum Data Set assessment was not submitted within 14 days from the completion of the Minimum Data Set assessment. The finding is: The facility's policy and procedure titled Completion of the RAI [Resident Assessment Instrument] Process documented that for all residents in certified beds, regardless of payer [source], assessments will be completed within the guidelines outlined in the Resident Assessment Instrument Manual. All assessments will be scheduled within Centers for Medicare Services guidelines. The Minimum Data Set Coordinator will be responsible for the transmission of Minimum Data Set assessments within the time frames outlined in the Resident Assessment Instrument manual and for checking validation reports to ensure acceptance of records sent. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report dated 10/25/2024 documented Resident #223's Discharge Minimum Data Set assessment, with an assessment reference date of 9/23/2024, was completed on 10/7/2024. The assessment was transmitted on 10/25/2024. Resident#223's Minimum Data Set assessment was transmitted four days late. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report dated 1/13/2025 documented Resident #171's quarterly Minimum Data Set assessment, with an assessment reference date of 12/15/2024 was completed on 12/29/2024. The assessment was transmitted on 1/13/2025. Resident #171's Minimum Data Set assessment was transmitted one day late. During an interview on 1/21/2025 at 1:22 PM, the Minimum Data Set Director stated the Minimum Data Set assessments are submitted weekly. For the two identified records, there was a discrepancy in the activity of daily living documentation, so the records were sent back to the interdisciplinary team for review to ensure accuracy, and that is what caused the delay in submission. During an interview on 1/21/2025 at 1:35 PM, the Administrator stated the Minimum Data Set assessments were late because some corrections related to activities of daily living were needed, which caused the delay in submission of the assessment. 10 NYCRR 415.11

Based on record review, and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure the Binding Arbitration Agreement explicitly granted the resident and their representative the right to rescind the agreement within 30 calendar days of signing the agreement. This was identified for two (Resident #139 and Resident #238) of two residents reviewed during the Arbitration Task. Specifically, the Binding Arbitration Agreement signed by Resident #139 and Resident #238's representatives did not specify that the resident/representatives had 30 calendar days to rescind the agreement. The finding is: The facility's policy titled Optional Arbitration Agreement dated 6/2023 documented that residents and responsible parties must be advised prior to admission that the facility will honor any written request by a resident and/or their representative to terminate the Optional Arbitration Agreement if such notice of termination is delivered either personally or by certified mail. The policy did not indicate a specific timeframe by which the written agreement could be rescinded. The facility's Optional Arbitration Agreement did not include that the resident and/or their representatives had the right to rescind the Optional Arbitration Agreement within 30 calendar days of signing the agreement. Resident # 139 was admitted with diagnoses including Hypertension, Hyperlipidemia (high cholesterol), and Gout. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. A Binding Arbitration Agreement, signed by Resident #139 on 10/9/2024 did not include that the resident and/or their representatives had the right to rescind the Optional Arbitration Agreement within 30 calendar days of signing the agreement. Resident # 238 was admitted with Diagnoses including Osteoarthritis, Joint Replacement Surgery, and Hypertension. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A Binding Arbitration Agreement, signed by Resident 139's representative on 12/19/2024, did not include that the resident and/or their representatives had the right to rescind the Optional Arbitration Agreement within 30 calendar days of signing the agreement. During an interview on 1/17/2025 at 2:22 PM, Resident #139 stated they were educated about entering the Optional Arbitration Agreement. Resident #139 stated they were verbally informed that they could cancel any services or agreement including the Optional Arbitration Agreement at any time. Resident #139 stated they reviewed the Optional Arbitration Agreement before signing but did not recall if the agreement included information on how to rescind it. During an interview on 1/17/2025 at 1:34 PM, Resident #238 stated they permitted their family member to participate, review, and sign all documents on their behalf. Resident #238 stated the facility would have discussed the admission agreement including the Optional Arbitration Agreement with the family member. During an interview on 1/21/2025 at 9:23 AM, Resident #238's family member stated they handled Resident #238's paperwork upon admission. Resident #238's family member stated they were educated about entering the Optional Arbitration Agreement prior to signing the document. Resident #238's family member stated they were verbally informed of their right to opt out of the agreement anytime. Resident #238's family member was not aware that the Optional Arbitration Agreement did not include a written statement on how to rescind it. During an interview on 1/17/2025 at 3:28 PM, the Director of Admissions stated resident and/or their representative were verbally educated that they could rescind the Optional Arbitration Agreement at any time during their stay. The timeframe to rescind the agreement is not limited to 30 calendar days from signing the Optional Arbitration Agreement. The Director of Admissions stated the Optional Arbitration Agreement did not include documented evidence that the agreement could be rescinded within 30 calendar days of signing the agreement. During an interview on 1/21/2025 at 1:51 PM, the Administrator stated they were aware that the resident and/or representative must be granted the right to rescind the Optional Arbitration Agreement within 30 calendar days of signing the agreement as per the regulation. The Administrator stated the facility's legal team was responsible for drafting the agreement. The Administrator stated they believed the agreement was written in compliance with all regulations. The Administrator acknowledged that the Optional Arbitration Agreement did not include written information about the resident's right to rescind the agreement within 30 calendar days of signing the agreement. The Administrator stated the resident and/or representative can request to opt out of the agreement at any time, even if the decision to rescind exceeds 30 calendar days. 10 NYCRR 415.30

Based on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all drugs and biologicals were labeled in accordance with professional standards of practice. This was identified for one (Unit 3 North medication cart A) of eight Medication Carts reviewed during the Medication Storage task and for one (Resident #498) of five residents reviewed for Accidents. Specifically, 1) the Unit 3 North medication cart was observed with two unlabeled medication cups, with medication tablets, in the top drawer. Licensed Practical Nurse #2 stated they stored the pre-poured medications in the medication cart because Resident #41 and Resident #105 had refused their medications during the medication administration pass. 2) Resident #498 was observed with multiple medications in their room that were not ordered by the resident's Physician. The findings are: 1) The facility's policy titled Mediation Storage, last reviewed on ,d+[DATE], documented that medications must be stored in accordance with the manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. The facility's policy titled Medication Administration and Documentation, last reviewed on ,d+[DATE], documented that all medications that are expired, contaminated, or refused [by the residents] will be disposed of promptly and properly by licensed medical/nursing personnel in accordance with applicable laws and guidelines. This process is designed to prevent medication misuse, diversion, and environmental harm. Resident #41 was admitted with diagnoses that included Adult Failure to Thrive, Hypertension, and Peripheral Vascular Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #41 was rarely or never understood and had severe cognitive impairment. Resident #41 received anticoagulant medication during the seven-day lookback period. A physician's order renewed on [DATE] documented to administer one tablet of Amlodipine 10 milligrams once a day by oral route. A physician's order renewed on [DATE] documented to administer one chewable tablet of Aspirin 81 milligrams once a day by oral route. The Medication Administration Record documented Resident #41 refused Amlodipine (heart medication) 10-milligram and Aspirin (blood thinner) 81-milligram chewable tablets on [DATE] during the 9:00 AM medication administration. Resident #105 was admitted with diagnoses that included Cerebral Infarction, Diabetes Mellitus Type 2, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #105 was rarely or never understood and had severe cognitive impairment. Resident #105 received anticoagulant medication during the seven-day lookback period. A physician's order renewed on [DATE] documented to administer one tablet of Metoprolol (medication to treat high blood pressure) Succinate extended-release 50-milligrams once a day by oral route; one tablet of Hydralazine 50 milligrams (medication to treat high blood pressure) once daily by the oral route; one tablet of Allopurinol 100 milligrams (medication (used to prevent or lower high uric acid levels in the blood) once daily by the oral route; and one tablet of Eliquis 5 milligrams (blood thinner) every 12 hours by oral route. The Medication Administration Record documented Resident #105 refused Metoprolol Succinate extended-release 50-milligram tablet, Hydralazine 50 milligram tablet, Allopurinol 100 milligram tablet, and Eliquis 5 milligram tablet on [DATE] during the 9:00 AM medication administration. During an observation on [DATE] at 10:23 AM, with Licensed Practical Nurse #2, Unit 3 North for the Medication Storage and Labeling task, Licensed Practical Nurse #2 opened the top drawer of the medication cart which contained two unlabeled medication cups with some tablets. Licensed Practical Nurse #2 stated initially they had mistakenly documented that the medications were administered to Resident #41 and Resident #105 and that they should not have signed for the medications before administering the medications to the resident. Licensed Practical Nurse #2 then proceeded to throw away the medications in the garbage pail. During an interview on [DATE] at 10:36 AM, Registered Nurse Unit Manager #1 stated the dispensed medications should not be stored in a medication cup in the medication cart. Medications refused by the resident should be discarded immediately and not saved in a medicine cup inside the medication cart. During a re-interview on [DATE] at 8:57 AM, Licensed Practical Nurse #2 stated they saved the unlabeled medication cups with Resident #41 and Resident #105's medications in the cart because they intended to reapproach the residents; however, they got too busy. Licensed Practical Nurse #2 stated they first documented that they had given the medications and that was in error, they then went back and corrected the record to document the refusal and notified the Physician. During an interview on [DATE] at 11:39 AM, the Director of Nursing Services stated nurses are expected to discard the medication if the resident refuses their medications and document the refusal in the Medication Administration Record. The Director of Nursing Services stated the nurse should not leave the medications in an unlabeled medication cup inside the medication cart. 45349 3) Resident #498 was admitted with diagnoses of Pulmonary Fibrosis and Pneumonia. The Minimum Data Set assessment was not yet completed as the resident was recently admitted to the facility. During an observation on [DATE] at 9:22 AM, multiple medications including Flonase (allergy relief medication) nasal spray, Deep Sea Premium Saline spray, and Icy Hot (topical pain reliever) Jar, with labels from the hospital, were observed on Resident #498's nightstand. There were additional medications including eye lubricant drops and Systane eye drops (used for eye lubrication) without a label were also noted on the resident's nightstand. There were no Physician's orders for Flonase (allergy relief medication) nasal spray, Deep Sea Premium Saline spray, Icy Hot, eye lubricant drops, and Systane eye drops. During an interview on [DATE] at 9:52 AM, Registered Nurse Manager #3 stated that medications should not be stored in a resident's room. All medications should be stored in the medication cart. A Physician's progress note dated [DATE] at 10:46 AM documented that Resident #498 was seen and examined. A clear plastic bag containing over-the-counter medications was found in the resident's personal belongings. The resident's family was contacted and confirmed that the observed medications belonged to Resident #498 and were inadvertently left at the facility. During an interview on [DATE] at 10:45 AM, the Director of Nursing Services stated only nurses handle medications. Nurses should remove the medications that are left in the resident's room. 10 NYCRR 415.18 (e) (,d+[DATE])

Based on observations, record review, and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified for one (Unit 3 North) of five units reviewed during the Medication Storage Task. Specifically, Licensed Practical Nurse #1 administered 3 tablets of Methadone 5 milligram tablets to Resident #124 and 1 tablet of Lorazepam 0.5 milligram to Resident #15 on 1/16/2025 during the 9:00 AM medication administration pass. Licensed Practical Nurse #1 did not reconcile the Individual Controlled Medication Records to reflect the actual number of remaining tablets in the blister packs. The findings are: The facility policy titled Medications -Management of Controlled Substances, last reviewed on 11/2024, documented that when a controlled substance is to be administered, the nurse will remove the dose from the inventory, the dose is then given to the resident, and the medication [administration administration] documented on the resident's MAR [Medication Administration Record] and on the Individual Controlled Medication Record. If the medication is not administered (refusal, medication dropped, held, etc.), two nurses must dispose of the medication properly by flushing the medication in the sink and both nurses will document the wasting of the medication. 1) Resident #124 was admitted with diagnoses that included Chronic Pain Syndrome, Type 2 Diabetes Mellitus, and Hypertension. The Minimum Data Set, dated [DATE], documented that Resident #124 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set documented Resident #15 had Chronic Pain and received a scheduled pain medication regimen which included an Opioid medication during the assessment period. A Physician's order dated 8/22/2023 last renewed on 1/9/2025 documented Methadone 5-milligram tablets; give 3 tablets (15 milligrams) by oral route once daily. During the Medication Storage task on Unit 3 North on 1/16/2025 at 10:50 AM, the narcotics cabinet was observed with Resident #124's Methadone 5 milligram tablet blister pack containing 18 tablets. The Controlled Substance Administration Record documented Resident #124's Methadone 5 milligram tablets were last administered on 1/15/2025 at 8:10 AM and the remaining amount was 21 tablets. The Medication Administration Record for January 2025 documented three tablets of Methadone 5 milligrams, for a total of 15 milligrams, were administered to Resident #124 on 1/16/2025 at 9:00 AM. 2) Resident #15 was admitted with diagnoses that included Chronic Pain, Anxiety Disorder, and Major Depressive Disorder. The Minimum Data Set, dated [DATE] documented that Resident #15 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. Resident #15 received a scheduled pain medication regimen during the assessment period. A Physician's order dated 7/14/2021 last renewed on 1/14/2025 documented Lorazepam 0.5 Milligram tablet to be given 1 tablet twice a day by oral route. During the Medication Storage task on Unit 3 North on 1/16/2025 at 10:50 AM, the narcotics cabinet was observed with Resident #15's Lorazepam 0.5 Milligram tablet blister pack containing one tablet. The Controlled Substance Administration Record documented Resident #15's Lorazepam 0.5 milligram tablet was last administered on 1/15/2025 at 9:00 PM and the remaining amount was 2 tablets. The Medication Administration Record for January 2025 documented one Lorazepam 0.5 milligram tablet was last administered to Resident #15 on 1/16/2024 at 9:00 AM. During an interview on 1/16/2025 at 11:25 AM, Registered Nurse Unit Manager #1 stated Licensed Practical Nurse #1 should have updated the Individual Controlled Medication Record immediately after they administered the medications to the residents. The number of medications in the blister pack should match the Individual Controlled Medication Record count. During an interview on 1/16/2025 at 11:28 AM, Licensed Practical Nurse #1 stated they should have updated the Individual Controlled Medication Record when they administered the medications to Resident #15 and Resident #124. Licensed Practical Nurse #1 did not know why they did not update the Individual Controlled Medication Record when they completed the medication administration. During an interview on 1/17/2025 at 11:39 AM, the Director of Nursing Services stated the medication nurse should immediately document the number of tablets remaining in the blister pack onto the Individual Controlled Medication Record after they administer the medication to the resident. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified for one (Unit 3 North) of five units reviewed during the Medication Storage Task. Specifically, Licensed Practical Nurse #1 administered 3 tablets of Methadone 5 milligram tablets to Resident #124 and 1 tablet of Lorazepam 0.5 milligram to Resident #15 on 1/16/2025 during the 9:00 AM medication administration pass. Licensed Practical Nurse #1 did not reconcile the Individual Controlled Medication Records to reflect the actual number of remaining tablets in the blister packs. The findings are: The facility policy titled Medications -Management of Controlled Substances, last reviewed on 11/2024, documented that when a controlled substance is to be administered, the nurse will remove the dose from the inventory, the dose is then given to the resident, and the medication [administration administration] documented on the resident's MAR [Medication Administration Record] and on the Individual Controlled Medication Record. If the medication is not administered (refusal, medication dropped, held, etc.), two nurses must dispose of the medication properly by flushing the medication in the sink and both nurses will document the wasting of the medication. 1) Resident #124 was admitted with diagnoses that included Chronic Pain Syndrome, Type 2 Diabetes Mellitus, and Hypertension. The Minimum Data Set, dated dated dated [DATE], documented that Resident #124 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set documented Resident #15 had Chronic Pain and received a scheduled pain medication regimen which included an Opioid medication during the assessment period. A Physician's order dated 8/22/2023 last renewed on 1/9/2025 documented Methadone 5-milligram tablets; give 3 tablets (15 milligrams) by oral route once daily. During the Medication Storage task on Unit 3 North on 1/16/2025 at 10:50 AM, the narcotics cabinet was observed with Resident #124's Methadone 5 milligram tablet blister pack containing 18 tablets. The Controlled Substance Administration Record documented Resident #124's Methadone 5 milligram tablets were last administered on 1/15/2025 at 8:10 AM and the remaining amount was 21 tablets. The Medication Administration Record for January 2025 documented three tablets of Methadone 5 milligrams, for a total of 15 milligrams, were administered to Resident #124 on 1/16/2025 at 9:00 AM. 2) Resident #15 was admitted with diagnoses that included Chronic Pain, Anxiety Disorder, and Major Depressive Disorder. The Minimum Data Set, dated dated dated [DATE] documented that Resident #15 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. Resident #15 received a scheduled pain medication regimen during the assessment period. A Physician's order dated 7/14/2021 last renewed on 1/14/2025 documented Lorazepam 0.5 Milligram tablet to be given 1 tablet twice a day by oral route. During the Medication Storage task on Unit 3 North on 1/16/2025 at 10:50 AM, the narcotics cabinet was observed with Resident #15's Lorazepam 0.5 Milligram tablet blister pack containing one tablet. The Controlled Substance Administration Record documented Resident #15's Lorazepam 0.5 milligram tablet was last administered on 1/15/2025 at 9:00 PM and the remaining amount was 2 tablets. The Medication Administration Record for January 2025 documented one Lorazepam 0.5 milligram tablet was last administered to Resident #15 on 1/16/2024 at 9:00 AM. During an interview on 1/16/2025 at 11:25 AM, Registered Nurse Unit Manager #1 stated Licensed Practical Nurse #1 should have updated the Individual Controlled Medication Record immediately after they administered the medications to the residents. The number of medications in the blister pack should match the Individual Controlled Medication Record count. During an interview on 1/16/2025 at 11:28 AM, Licensed Practical Nurse #1 stated they should have updated the Individual Controlled Medication Record when they administered the medications to Resident #15 and Resident #124. Licensed Practical Nurse #1 did not know why they did not update the Individual Controlled Medication Record when they completed the medication administration. During an interview on 1/17/2025 at 11:39 AM, the Director of Nursing Services stated the medication nurse should immediately document the number of tablets remaining in the blister pack onto the Individual Controlled Medication Record after they administer the medication to the resident. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025 the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was identified for one (Resident #115) of three residents reviewed for Skin Conditions. Specifically, Resident #115 was recommended to use an orthotic carrot device (a device shaped like a carrot that supports the hand, prevents injury, and improves function) for their left hand by the Occupational Therapy Department on 4/7/2023. A Physician's order for the use of an orthotic carrot device was never obtained, therefore, Resident #115 was never offered and did not use the orthotic carrot device. The finding is: The facility's policy titled Rehabilitation Services, dated 1/1/2025 documented the facility offers specialized rehabilitative services by qualified personnel in Physical, Occupational, and Speech Therapy to improve and maintain optimal functioning. Residents will also be screened quarterly, annually, and for significant changes or as needed. If further assessment and modifications to the plan of care are needed by the Therapy Department, a Physician's order will be obtained to complete a full evaluation. Resident #115 was admitted with diagnoses including Diabetes Mellitus, Hemiplegia (weakness on one side of the body) affecting the left non-dominant side, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, indicating the resident had moderately impaired cognition. The resident had Functional Limitation in Range of Motion on one side of the upper extremities and both sides of the lower extremities. On 1/21/2025 at 8:21 AM, Resident #115 was observed in bed. The resident's left hand appeared contracted. The resident stated they have not been offered any type of device to wear for the left hand. The resident used their right hand to open the fingers of their left hand. There was no orthotic device in the resident's left hand. A Quarterly Rehabilitation Department Screen dated 4/7/2023 completed by Occupational Therapist (Registered-Licensed) #1 documented the resident had a functional limitation to range of motion to the upper extremity. The screen Recommendations to Nursing documented Left Hand Carrot Orthosis to be worn at all times. Remove for skin check, hygiene, and range of motion exercises. A Quarterly Rehabilitation Department Screen dated 1/15/2025 completed by Occupational Therapist (Registered-Licensed) #1 documented the resident had a functional limitation to range of motion to the upper extremity. The Recommendations to Nursing included the left-hand carrot orthosis to be worn at all times. Remove the carrot orthosis for skin check, hygiene, and range of motion exercises. A review of the medical record revealed no Physician's orders for the left-hand carrot orthosis or range of motion exercises for the left upper extremity. During an interview on 1/21/2025 at 8:36 AM, Certified Nursing Assistant #1 stated this was the first time they were assigned to care for Resident #115. Certified Nursing Assistant #1 stated they did not know anything about the left-hand orthotic device. During an interview on 1/21/2025 at 8:37 AM, Registered Nurse Unit Manager #2, at the surveyor's request, checked the resident's room and stated they could not find the orthotic device and were not aware of the resident using the device. Registered Nurse Unit Manager #2 stated they would have to check with the Rehabilitation Department for clarification. During an interview on 1/21/2025 at 2:23 PM, Rehabilitation Department Director #1 stated the orthotic device was never ordered for Resident #115. Rehabilitation Department Director #1 stated they asked Occupational Therapist #1 to perform another screen today, 1/21/2025, to determine if the orthotic device was still appropriate for Resident #115. The Occupational Therapy screen was completed on 1/21/2025 which indicated that the orthotic carrot device was no longer appropriate. New recommendations for the range of motion to the left upper extremities were provided and a new Physician's order for the range of motion was obtained on 1/21/2025. A Rehabilitation Department Screen dated 1/21/2025, completed by Occupational Therapist #1, recommended Active (completed by the resident) Range of Motion to the Right Upper Extremity and Passive Range (assisted by the staff) of Motion to the Left Upper Extremity, 5-10 repetitions twice a day as tolerated during Activities of Daily Living care. A Physician's order dated 1/21/2025 documented Active Assist Range of Motion to the Right Upper Extremity and Passive Range of Motion to the Left Upper Extremity, 5-10 repetitions twice a day as tolerated during Activities of Daily Living care. During an interview on 1/22/2025 at 9:39 AM, Occupational Therapist #1 stated the resident never received the orthotic carrot device after the resident was screened by them on 4/7/2023 because they (Occupational Therapist (Registered-Licensed) #1) did not obtain an order from the Physician for the device. Occupational Therapist #1 stated they again completed the Rehabilitation Screen for Resident #115 on 1/21/2025 and determined the orthotic carrot device was no longer indicated at this time because the resident needed range of motion exercises. During a re-interview on 1/23/2025 at 10:35 AM, Rehabilitation Director #1 stated when Therapists make recommendations, they need to follow up and obtain the physician's order related to the recommendations. Resident #115 did not receive the recommended orthotic carrot device because Occupational Therapist #1 did not obtain the Physician's order for the orthotic carrot device and should have. 10 NYCRR 415.12(e)(2)

Based on record review and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure it provided timely laboratory services to each resident. This was identified for one (Resident #398) of two residents reviewed for Mood and Behavior. Specifically, Resident #398's Physician ordered a Urinalysis (a test that checks urine for signs of health issues like infections and kidney problems) STAT (without delay/prioritized with urgency) on 1/18/2025 to rule out Urinary Tract Infection. The results of the test were not reported by the laboratory to the facility timely. The finding is: The facility's policy titled Laboratory Services, Results, and Physician Notification, dated 5/2024 documented the facility will provide and/or obtain laboratory services in a timely manner to meet the needs of its residents. The facility will provide and/or obtain laboratory services when ordered by a practitioner (physician, physician assistant, nurse practitioner, and or clinical nurse specialist) in accordance with State and Federal regulatory requirements. The physician and/or practitioner will be notified in a timely manner of the laboratory results that fall outside of clinical reference ranges. STAT labs [specimen samples] will be drawn/ collected by the laboratory service provider within 4-6 hours. Laboratory results will be reported to the ordering medical practitioner or designee by unit nursing staff assigned during the shift the laboratory results are received. The nurse will document the Physician's notification of the laboratory results on the laboratory result sheet and/or the progress note. Resident #398 was admitted with diagnoses including Diabetes Mellitus, Chronic Obstructive Pyelonephritis (kidney infection), and Cerebrovascular Accident. The 12/24/2024 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderately impaired cognition. The resident had no behavioral issues and no signs and symptoms of Delirium. The resident had an indwelling urinary catheter. A progress note dated 1/18/2025 (Saturday) at 11:39 AM, written by Physician #1, documented the Physician was asked by the resident's family member to see the resident because the resident was hallucinating (hearing, seeing, smelling, tasting, or feeling things that appear to be real but only exist in your mind). The resident's blood pressure was 74/44 millimeters of Mercury (normal range 120/80 millimeters of Mercury). Physician #1 documented the resident may have Sepsis (a serious response to an infection) or over-diuresis (excessive urination). Physician #1 recommended bolus (quick delivery) intravenous fluids and checking STAT laboratory workup to look for Sepsis or Azotemia (kidneys not filtering enough nitrogen out of blood). A Physician's order dated 1/18/2025 at 11:35 AM documented to obtain a Urinalysis and a Urine Polymerase Chain Reaction (PCR) test (a laboratory test that detects bacterial organisms and some antibiotic resistance genes in a urine sample) STAT. A Physician's order dated 1/18/2025 at 11:35 AM documented Comprehensive Metabolic Panel STAT. A review of the laboratory requisition form documented that the urine sample was picked up from the facility by the laboratory on 1/18/2025 at 4:15 PM. A review of the medical record revealed there was no documented follow-up regarding the Urinalysis results until 1/21/2025. During an interview on 1/21/2025 at 11:20 AM, Registered Nurse Unit Manager #3 stated Resident #398 had a change in mental status over the weekend and the resident was hallucinating. Registered Nurse Unit Manager #3 stated that this morning, they noticed that Resident #398's Urinalysis results were not received over the weekend. A nursing progress note, written by Registered Nurse #5 (weekend supervisor), dated 1/21/2025 at 1:23 PM documented that on 1/18/2025 laboratory results, including Complete Blood Count and Comprehensive Metabolic Panel, were obtained and reviewed with the Physician. The Urinalysis sample was also collected during the 7:00 AM-3:00 PM shift on 1/18/2025 and the results were pending. During an interview on 1/21/2025 at 1:44 PM, Laboratory Representative #1 stated the blood sample was collected on 1/18/2025 at noon and STAT bloodwork results were reported back to the facility within 6 hours of collection. Laboratory Representative #1 stated there was no record of the Urinalysis order or sample collection that was ordered on 1/18/2025; the courier who collected the samples on 1/18/2025 did not return to the laboratory with the urine sample. Laboratory Representative #1 stated they did not know what happened with the Urinalysis testing. A Medical progress note dated 1/21/2025 at 2:39 PM, written by Physician #2, documented to start empiric (based on observation or experience) treatment with Ceftriaxone (an antibiotic) 1 gram intravenous once daily for 7 days while awaiting results of Urinalysis and Urine Culture. A review of the laboratory results revealed that the Urinalysis results were received by the facility on 1/21/2025 at 8:11 PM. The report indicated that the urine sample had a cloudy appearance; was positive for Nitrites (indicative of Urinary Tract Infection); had a small amount of blood; many bacteria; and a large amount of Leukocyte Esterase (an enzyme found in white blood cells). A comment was added from the laboratory in the Urinalysis report on 1/22/2025 documenting that the laboratory will follow up with the culture/sensitivity (a lab procedure that identifies the cause of an infection and determines the best treatment). A comment from Physician #2 (primary physician) in the Urinalysis report dated 1/22/2025 documented that Urinalysis looks positive (for infection); Empiric Ceftriaxone (an antibiotic) was in progress while awaiting urine culture results. During an interview on 1/22/2025 at 8:49 AM, Registered Nurse #5 (the weekend supervisor) stated they reported the STAT bloodwork results to Physician #1 on 1/18/2025. There was no Urinalysis result available on 1/18/2025. Registered Nurse #5 stated they called the laboratory on 1/18/2025 but the laboratory staff did not pick up the phone. Registered Nurse #5 stated they did not know what happened to the Urinalysis or why the urine test was not completed as ordered. During an interview on 1/22/2025 at 9:01 AM, Primary Physician #1 stated they discussed the blood test results with Registered Nurse #5 on 1/18/2025; however, the Urinalysis results were not available on 1/18/2025. Primary Physician #1 stated STAT orders for blood work and Urinalysis should be collected the same day and results should be returned the same day. During an interview on 1/22/2025 at 10:06 AM, the Director of Nursing Services stated they would expect STAT laboratory orders to be carried out and completed the same day including receiving the laboratory results. During an interview on 1/23/2025 at 10:28 AM, Primary Physician #2 stated results for a STAT order should be returned within the day to begin timely treatment. 10 NYCRR 415.20

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023, the facility did not ensure proper sanitation and food handling practices to prevent the outbreak of food born illnesses. This was identified during the initial kitchen observation. Specifically, a high-temperature automatic dishwashing machine was observed on two occasions on 5/3/2023 with a final rinse temperature below the manufacturer's recommended 180 degrees Fahrenheit (F). Additionally, there was no sanitizing agent attached to the dishwashing machine which would have automatically dispensed when the recommended 180 degrees temperature was not achieved during the final rinse cycle. The finding is: The facility's dishwashing machine manual documented the unit is a high-temperature dishwashing machine. The manual documented a final rinse temperature requirement of 180 degrees Fahrenheit to achieve satisfactory operation. During a kitchen observation on 5/3/2023 at 11:10 AM, the automatic dishwashing machine's final rinse temperature was observed to reach a maximum of 140 degrees Fahrenheit. Two cleaning agents, an Automatic Dish Detergent and a Performance Rinse Additive, were observed connected via tubing to a pump manifold which was connected to the dishwashing machine. During an interview on 5/3/2023 at 11:15 AM, the Food Service Director (FSD) stated that the dishwashing machine had a heat booster that was set to 195 degrees Fahrenheit. The FSD stated they were not aware that the dishwashing machine was not achieving a temperature of 195 degrees Fahrenheit. The FSD stated that the dishwashing machine is supplemented by a chemical rinse agent which automatically provides chemical sanitization when the desired 180 degrees Fahrenheit rinse cycle temperature is not achieved. A second observation was made on 5/3/2023 at 3:34 PM. The automatic dishwashing machine's final rinse temperature was observed to reach a maximum of 138 degrees Fahrenheit. The two cleaning agents, an Automatic Dish Detergent and a Performance Rinse Additive, were observed connected via tubing to a pump manifold which fed into the dishwashing machine. There was a third tube that was connected to the pump manifold; however, the other end of the tube was hanging and not connected to anything. During an interview on 5/3/2023 at 3:38 PM, the FSD stated there should be sanitizing agent connected to the third tube; however, the sanitizing agent was missing. The FSD stated that the sanitizing agent was not connected to the dishwashing machine during the first observation at 11:10 AM and should have been connected. The FSD located a 5-gallon container of the sanitizing agent in the supply closet and connected the sanitizing agent to the dishwashing machine. The FSD stated that it was their responsibility as well as the responsibility of the kitchen shift supervisors to ensure that the dishwashing machine was operating properly. The FSD stated that the evening supervisor cleaned the machine on 5/2/2023 and forgot to reconnect the sanitizing agent. During an interview on 05/3/2023 at 4:00 PM, the Administrator stated that they would have the service company inspect the dishwashing machine regarding the low temperatures immediately. The Administrator stated that the dishes observed at 11:10 AM were not utilized for lunch services as the facility had a second set of dishes. The Administrator further stated that all the dishes would be re-washed prior to serving the residents. During an interview with the 11:45 AM-7:00 PM evening kitchen supervisor on 05/4/2023 at 2:04 PM, they stated they (kitchen supervisor) worked the evening of 5/2/2023 and disconnected the sanitizing rinse agent from the machine with the intention to reconnect it but forgot to do so. They stated that it was their responsibility to ensure that the dishwashing machine was operational. 10 NYCRR 415.14(h)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023, the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #50) of four residents reviewed for Respiratory Care. Specifically, during the observation of Resident #50's tracheostomy (trach) care, the Respiratory Therapist (RT)#1 did not perform hand hygiene after glove changes and did not perform hand hygiene prior to replacing the sterile inner cannula back into the tracheostomy tube. The finding is: The facility's policy titled, Trach Care last reviewed 1/2023, documented a goal of trach care is to prevent infection; tracheostomy care should be performed using aseptic technique. The policy listed hand washing as the first step when caring for a disposable inner cannula. Resident #50 was admitted with diagnoses including Tracheostomy, Mandibular Cancer, and Diabetes Mellitus. The 3/24/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented the resident received tracheostomy care while a resident at the facility. A Comprehensive Care Plan (CCP), effective 3/28/2023, titled Infection: Abnormal Sputum Culture, documented sputum culture reports heavy growth of both Klebsiella Pneumonia and Serratia Marcescens. An intervention included to maintain infection control practices through proper handwashing. A Physician's order dated 4/30/2023 documented to -provide trach care every shift and when needed. -change the disposable inner cannula twice daily and when needed. -change the heat moisture exchanger (HME) every 24 hours and when needed. -Contact Precautions for Klebsiella Pneumonia and Serratia Marcescens. Resident #50's trach care was observed, performed by Respiratory Therapist (RT#1), on 5/8/2023 at 7:25 AM. A contact precautions sign was observed at the door and personal protective equipment (PPE) supplies were at the entrance. RT #1 donned (put on) full PPE (a mask, an eye shield, a gown, and gloves) to perform the trach care. RT #1 washed their hands first, put on clean gloves and set up the sterile field on the overbed table and then prepared all the supplies. RT #1 changed their gloves without performing hand hygiene. RT #1 suctioned the resident, changed their gloves; however, did not perform hand hygiene prior to donning a new pair of gloves. RT #1 stated they perform hand hygiene after every three glove changes. RT #1 then sanitized their hands and put on clean gloves. RT #1 then removed the HME device and took out the old trach dressing, removed the dirty gloves, and then put on sterile gloves without performing hand hygiene. RT #1 used their non-dominant hand to remove the old inner cannula and discarded it and used the dominant hand to pick up the sterile inner cannula and then placed the inner cannula into the trach tube. RT #1 changed the sterile gloves and put on new gloves without performing hand hygiene and then proceeded to complete the remainder of the trach care. The Respiratory Therapy (RT) Director was interviewed on 5/8/2023 at 8:08 AM. The RT Director stated that hands should be sanitized after removing the gloves. The RT Director stated the only sterile part of the whole procedure is replacing the inner canula, and the hands should have been sanitized before that. The Infection Preventionist/Inservice Coordinator (RN #1) was interviewed 5/8/2023 at 12:32 PM and stated that the staff member should have performed hand hygiene after each glove change. The Director of Nursing Services (DNS) was interviewed on 5/8/2023 at 2:10 PM. The DNS stated the best practice is to sanitize hands after each glove change. 10NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023 the facility did not ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This was identified for one (Resident #33) of five residents observed during Medication Administration Task. Specifically, during Resident #33's medication administration observation, the Licensed Practical Nurse (LPN) #1, medication nurse, drew up an injectable medication at the medication cart in the hallway and walked with the exposed needle to the resident's bedside. The finding is: The facility's policy titled Medication Administration (Injectable Medications), last reviewed 1/2023, documented to administer medications via injection maintaining sterility throughout the procedure. Withdraw specific dose (from vial) with syringe and replace needle protector to maintain sterility of needle. Resident #33 was admitted with diagnoses including Anemia, Diabetes Mellitus, and Chronic Kidney Disease (CKD). The 3/21/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's order dated 4/10/2023 documented to administer Retacrit 20,000 unit/milliliter (ml) injection solution, inject 20,000 units by subcutaneous route, every month on the first Thursday at 9 AM, for diagnosis of Anemia in CKD. During the medication administration observation on 5/4/2023, the first Thursday of May, at 9:13 AM, LPN #1 drew up the Retacrit injection into a syringe from a single-use vial at the medication cart in the hallway outside Resident #33's room. There was no needle protector to maintain sterility. LPN #1 then walked from the medication cart holding the syringe with the needle exposed, opened the resident's room door, and walked through the room to the resident's bedside while coming in close proximity to a Certified Nursing Assistant (CNA) who was in the room. LPN #1 was interviewed on 5/4/2023 at 9:49 AM and stated they (LPN #1) do not recap needles and stated they (LPN #1) should have drawn up the medication at the resident's bedside. The Registered Nurse (RN #1) Infection Preventionist/Inservice Coordinator was interviewed on 5/5/2023 at 8:30 AM. RN #1 stated ideally an injectable medication should be drawn up at the bedside to maintain sterility and avoid accidents. The Director of Nursing Services (DNS) was interviewed on 5/5/2023 at 8:51 AM. The DNS stated ideally an injectable medication should be drawn up at the bedside and the nurse should not walk around with the needle exposed. 10NYCRR 415.26(c)(1)(iv)

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023 the facility did not ensure that staff implemented and provided care and services according to resident needs and professional standards of practice for each resident with a feeding tube. This was identified for one (Resident #144) of five residents observed during the Medication Administration Task. Specifically, during Resident #144's medication administration observation, Licensed Practical Nurse (LPN) #2 did not check placement of the resident's feeding tube prior to administering the medications through the feeding tube. The finding is: The facility's policy titled Medication Administration via Enteral Feeding Tube, last reviewed 2/2023, documented the facility staff shall use appropriate procedures for the administration of medication via enteral feeding tube; and prior to administration if no feeding is in progress, check patency by attaching a syringe and aspirating a small amount of stomach content. Resident #144 was admitted with diagnoses including Chronic Respiratory Failure with Hypoxia, Gastrostomy Tube (G-Tube), and Diabetes Mellitus. The 2/5/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident had a feeding tube. A physician's order dated 4/14/2023 documented the resident had a feeding tube, was ventilator dependent, and was to receive nothing by mouth (NPO). During the medication administration observation for Resident #144 on 5/4/2023 at 8:50 AM, LPN #2 prepared the following physician-ordered medications at the medication cart in the hallway to be administered to the resident: Liquid protein supplement (LPS) 30 milliliter (ml) placed in a separate cup; Amiodorone (a cardiac medication) 200 milligram (mg) tablet crushed and mixed with 30 ml of water in a separate cup; Clopidogrel (a blood thinner) 75 mg tablet crushed and mixed with 30 ml of water in a separate cup; mineral oil (for constipation) 15 ml placed in a separate cup. After the medications were prepared at the cart, they were brought to the bedside by LPN #2. The resident was not currently receiving the tube feeding and the G-Tube was capped. LPN #2 did not check placement of the G-Tube prior to administering the medications and stated that the G-Tube placement was checked previously that morning. LPN #2 was re-interviewed on 5/4/2023 at 12:00 PM and stated they (LPN #2) have a lot of residents on transmission-based precautions to administer medications to. LPN #2 stated they (LPN #2) perform G-Tube placement checks and vital signs for all residents first thing in the morning, shortly after the shift starts at 7 AM. LPN #2 stated it saves time to check the tube placement in the morning because of all of the personal protective equipment (PPE) that has to be donned (putting on) and doffed (take off). Registered Nurse (RN) #2, the unit charge nurse, was interviewed on 5/4/2023 at 2:44 PM and stated checking for the placement of the G-Tube should be done at the time when the medications are being administered. RN #1, the Infection Preventionist/Inservice Coordinator, was interviewed on 5/5/2023 at 8:30 AM. RN #1 stated the G-Tube placement should be checked before giving medications; a few minutes before is acceptable, not an hour before. The Director of Nursing Services (DNS) was interviewed on 5/5/2023 at 8:55 AM and stated ideally the G-Tube placement check should be performed right before the medications are administered. 10NYCRR 415.12(g)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023, the facility did not ensure that each resident received care and necessary treatment and services in accordance with professional standards of practice to prevent pressure ulcers. This was identified for one (Resident #144) of six residents reviewed for Pressure Ulcers. Specifically, 1) Resident #144, who was ventilator dependent and required total assistance for bed mobility, was assessed at high risk for developing pressure ulcers. Resident #144 was assessed by the Dermatologist for a scabbed lesion to the right side of the scalp in March 2023 and was diagnosed with a Neoplasm (lesion). The Wound Care Physician categorized the lesion as a Stage II Pressure Ulcer on 3/24/2023. The Wound Care Physician also identified an Unstageable pressure ulcer to the left occipital area on 4/28/2023. On multiple occasions Resident #144 was observed lying in bed without a pillow and their head was making direct contact with the mattress. The resident was not assessed by the Rehabilitation Department for positioning devices to offload the head as per the resident's comprehensive care plan. 2) The resident weighed 180 pounds (lbs); however, the alternating air mattress utilized by the resident was observed with the air mattress pump set for 85 lbs weight. The finding is: The facility's policy titled Pressure Ulcer Prevention and Intervention Program, last reviewed 11/2022, documented residents of the facility will have a pressure ulcer and intervention program to identify risk factors, prevent pressure ulcer formation when avoidable and promote skin integrity, as well as interventions to heal existing pressure ulcers and prevent new pressure ulcers from developing. Resident #144 was admitted with diagnoses including Chronic Respiratory Failure with Hypoxia (Ventilator Dependent), Gastrostomy Status, and Diabetes Mellitus. The 2/5/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented the resident required extensive assistance of two staff members for bed mobility. The MDS documented that the resident had a Stage 2 pressure ulcer and was at risk for pressure ulcer development. Preventive treatments for pressure ulcers included pressure reducing device for chair, pressure reducing device for bed, nutrition and hydration interventions, and pressure ulcer care. The MDS documented the resident weighed 180 pounds and received tube feeding. The nursing admission assessment dated [DATE] included a Braden Scale (tool used to identify pressure ulcer risk). The resident's Braden Scare Score was 6, which indicated Resident #144 was at a very high risk for pressure ulcer development. A Dermatology Consult dated 3/10/2023 documented Resident #144 had a scabbed lesion on the right side of the scalp which was diagnosed as a neoplasm of uncertain behavior. The Dermatologist recommended a biopsy and to obtain family consent if the family wishes to proceed. Follow up in one month. The nursing progress note dated 3/13/2023 documented the resident's family refused to give consent for the biopsy. A Medical Wound Care Assessment note dated 3/24/2023 documented Stage 2 Pressure Injury to the Right Head Temporal region measuring 1.5-centimeter (cm) Width: 1.0 cm Depth: 0.1 cm The wound bed was 100% red. The recommendations were to adhere to the facility repositioning and decubitus prevention protocol. A Wound care nursing note dated 3/24/2023 documented the resident was seen for a re-opened wound to the right temporal area of the head. The Wound Care Physician ordered to apply Hydrogel to the area and cover with a dry protective dressing. A pressure relieving care plan was initiated. A Comprehensive Care Plan (CCP) titled Skin Integrity: Right Temporal Head, Stage 2 pressure injury to right temporal head, effective: 3/24/2023, documented interventions to offload pressure using a pillow and Physical Therapy (PT)/Occupational Therapy (OT) screen for proper positioning and devices. The CCP was created by the Registered Nurse (RN) wound care nurse (RN #3). A Medical Wound Care Assessment note dated 4/28/2023 documented suspected deep tissue pressure injury to the Left Head Occipital area measuring Length: 3.0 cm, Width: 2.5 cm, and the was Depth: 0. The Wound Bed was noted to be 10% red, 10% bruise, 80% black scab. The wound was located over a severe bony prominence. The Wound care nursing note dated 4/28/2023 documented the resident was seen by wound care team for a weekly follow up for a new skin opening to the left occipital head (deep tissue injury). The resident was assessed by the Wound Care Physician and ordered to apply Hydrogel to the area, then cover with a dry protective dressing. Pressure relieving devices in place. A CCP titled Skin Integrity, Unstageable to Left Occipital Head, effective: 4/28/2023, documented interventions to offload pressure using pillow and PT/OT screen for proper positioning and devices. The CCP was created by RN #3. A Comprehensive Care Plan (CCP) titled Skin Integrity: At Risk for further Skin Breakdown, effective 9/13/2022, last updated 4/29/2023, documented an intervention for PT /OT evaluation for appropriate preventive positioning device or equipment. The CCP was last updated by the RN #3. The Weekly Wound Care Notes from 3/24/2023 to 4/28/2023 documented the left occipital and right temporal head wounds as pressure ulcers. Resident #144 was observed lying in bed on 5/4/2023 at 2:32 PM. The resident's family member was present. The resident had dressings on both occipital (near the back) sides of the head and was observed with a small pillow behind the neck. The back of the resident's head was in direct contact with the mattress. There was no other pillow or offloading device present. The Rehabilitation (Rehab) Department Director was interviewed on 5/5/2023 at 2:21 PM and stated they have not received a referral to evaluate Resident #144 for pressure relieving devices from the wound care team. RN #3, the Wound Care Nurse, was interviewed on 5/5/2023 at 3:09 PM and stated the resident was on a turning and positioning and offloading protocol. A Wound Care Physician note dated 5/5/2023 at 7:52 PM documented due to the resident's medical history/comorbidities including respiratory failure, on ventilator to trach/quadriplegia, total assist, non-responsive, and with a history of pressure injuries, despite interventions in place to prevent skin breakdown such as pressure relieving devices, this wound occurrence was unavoidable. The wound is located over severe bony prominence. Resident #144 was observed in bed on 5/8/2023 at 7:06 AM. The resident had a small pillow behind their neck. There was no other pillow or offloading device present. The resident's left side occipital head was in direct contact with the mattress. Resident #144's wound care treatment was observed on 5/8/2023 at 7:46 AM. The treatment was performed by RN #7 and assisted by Certified Nursing Assistant (CNA #1, the resident's primary CNA). Also present was RN #2 (unit charge nurse). The resident was observed with a small pillow behind their neck. RN #2 stated the pillow was brought in by the resident's family last week. RN #2 stated the family refused to have a regular pillow and all the family allowed was a rolled-up sheet to be put behind the resident's neck. CNA #1 was interviewed on 5/8/2023 at 8:05 AM and stated just the rolled-up sheet had been used until the family brought in the small pillow. CNA #1 demonstrated putting a rolled-up sheet behind the resident's neck. The sheet did not prevent the head from coming in contact with the mattress. The Director of Nursing Services (DNS) was interviewed on 5/8/2023 at 8:32 AM and stated the wounds were clearly offloaded. The DNS stated there was no root cause investigation done to determine the cause of the wounds. The DNS stated the wound doctor did not recommend any offloading devices. The resident's family member was interviewed on 5/8/2023 at 9:20 AM. The family member stated the resident had redness to their ears, so they (family member) asked the staff to remove the regular pillow and just use a rolled-up sheet. The family member stated they then brought a small pillow approximately 10 days ago because the facility never provided any kind of device to take the pressure off and keep the head off the bed. RN #3 was re-interviewed on 5/8/2023 at 9:58 AM. RN #3 stated they (RN #3) were unaware that the resident was not utilizing a pillow and that the staff was using a rolled-up sheet to offload the resident's head. RN #3 stated the plan included use of an air mattress and a turning and positioning program. RN #3 stated no new interventions were added after the resident developed pressure ulcers to their head. RN #3 stated if they knew the family refused the use of a pillow, they would have put other interventions in place. The wound care physician was interviewed on 5/8/2023 at 10:50 AM and stated they did not know that the resident was not utilizing a pillow. The wound care physician stated they did not request a rehabilitation intervention, but the primary doctor or nursing could have done that. Resident #144's was observed lying in bed on an air mattress on 5/9/2023 at 10:21 AM. The air mattress pump was set at 85 pounds. The Primary Physician was interviewed on 5/9/2023 at 10:23 AM and stated that turning and positioning and use of an air mattress are great starting points. The Primary Physician stated the Rehabilitation Department should have been consulted regarding an offloading device or intervention because they (Primary Physician stated) did not know of any such device for offloading that could be used for the head. RN #2 was re-interviewed on 5/9/2023 at 10:45 AM and stated that the Housekeeper Lead is responsible for adjusting the settings on the air mattress. The Housekeeping Lead was interviewed in Resident #144's room on 5/9/2023 at 10:50 AM. The Housekeeping Lead stated they (Housekeeping Lead) only bring the air mattress from the storage area when an air mattress is ordered by the doctor. The Housekeeping Lead stated they situate the mattress in the resident's room but do not adjust settings on the pump. The Housekeeping Lead stated the setting is based on the weight of the resident. The Housekeeping Lead further stated they show the nursing staff how to change the settings on the pump, but they do not touch the settings. RN #2 was re-interviewed in Resident #144's room on 5/9/2023 at 10:58 AM and stated Resident #144's weight was 185 pounds. RN #2 stated the setting on the pump was incorrect and had to be shown by the Housekeeping Lead how to change the pump setting. RN #2 changed the weight setting to 185 pounds. RN #2 stated the CNAs change the settings. CNA #2, who was assigned to care for Resident #144, was interviewed on 5/9/2023 at 12:40 PM and stated they do not adjust the settings on the air mattress, and they were not sure who adjusts the setting on the air mattress. The Wound Care Physician was re-interviewed on 5/9/2023 at 2:00 PM. The wound care physician stated the right-side head wound has been diagnosed as a malignancy as per a dermatology consult of 3/10/2023. The Wound Care Physician stated the diagnosis of a Stage 2 pressure ulcer is wrong and it is their fault to call it Stage 2--it should have been malignancy. The wound care physician further stated it is possible that the left side head wound is a malignancy also. RN #3 (wound care nurse) was re-interviewed on 5/9/2023 at 02:50 PM and stated the setting on the air mattress has to be equal to the resident's weight to provide proper pressure relief. If the weight setting is too low, it will not provide appropriate pressure relief. 10NYCRR 415.12(c)(1)

Based on observation, interview, and record review during an abbreviated survey (NY 965) conducted on 7/16/2022 the facility did not ensure the residents environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, two Certified Nursing Assistants (CNA) failed to follow the Comprehensive Care Plan for two (Resident #1 and Resident #2) of three residents reviewed for accidents, resulting in a fall for both residents. The finding is: The facility's policy titled Accident Investigations reviewed 2/21/2018 documented it is the policy of the facility to maintain the safety of all residents, in as much as possible. The resident's environment remains as free of accident hazards as possible and at this facility each resident receives adequate supervision and assistive devices to prevent accidents. An incident is any occurrence that produces very slight physical injury. This includes but not limited to, a resident fall with or without injury. Injury in this case means superficial cuts, scratches, scrapes, and ecchymosis area. Staff training and practices that may endanger a resident's safety including but not limited to failure to provide assistive ambulatory/transfer devices to residents per plan of care. 1) Resident #1 was admitted to the facility on [DATE] with diagnoses including Fracture of 4th Cervical Vertebra, Multiple Fracture of Ribs, Dysphagia, and [CONDITION(S)]. The Minimum Data Set (MDS-an assessment tool) dated 4/18/2022 documented that Resident #1 had severely impaired cognitive skills for daily decision making. The MDS also documented Resident#1 required total assistance of 2 staff members for bed mobility and transfers. The Comprehensive Care Plan (CCP) dated 9/29/2021 documented that Resident #1 had a decrease in mobility, ambulation, and transfers. Interventions included extensive assistance with two staff members for bed mobility and mechanical lift transfers. The Certified Nursing Assistant (CNA) Accountability Record dated 10/6/2021 documented that Resident #1s transfer status was total dependence with two staff members while using a mechanical lift. The Physician's Orders (PO) dated 5/11/2022 documented to transfer Resident #1 was to get out of bed with a mechanical lift and two staff member assistance. The Nurse's Progress Notes (NPN) dated 5/26/2022 at 4:09 PM documented that at approximately 12:30 PM Resident#1 was found lying on the floor attached to the tilted mechanical lift in their room. Registered Nurse Manager (RNM) assessed Resident #1 and observed, redness to Resident #1's right knee with no pain. The Physician's Note (PN) dated 5/27/2022 documented resident was evaluated for a status post fall from bed onto the floor while staff attempted to transfer resident with a mechanical lift. The PN note documented that Resident #1 was examined and had right knee and bilateral lip swelling. The Accident/Incident (A/I) report dated 5/26/2022 documented that the Licensed Practical Nurse#1 (LPN) #1 entered Resident #1's room and observed that Resident#1 was partially attached to the mechanical lift and was lying on the floor. CNA #1 documented in the A/I report that Resident#1 was in their Geri chair with mechanical lift attached to Resident #1, the mechanical lift tilted, and Resident #1 was on the floor. The Investigative Summary dated 5/30/2022 documented that the investigation found that CNA#1 failed to use proper technique by not using a two staff member transfer. The facility concluded that there was no cause to believe any alleged abuse, mistreatment or neglect regarding this Resident#1 occurred. Review of CNA #1's personnel file documented that they (CNA#1) received a disciplinary suspension for 3 days (5/27/2022 to 5/29/2022) for failure to follow the Comprehensive Care Plan (CCP) which documented that Resident #1 was a two staff member assistance with transfer, with mechanical lift. During an interview with the Registered Nurse Manager (RNM) on 7/27/2022 at 3:00 PM they stated that they (RNM) saw Resident #1 in the mechanical lift with the pad attached and leaning on Geri chair. The RNM stated that Resident #1 was on their right-side in a lying position on the floor and that Certified Nursing Assistant#1 (CNA #1) was alone in the room. The RNM stated they assessed Resident #1 with redness of their right knee and a small bruise to their face (unable to recall if right or left). Resident #1 denied any pain. The RNM interviewed CNA #1 and stated they (CNA#1) was doing the mechanical lift transfer alone and that Resident #1 fell . The RMN stated that Resident #1's care plan documented two staff member assistance when using a mechanical lift. The RNM stated that CNA #1 did not follow the CCP. During an interview with the Director of Nursing (DON) on 7/27/2022 at 4:38 PM they stated that they (DON) reviewed the incident report for Resident #1 and there was no harm. The DON stated that, CNA#1 failed to follow the care plan and that CNA #1 admitted that they transferred Resident#1 via mechanical lift by themselves (CNA#1). During a telephone interview with CNA #1 on 8/15/2022 at 3:56 PM, CNA #1 stated that Resident#1 required a mechanical lift using two staff members. CNA#1 stated that at approximately 12:30 PM, they (CNA#1) wanted to transfer Resident#1 to the Geri chair. CNA #1 stated Resident#1 was safely over the Geri chair but when they started to straighten the mechanical lift it tilted, and Resident#1 was lowered to the floor. CNA#1 stated Resident #1 was still strapped to the mechanical lift. CNA #1 stated they transferred Resident #1 by themselves and knew there was a risk and that they were suspended for 3 days because they did not follow the care plan which documented two staff members for transfer. During a telephone interview with the Register Nurse Risk Manager (RNRM) who is also the Assistant Director of Nurses (ADON) on 8/23/2022 at 12:44 PM. The ADON stated that the facility concluded that Certified Nursing Assistant #1 (CNA#1) did not follow the CCP for Resident #1. The ADON stated Resident#1 had a CCP that documented two staff member assistance when transferring Resident #1 with a mechanical lift. The ADON stated that CNA #1 acknowledged that they transferred Resident#1 by themselves and was aware that Resident #1 required two staff member assistance. The ADON stated it was an avoidable fall since the care plan was not followed. 2) Resident #2 was admitted to the facility on [DATE] with diagnoses including Spinal Stenosis, [CONDITION(S)], Neuralgia and Chronic pain. The 5-day Minimum Data Set (MDS) assessment dated [DATE] documented that Resident#2 had intact cognition. The MDS also documented that Resident #2 required two staff members for transfers and bathing. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), Mobility, Ambulation and Transfers dated 4/19/2022 documented interventions for transfer from bed with two staff members assistance for Resident#1. The Physician Oder dated 5/9/2022 documented to transfer Resident #2 out of bed with two staff assistance. The Certified Nursing Assistant Accountability Record (CNAAR) dated 5/9/2022 documented that Resident#2 was a two staff member transfer. The CNAAR also documented that Resident#2 was on fall precautions. The Nursing Progress Notes (NPN) dated 6/16/2022 documented that at approximately 11:25 AM, Resident#2 was found sitting on the floor, the wheelchair was located on Resident#2's back. The NPN documented that Resident#2 just finished with a shower. The NPN documented that the overhead light in the shower room was off, and the floor was wet and slippery. The NPN documented Resident #1 was observed with a s (2-centimeter by centimeters) skin tear on their left wrist. The Medical Doctor notes dated 6/16/2022 documented that the Resident#2 had a fall today which was witnessed by Resident#2's Certified Nursing Assistant (CNA#2). Resident#2 did not hit their head. Resident did sustain a left wrist skin tear. The Occurrence Investigation Report dated 6/25/2022 documented the facility ruled out abuse, neglect, and mistreatment. During an interview with CNA #2 on 7/27/2022 at 2:08 PM, CNA #2 stated Resident#2 required two staff member assistance for transfers. CNA#2 stated that on 6/16/2202 Resident #2 was transferred from their wheelchair to a shower chair with CNA#3 while in their room. CNA #2 then transferred Resident #2 from the shower chair to their wheelchair by themselves. CNA #2 was holding Resident#2, but Resident#2 was too heavy, and CNA #2 sat Resident#2 on the floor. CNA #2 stated they thought Resident #2 was able to transfer with one staff member assistance. CNA #2 stated they failed to follow the Comprehensive Care Plan (CCP). During a telephone interview with the Registered Nurse Risk Manager/Assistant Director of Nurses (ADON) on 8/23/22 at 12:44 PM, the ADON stated the investigation summary documented that Resident#2 used a different chair and tried to self-transfer and the facility concluded that CNA#2 followed the CCP. The ADON then reviewed the written statement documented by CNA #2 and acknowledged that CNA #2 transferred Resident#2 from the shower chair to their wheelchair by themselves. The ADON stated that CNA#2 documented in the investigation that Resident#2 transferred independently (which was incorrect). The ADON stated from their recollection, CNA #2 tried to transfer the Resident#2 from the shower chair to their wheelchair by themselves and should not have. The ADON stated the fall was avoidable, because if CNA #2 followed the CCP for transfer, Resident#2 sliding from the wheelchair could have been avoided. During a telephone re-interview with the Director of Nursing Services (DON) on 8/23/2022 at 2:31 PM, the DON stated that it was reported that CNA #2 transferred Resident #2 from the shower chair to their wheelchair and that Resident#2 slid to the floor on their buttocks. The DON stated that based on the investigation and interview conducted with CNA #2 the facility acknowledged that Resident#2 required two-staff member assistance for transfers. The DON stated they were informed that the facility's investigative summary concluded that CNA#2 followed the CCP (which was incorrect). The DON reviewed the investigative summary and acknowledged that was the conclusion written and stated the facility should have investigated the incident more thoroughly. During a telephone interview with the Administrator on 9/15/2022 at 4:13 PM stated that CNA #1 and CNA #2 did not follow the plan of care for Resident #1 and Resident #2 which resulted in a fall. Administrator stated they reviewed the A/I summary with the DON and RM and discussed that the root cause analysis was that CNA#2 transferred Resident #2 with one staff member assistance instead of two. 415.12(h)(2)

Based on observation, interview, and record review during an abbreviated survey (NY 965) conducted on 7/16/2022 the facility did not thoroughly investigate the root cause of the incident related to a resident fall for one (Resident #2) of three residents reviewed for accidents. Specifically Resident #2 had a fall and the investigative report documented inaccuracy regarding how the resident (Resident #2) fell . The finding is: The facility's policy titled Accident Investigations reviewed 2/21/2018 documented that all accidents or incidents, involving residents, must be thoroughly documented in the resident's medical record. The CNA assigned to the resident will complete an investigation statement and a statement will be completed by the person who found or witnessed the accident/incident. The ADNS or designee will complete the accident/incident Investigation Report Summary, draw a conclusion and formulate a root cause analysis and implement any intervention, to prevent reoccurrence. All accidents/incidents will be investigated with a root cause analysis. The findings of such investigation will be determined by the ADNS or the DNS and will be recorded on the Investigation Summary Report form, accordingly. The DNS will review with Medical Director and Administrator. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set (MDS) assessment dated [DATE] documented Resident#2 had intact cognition. The MDS also documented that Resident #2 required extensive assistance of two staff members for transfers. The fall risk assessment dated [DATE] and 5/7/2022 documented resident was at risk for falls. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL), Mobility, Ambulation and Transfers dated 4/19/2022 documented interventions including but not limited to transfer Resident #2 with two staff members. The Certified Nursing Assistant Accountability Record dated 5/9/2022 documented Resident#2's transfer instructions were two staff member assistance. The Certified Nursing Assistant (CNA#2) Investigation Statement dated 6/16/2022 documented that CNA#2 finished showering Resident#2, and then attempted to transfer the resident from the shower chair to their wheelchair but the shower chair slid, and Resident#2 slid to the floor. The facility's Occurrence Investigation Report (OIR) completed by the Director of Nursing (DON) dated 6/25/2022 documented Registered Nurse Manager(RNM) reported that at approximately 11:25 AM, RNM entered the shower room and observed Resident #2 sitting on the floor with their wheelchair on their back. Inspection of the shower room floor revealed it was wet and slippery. RNM completed an assessment and a 2 x 2 skin tear was observed on Resident #2's left wrist. The OIR documented CNA#2 reported Resident#2 slipped from the shower chair. The OIR documented that staff interviews and statements were collected and revealed that staff (CNA#2) followed the Comprehensive Care Plan for Resident#2. The OIR documented the facility concluded that there was no cause to believe that resident abuse, mistreatment, or neglect had occurred. The OIR lacked documented evidence that the incident was thoroughly investigated; regarding Comprehensive Care Plan violation. During an interview with Certified Nursing Assistant#2 (CNA #2) on 7/27/2022 at 2:08 PM, CNA#2 stated that Resident#2 required one staff member assistance during a shower or bed bath but for transfers requires two staff member assistance. CNA#2 stated that on 6/16/2022 CNA #2 was transferring Resident #2 from the shower chair to their wheelchair alone. CNA #2 stated they were holding the resident from their back but was unable to hold resident's weight and Resident #2 was sliding and they lowered the resident to the floor. CNA #2 stated they thought Resident #2 was able to transfer with one person assistance and they did not call for assistance. CNA #2 stated that they knew they (CNA#2) failed to follow the Comprehensive Care Plan. During an interview with the Registered Nurse Manager (RNM) on 7/27/22 at 3:00 PM, the RNM stated they heard a fall in the shower room. RNM checked the shower room and saw Resident #2 sitting on the floor with their wheelchair on their back and CNA #2 was holding the resident. RNM stated the floor was wet. CNA #2 was interviewed and stated the Resident#2 slipped from their wheelchair when CNA #2 was transferring them without assistance. Resident #2's CCP documented two staff member assistance with transfer. The RNM stated that CNA #2 did not follow the plan of care. During an interview with the Assistant Director of Nursing (ADON)/Risk Manager (RM)on 7/27/2022 at 1:09 PM the ADON stated that right now they are still in the process of writing the investigative summary and they have a backlog from December 2021. During a phone reinterviewed with the ADON/RM on 8/23/2022 at 12:44 PM, the ADON stated that Resident #2's fall was a witnessed incident and according to the investigation, Resident#2 tried to self-transfer. The ADON stated the facility concluded that the staff (CNA#2) followed the CCP. The ADON reviewed CNA#2's statement and stated they (CNA#2) documented Resident#2 was transferred independently. ADON stated from their recollection, CNA #2 tried to transfer the Resident#2 from shower chair to wheelchair by themselves. ADON/RM was informed about the inconsistencies in the investigative summary and the The ADON stated that they should have further investigated the incident due to the inconsistencies. The ADON stated the conclusion should have been that CNA #2 did not follow the Comprehensive care Plan which documented that Resident #2 was a two staff member transfer. During a telephone reinterviewed with the Director of Nursing (DON) on 8/23/2022 at 2:31 PM the DON stated that based on investigation and interview conducted with CNA #2 they acknowledged that Resident#2 required two staff members to assist with transfers. The DON stated that CNA #2 transferred Resident#2 by themselves and should have known better. The DON stated they reviewed the investigative summary and acknowledged that the conclusion no CCP violation should not have been based on staff (CNA#2's) statement. The investigative summary should have been revised to reflect the actual incident that occurred. During a telephone interview with the Administrator on 9/15/2022 at 4:13 PM the Administrator stated they were aware of the backlog in writing the investigative report and stated the investigative summaries were not timely as they could but the A/I was reviewed, and interventions were put in place. The Administrator stated they will be looking into the root cause anylisis. 415.4(b)(3)

Based on observations, record review and interviews during a COVID-19 Focused Infection Control Survey conducted on 01/29/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of COVID-19. Specifically, the facility did not implement Transmission Based Precautions (TBP) and utilize required Personal Protective Equipment (PPE) during direct resident care for one of seven units observed. The finding is: The Centers for Disease Control and Prevention (CDC) Responding to Coronavirus (COVID-19) in Nursing Homes guidance, updated 4/30/2020, documented that if the Health Care Professional (HCP) is diagnosed with [REDACTED]. The CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20, documented: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. The New York State Department of Health (NYSDOH) Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/2020 revised 7/10/2020, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. The facility COVID -19 Pandemic Specific Infection Control Plan Policy and Procedure dated 3/4/2020 last revised 9/17/2020 documented it is the policy of the facility that residents, visitors, and staff risk for COVID-19 virus is minimized. In addition, the facility will implement appropriate infection control precautions as needed in the event of a positive case of COVID-19. The procedure for wearing Personal Protective Equipment include: GLOVES - perform hand hygiene, then put on non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient care area and immediately perform hand hygiene. GOWNS - Put on a clean isolation gown upon entry into the patient room or care area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient care area. During an entrance interview on 1/29/2021 at 10:00 AM with the Administrator and the Director of Nursing, both stated the whole facility was on contact and droplet precautions. They further added that the use of an isolation gown was required when entering any resident room in the facility. The facility list of employees furloughed from COVID-19 Positive Test/Exposure dated 1/29/2021, documented that Certified Nursing Assistant (CNA) #3 was tested on [DATE] and tested positive for COVID-19 on 1/20/2021. CNA #3 last worked on Unit 4 on 1/20/2021. The 4 North Unit was observed on 1/29/2021 from 12:45 PM to 1:30 PM. Signs on the double doors read upon entry to unit wash hands. Face shield/goggles are required in this area. Keep doors closed at all times. Cover your cough. Each door to the resident rooms had green droplet precaution and yellow contact precaution signs. The green sign for droplet precaution documented everyone must clean their hands, including before entering and when leaving the room. Make sure eyes, nose and mouth are fully covered before room entry or remove face protection before room exit. The Yellow sign for contact precautions documented everyone must clean their hands including before entering and when leaving the room. Providers and staff must also put on gloves before room entry, discard gloves before room exit, put on gowns before room entry, discard gown before room exit. Do not wear the same gown and gloves for the care of more than one resident. Use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person. On 1/29/2021 at 12:50 PM, an observation on Unit 4 revealed, CNA #1 was observed feeding Resident #3. CNA #1 was not wearing an N95 respirator, gloves, or a gown. She was wearing a surgical mask, hair covering, and a face shield. On 1/29/2021 at 12:55 PM, an observation on Unit 4 revealed, CNA #2 was observed feeding Resident #4. CNA #2 was not wearing an N95 respirator, gloves, or a gown. She was wearing a surgical mask, hair covering, and a face shield. Registered Nurse (RN) #1 on Unit 4 was interviewed on 1/29/2021 at 1:00 PM. RN #4 stated that a gown is needed if there is direct care and a gown should be worn when feeding residents in the resident rooms. CNA # 1 was interviewed on 1/29/2021 at 2:10 PM and stated that she was told during an infection control in-service given by the in-service coordinator, that anytime you go into the room for more than 10 minutes, you should wear a gown, gloves, face shield, and a mask. She stated that she should have worn a gown and gloves while feeding Resident #3, but she forgot to put on a gown and gloves after feeding another resident in another room. CNA # 2 was interviewed on 1/29/2021 at 2:20 PM and stated that taking care of the resident means we should wear a gown, a face shield, an N95 with a surgical mask, and gloves when washing, feeding and providing direct care such as toileting the residents. The gown, gloves and the surgical mask should be discarded into a bag and hands should be washed. CNA #2 stated that she did not put on a gown while feeding Resident# 4 because she did not think it would take her more than 10 minutes to feed the resident. The Administrator was interviewed on 1/29/2021 at 3:30 PM and stated that the staff is expected to wear gowns and gloves when feeding residents because the whole facility is on contact and droplet precautions. 415.19(a)(1-2); 400.2

Based on observations, record reviews, and staff interview during the recertification survey the facility did not ensure that a comprehensive person-centered care plan was developed for each resident. This was identified for one (Resident # 226) of six residents reviewed for pressure ulcer. Specifically, Resident # 226 had a physician's orders [REDACTED]. The finding is: Resident #226 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. The resident required total assist of one to two staff members for all Activities of Daily Living (ADLs) and had an indwelling Foley Catheter. The resident was at risk for PU and had one unhealed Stage III PU that was present on admission. A physician's orders [REDACTED]. A CCP for Skin Integrity dated 9/11/20 documented the resident had a Stage III skin breakdown on the Sacrum. The interventions included to apply local treatment as ordered by the Physician. The CCP did not include the Diathermy Treatment and the frequency of the treatment. Physical Therapy Progress Notes dated 9/8/2020 to 9/18/2020 documented the resident will receive Diathermy treatment to the sacrum to promote wound healing. Physical Therapy Progress Note dated 9/19/2020 to 9/30/2020 documented the resident displayed a decrease in wound size in length and depth. Will continue with treatment plan to promote continued healing. An interview was conducted on 10/28/20 at 9:50 AM with the Director of Rehabilitation regarding the CCP for the Diathermy Treatments. She stated that the Physical Therapist (PT) and Occupational Therapist (OT) were responsible for completing the activities of daily living (ADL) CCP and that they do not usually initiate a CCP for treatments. She stated all documentation for the treatment would be completed in the PT progress notes. An interview was conducted on 10/28/20 at 10:07 AM with the Physical Therapy Assistant (PTA). The PTA stated she was assigned to the resident and was responsible for administering the Diathermy treatment. The PTA stated that the treatment was initiated due to the presence of a Stage III PU and was a part of the resident's treatment plan. When the PTA was asked if the resident received the Diathermy treatments, the PTA stated when she attempted to administer the treatment, however, because of the resident's positioning and behavioral issues, she was unable to administer the treatment. The PTA stated the Diathermy Treatment required staying very still and that the resident was unable to stay still for the treatment to be administered. An interview was conducted on 10/28/2020 at 11:21 AM with the Physical Therapist (PT) Supervisor. The PT stated that he initiated the Diathermy Treatment order and that usually to get the optimum result for this treatment a minimum of 3 times weekly is best. The PT stated when treatments are initiated all administration of treatment is documented in the Physical Therapy progress notes and did not state who was responsible for updating the CCP. An interview was conducted on 10/28/2020 at 1:06 PM with the Director of Nursing Service (DNS). The DNS stated that for any treatment modality initiated by the Rehabilitation department, the staff member that initiates the order was responsible for initiating or updating the CCP. 415.11(c)(1)

Based on interviews and record review during an abbreviated survey (Case # NY 481), the facility did not ensure that one (Resident #1) of four residents reviewed for drugs and medication remained free of significant medication error. Specifically, facility staff administered [MEDICATION NAME] (an opioid (narcotic) [MEDICATION NAME]) without a prescribed order to Resident #1. Subsequently, the resident was transferred and admitted to the hospital with [REDACTED]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings were: The facility's policy titled Administration of Medication - Medication Dispensing System dated 1/2009 documented that all medications will be prepared and administered in a manner consistent with the general requirements which included verifying each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, right time and right customer. Verify that the Medication Administration Record [REDACTED]. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 8/31/18 documented the resident's cognitive status as moderately impaired. He required limited assistance for bed mobility, transfer, eating, dressing and toilet use. The physician's orders [REDACTED]. The Nursing Progress Notes (NPN) dated 9/5/18 to 9/14/18 documented the resident was alert, verbally responsive with periods of confusion. The NPN dated 9/15/18 at 1:11 PM documented the resident was usually alert and verbal. He was out of bed at 9:00 AM to wheelchair, ate breakfast and was communicating with other residents. The resident was noted with change in mental status, hard to arouse, blood sugar taken 367mg/dl (time not documented). The physician (MD) was made aware. The resident was transferred to the hospital to rule out [MEDICAL CONDITIONS]. The NPN dated 9/15/18 at 5:25 PM by the Registered Nurse (RN) documented at 1:15 PM the resident was admitted to hospital with altered mental status. The hospital urine toxicology results dated 9/15/18 at 3:15 PM documented positive for [MEDICATION NAME]. The PO lacked documented evidence of orders for narcotics including [MEDICATION NAME]. The medical record lacked documented evidence of a history of drug abuse for the resident. The Medication Administration Record [REDACTED]. The facility medication incident report dated 9/18/18 documented an incorrect medication was administered to the incorrect resident (#1). Resident #1 was transferred to the hospital secondary to marked lethargy. The hospital urine toxicology for Resident #1 tested positive for [MEDICATION NAME]. The resident was not on [MEDICATION NAME] however, his roommate (Resident #2) was on a routine [MEDICATION NAME] 40 mg daily. The facility's investigative summary dated 9/19/18 documented, on 9/15/18 at approximately 12:15 PM, a staff member in the dining room observed the resident with marked weakness. The RNS assessed the resident. The resident was not responding to a sternal rub (painful stimuli), verbal or tactile stimuli. The physician ordered to transfer the resident to the hospital to rule out [MEDICAL CONDITION]. The physician later notified the facility that a CT (computerized tomography) scan was negative for [MEDICAL CONDITION], however a urine toxicology test was positive for [MEDICATION NAME]. The resident was not receiving [MEDICATION NAME] while at the facility and did not have a PO to receive [MEDICATION NAME]. The facility investigation concluded that a medication error occurred. The hospital discharge summary dated 9/25/18 documented the resident presented to Emergency Department (ED) unresponsive, not responding to deep painful stimuli, bilateral pinpointed pupils and shallow, sluggish respirations. The patient was found to be positive for [MEDICATION NAME] on urine toxicology, but unresponsive to [MEDICATION NAME] (antidote for narcotic) twice in the ED. He was admitted to medical intensive care unit for altered mental status. His symptoms were likely secondary to accidental [MEDICATION NAME] administration at the facility. The 7:00 AM-3:00 PM Certified Nurse's Aide (CNA) #1 was interviewed on 1/2/19 at 2:35 PM and stated on 9/15/18 Resident #1 was alert and greeted staff and residents during breakfast. Prior to lunch, Resident #1 was in the dining room sitting in a wheelchair. His eyes were closed, she shook him a couple of times, but he was not moving. CNA #1 notified LPN #1 who instructed her to place him back to bed. The 7:00 AM-3:00 PM Certified Nurse's Aide (CNA) #2 was interviewed on 1/2/19 at 2:59 PM and stated she was assigned to Resident #1 on 9/15/18. She dressed Resident #1 in the morning and he was responsive and was talking to her during care. She placed him in the dining room for breakfast at approximately 8 AM. Prior to lunch Resident #1 became unresponsive and she assisted in placing him back to bed. The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN) #1 was interviewed on 1/2/19 at 3:14 PM and stated she worked on 9/15/18 on the unit but was not assigned to Resident #1. LPN #2 was assigned to administer medications from 7AM -11 AM for Resident #1 and #2. Usually the resident was alert, talkative and joked around with staff. In the morning (could not recall time) the resident was alert and talkative. CNA #1 (time not recalled) reported to her that Resident #1 was not his usual self. LPN #1 observed Resident #1, he was very lethargic almost non-responsive. LPN #1 called the Registered Nurse Supervisor (RNS). The RNS evaluated Resident #1 and he called the physician who ordered to transfer Resident #1 to the hospital. The RNS was interviewed on 1/2/19 at 3:47 PM and stated that he responded to a call from LPN #1 at approximately 12:45 PM. Upon assessment Resident #1 was not responsive to verbal and tactile stimuli. He did not respond to a sternal rub (painful stimuli). He appeared as if he was in a deep sleep. RNS called physician and the resident was sent to the hospital. His vital signs were stable but there was a sudden change in his mental status since the morning. The RNS did not know the reason why there was a change in the resident's mental status. Later he was informed by the physician that the resident was admitted to the hospital and found to have [MEDICATION NAME] in his system. The Director of Nursing (DON) was interviewed on 1/2/19 at 3:41 PM and stated the facility initiated an investigation when the physician notified the facility of the positive toxicology results for [MEDICATION NAME] for Resident #1. The resident's roommate (Resident #2) was on [MEDICATION NAME]. LPN #2 denied administering [MEDICATION NAME] to Resident #1. However, the DON believed that a medication error occurred and LPN #2 inadvertently administered [MEDICATION NAME] to Resident #1 instead of Resident #2. The DON stated that the 9 AM dose of [MEDICATION NAME] administered on 9/15/18 resulted in Resident #1's change in mental status. A subsequent interview was conducted with the DON on 1/3/19 at 5:03 PM. She stated that the resident did not have any history of drug use or [MEDICATION NAME] use based on both record review and interview with the resident's family. The family was also interviewed and denied supplying [MEDICATION NAME] to the resident. LPN #2 was the only nurse who administered the medications on 9/15/18 in the morning to both the residents (#1 and #2). The facility concluded that medication error had occurred at the facility and the resident received the [MEDICATION NAME] in error. The Primary Medical Doctor (PMD) was interviewed on 1/2/19 at 4:40 PM via phone and he stated he was called by the nurse and reported that Resident #1 might have had a stroke and he was sent to hospital. The CT scan was negative for stroke. Urine toxicology came back positive for [MEDICATION NAME]. Resident #1 was not on [MEDICATION NAME] and had no order for it. The PMD stated the [MEDICATION NAME] effects are evident within 2-3 hours after administration. The MD stated that the only explanation for a positive toxicology report was that the resident received the medication ([MEDICATION NAME]) on 9/15/18 with his morning medication administration. The Resident had a [MEDICAL CONDITION] and the [MEDICATION NAME] stayed in his system longer. The PMD stated that he agreed with the facility's investigation conclusion that a medication error had occurred. The PMD was confident that the only way Resident #1 could have received the [MEDICATION NAME] was from the facility. During a subsequent interview with PMD on 1/3/19 at 5:15 PM he stated he saw Resident #1 in the hospital on [DATE] and he was still lethargic. He received intravenous fluids in the hospital and on 9/17/18 the resident was back to his baseline. The 7:00 AM-3:00 PM LPN #2 was interviewed via phone on 1/7/18 1:08 PM and stated on 9/15/18 she was the medication nurse from 7:00 AM-11:00 AM assigned to Resident #1 and #2. LPN #2 denied administering [MEDICATION NAME] to the resident (#1). 415.12(m)(2)

Based on staff interviews and record review during an abbreviated and partial extended survey (Complaint # NY 307) the Medical Director failed to ensure that the facility provided care in accordance with current standards of practice to meet the needs for 1 Resident (#1) of 3 residents reviewed for Respiratory/[MEDICAL CONDITION] Care. Specifically, the Medical Director failed to ensure that the Policies and Procedures were developed and implemented to provide and monitor the respiratory support necessary to ensure adequate ventilation for Resident #1. The Medical Director also failed to coordinate the medial care of Resident #1 with a known recent history of not tolerating the weaning process. This failure resulted in Resident #1 not being placed back on the ventilator on [DATE] as recommended by the pulmonologist. On [DATE] at 7:52 PM resident was found unresponsive and without pulse; not on a ventilator. Subsequently, Resident #1 was sent to the hospital and expired in the hospital. This resulted in actual harm with potential for serious harm that is Immediate Jeopardy. Cross References: F695-Respiratory/[MEDICAL CONDITION] Care and Suctioning F710- Physician Services F835-Administration The findings are: The Policy & Procedure titled Flow Sheet for Trach(eostomy) Resident dated [DATE] documented it was the policy of facility to check [MEDICAL CONDITION] resident every 4 hours and as needed. Each time when therapist checked the residents they were to fill out the flow sheet for ventilator and [MEDICAL CONDITION] residents. For 8-hour shift, residents were to be checked twice and for 12 hours shift, 3 times per shift and findings documented on the flow sheet. In between the flow sheet, checks were to be done to make sure resident was ok and if needed, to suction the resident. Pulse oximetry should be done each time during the 4-hourly checks. The oxygen saturation, Heart Rate, Respiratory Rate, oxygen settings and suction were to be documented on the flow sheet. The Policy and Procedure Titled Physician orders [REDACTED]. If patient did not tolerate the physicians order make changes and notify the Director of Respiratory, nurse in charge of the patient and physician to get new orders. The Policy and Procedure titled Tracheolife dated [DATE] documented [MEDICAL CONDITION] Physician or Physician assistant will make decision of the use of Tracheolife in residents. Monitor the oxygen saturation with pulse oximeter for ventilator weaning residents. The facility lacked documented evidence of policies and procedures related to Respiratory Therapist assignments and scheduling. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set assessments dated [DATE] and [DATE], the resident had severely impaired cognitive status, required total assistance with activities of daily living (ADLs) and was receiving special treatments including oxygen therapy, suctioning, [MEDICAL CONDITION] care and ventilator use. The Primary Medical Doctor (PMD) was interviewed on [DATE] at 1:30 PM and he stated that he did not write the respiratory orders. They were written by the Director of Respiratory Therapy (DRT) in conjunction with the Pulmonologist and he just okayed them. The PMD stated when the [MEDICAL CONDITION] consultant saw the resident, the staff did not necessarily have to call him to report the recommendation. The PMD stated that the RT team did not need PMD approval in writing the orders. There was no report to him regarding resident's desaturation episode on previous occasions including not tolerating the weaning process. The MD stated that no one from the facility made him aware of [MEDICAL CONDITION] recommendation on [DATE]. The DRT was interviewed on [DATE] at 10:15 AM and he stated that the Pulmonologist evaluated resident and decided if resident should be weaned. Pulmonologist would inform the RT. The Pulmonologist or DRT would write the orders related to ventilator care. The Pulmonologist controlled the ventilator setting orders except in emergency where the Primary Physician could approve the changes in vent settings based on RT recommendations. The DRT stated he did not usually inform the PMD of the Pulmonologist's recommendations. The DRT stated at times he did verbally inform the PMD, if the PMD was onsite. the DRT stated on [DATE] he received the written recommendation from the Pulmonologist Physician Assistant (PA) but he did not notify the PMD. The Medical Director (MD) was interviewed via phone on [DATE] at 3:40PM and he stated that he reviewed all the policies and procedures related to nursing and medical and not the respiratory department. MD stated he was not responsible for the Respiratory Care Policy and Procedures. The Respiratory Department Director of RT was responsible for them. The MD stated that he expected that when the Pulmonologist made recommendations, the PMD should be contacted, made aware and approve the order. The MD stated he could not recall who wrote the respiratory orders. The facility policy was that all consultants would make recommendations; all orders should be called in to PMD who should then approve the orders. The Administrator was interviewed on [DATE] at 4:04 PM and she stated that the MD should review the policies and procedures related to medical care including the Respiratory Care Policies. 415.15(a)

Based on staff interviews and record review during an abbreviated and partial extended survey (Complaint # NY 307) it was determined that the administrations failed to have an effective system in place to provide and monitor the respiratory support necessary to ensure adequate Ventilation for Resident #1. Specifically, the Administration failed to ensure that policies and procedures to effectively communicate resident's respiratory condition/needs were developed and implemented. Additionally, the Administration also failed to ensure appropriate Respiratory Therapy (RT) coverage and hand off of the assignment when an assigned Respiratory Therapists completed their scheduled shift. Resident #1 was found unresponsive without a pulse by facility staff, emergency services were activated. Resident #1 subsequently died in the hospital. This resulted in actual harm with potential for serious harm that is Immediate Jeopardy. Cross References: F695-Respiratory/[MEDICAL CONDITION] Care and Suctioning F710- Physician Services F841-Medical Director The findings are: The Policy & Procedure titled Flow Sheet for Trach(eostomy) Resident dated [DATE] documented it was the policy of facility to check [MEDICAL CONDITION] resident every 4 hours and as needed. Each time when therapist checked the residents they were to fill out the flow sheet for ventilator and [MEDICAL CONDITION] residents. For 8-hour shift, residents were to be checked twice and for 12 hours shift, 3 times per shift and findings documented on the flow sheet. In between the flow sheet, checks were to be done to make sure resident was ok and if needed, to suction the resident. Pulse oximetry should be done each time during the 4-hourly checks. The oxygen saturation, Heart Rate, Respiratory Rate, oxygen settings and suction were to be documented on the flow sheet. The Policy and Procedure Titled Physician orders [REDACTED]. If patient did not tolerate the physicians order make changes and notify the Director of Respiratory, nurse in charge, patient and physician to get new order. The Policy and Procedure titled Tracheolife dated [DATE] documented [MEDICAL CONDITION] Physician or Physician assistant will make decision of the use of Tracheolife in residents. Monitor the oxygen saturation with pulse oximeter for ventilator weaning residents. The facility lacked documented evidence of policies and procedures related to Respiratory Therapist assignments and scheduling. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set assessments dated [DATE] and [DATE], the resident had severely impaired cognitive status, required total assistance with activities of daily living (ADLs) and was receiving special treatments including oxygen therapy, suctioning, [MEDICAL CONDITION] care and ventilator use. The Primary Medical Doctor (PMD) was interviewed on [DATE] at 1:30 PM and he stated that he did not write the respiratory orders. They were written by the Director of Respiratory Therapy (DRT) in conjunction with the Pulmonologist and he just okayed them. The PMD stated when the [MEDICAL CONDITION] consultant saw the resident, the staff did not necessarily have to call him to report the recommendation. The PMD stated that the RT team did not need PMD approval in writing the orders. There was no report to him regarding resident's desaturation episode on previous occasions including not tolerating the weaning process. The MD stated that no one from the facility made him aware of [MEDICAL CONDITION] recommendation on [DATE]. The DRT was interviewed on [DATE] at 10:15 AM and he stated that the Pulmonologist evaluated resident and decided if resident was for weaning. Pulmonologist would inform the RT. The Pulmonologist or DRT would write the orders related to ventilator care. The Pulmonologist controlled the ventilator setting orders except in emergency where the Primary Physician could approve the changes in vent settings based on RT recommendations. The DRT stated he did not usually inform the PMD of the Pulmonologist's recommendations. The DRT stated at times he did verbally inform the PMD, if the PMD was onsite. the DRT stated on [DATE] he received the written recommendation from the Pulmonologist Physician Assistant (PA) but he did not notify the PMD. The Medical Director (MD) was interviewed via phone on [DATE] at 3:40PM and he stated that he reviewed all the policies and procedures related to nursing and medical and not the respiratory department. MD stated he was not responsible for the Respiratory Care Policy and Procedures. The Respiratory Department Director of RT was responsible for them. The MD stated that he expected that when the Pulmonologist made recommendations, the PMD should be contacted, made aware and approve the order. The MD stated he could not recall who wrote the respiratory orders. The facility policy was that all consultants would make recommendations; all orders should be called in to PMD who should then approve the orders. The Administrator was interviewed on [DATE] at 4:04 PM and she stated that the facility staff reviewed the Policy and Procedures on yearly basis. The Administrator stated that as an Administrator she was made aware of changes in Policies and Procedures but she did not have any part in implementing the Polices. The Administrator stated that she was made aware of incident with Resident #1 by the Director of Admissions on [DATE] due to concerns raised by Resident #1's family related to her death, care and other issues. The Administrator stated that the facility concluded that RT #1 had falsely documented that she placed Resident #1 back on vent yet, Resident #1was not placed back on the Ventilator. RT #1 left her shift and did not give report to other RTs on the unit. RT #1 left the entire Ventilator log blank. The Administrator stated looking back into the incident there was a lapse in communication between Pulmonologist, RT and PMD. The Administrator stated that the MD is expected to be overseeing policies related to all medical care areas including Respiratory Care Policies. 415.26

Based on observation, interview and record review during an abbreviated and Partial Extended survey (Complaint # NY 307) the facility failed to ensure that Resident #1's medical care was supervised by a Primary Care Physician (PMD) who was responsible for managing resident's medical care. Specifically, Resident #1's PMD was not aware of resident's failure of weaning from a ventilator to Tracheolife and recommendations provided by the Pulmonologist to place Resident #1 back on the ventilator on [DATE]. Resident #1 was found unresponsive without a pulse and subsequently died in the hospital. Upon interview the PMD stated that the Respiratory Therapists (RT) did not need PMD's approval in writing the physician's orders [REDACTED]. The PMD was not necessarily informed of new recommendations from the [MEDICAL CONDITION] consultant. This resulted in actual harm and potential for serious harm that is Immediate Jeopardy. Cross References: F695-Respiratory/[MEDICAL CONDITION] Care and Suctioning F835-Administration F841-Medical Director The findings are: The Policy and Procedure Titled Physician order [REDACTED]. When making changes to the Ventilator setting, the RT would write a note in respiratory progress note section with the Ventilator settings. If resident did not tolerate the physician's orders [REDACTED]. The Policy lacked guidance related to communicating recommendations of the [MEDICAL CONDITION] Consultant to the PMD. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set assessments dated [DATE] and [DATE], the resident had severely impaired cognitive status, required total assistance with activities of daily living (ADLs) and was receiving special treatments including oxygen therapy, suctioning, [MEDICAL CONDITION] care and ventilator use. The Primary Medical Doctor (PMD) was interviewed on [DATE] at 1:30 PM and he stated that he did not write the respiratory orders. The orders were written by the DRT in conjunction with the Pulmonologist and he just okayed them. Resident #1 was due for discharge to home on [DATE]. The PMD stated that he saw the resident on [DATE] at 3:30 PM, resident was on Tracheolife, not in distress and hemodynamically stable. The PMD stated when the [MEDICAL CONDITION] consultant saw the resident, the staff did not necessarily have to call him to report the recommendation given by the pulmonologist. The PMD stated that the RT team did not need PMD approval in writing the orders. There was no report to him regarding resident desaturation episode on previous occasions or not tolerating the weaning. The PMD stated that no one from the facility made him aware of [MEDICAL CONDITION] recommendation on [DATE]. He received a call at 8:00 PM on [DATE] regarding Resident #1 being unresponsive, CPR started and 911 was called. The DRT was interviewed on [DATE] at 10:15 AM and he stated that the Pulmonologist would inform the RT of his recommendations to wean residents off the ventilator. The Pulmonologist or DRT would write the orders related to ventilator care. The Pulmonologist controlled the ventilator setting and orders except in emergency where the Primary Physician could approve the changes in vent settings based on RT's recommendations. The DRT stated he did not usually inform the PMD of the Pulmonologist's recommendations. The DRT stated at times he did verbally inform the PMD, if he was onsite. the DRT stated on [DATE] he received the written recommendation from the Pulmonologist Physician Assistant (PA) but he did not notify the PMD. The Medical Director (MD) was interviewed via phone on [DATE] at 3:40PM and he stated that he reviewed all the policies and procedures related to nursing and medical and not the respiratory department. MD stated he was not responsible for the Respiratory Care Policy and Procedures. The Respiratory Department Director of RT was responsible for them. The MD stated he expected that when the Pulmonologist made recommendations, the PMD should be contacted, made aware and approve the order. The MD stated he could not recall who writes the respiratory orders. The MD further stated that when a consultant made recommendations; all recommendations should be communicated to the PMD who would then approve the orders. The Administrator was interviewed on [DATE] at 4:04 PM, she stated that the DRT could not write the orders. The Administrator stated that the expectation was that the PMD approved the recommendations from the pulmonologist and wrote orders or gave approval for the recommendations. The DRT should have notified the PMD of any changes in resident's condition. The Administrator further stated that the DRT also should have communicated the consultant's recommendations to the PMD. 415.15(b)(1)(i)(ii)

Based on observation, interview and record review during an abbreviated survey (Complaint #NY 307) the facility failed to have effective systems in place to assure that the respiratory support needed to ensure adequate ventilation was communicated, ordered and implemented and that respiratory status was monitored by staff and/or equipment to readily identify and address respiratory distress resulting in serious harm for one of three residents reviewed for respiratory care (Resident #1). Specifically, Resident #1 was being weaned from mechanical ventilation to use of Tracheolife (a respiratory support system using a heat moisture exchanger) and an oxygen concentrator. The resident had a known, recent history of not tolerating the weaning process. A pulmonologist recommended to discontinue weaning and place the resident back on the ventilator around the clock. The recommendation was not ordered, communicated to, or carried out by, direct care staff. The resident remained on Tracheolife. Additionally, lack of an effective system to assign resident care when a respiratory therapist completed a scheduled shift resulted in failure to monitor the resident's respiratory status by a caregiver. There was also no protocol or monitoring of oxygen saturation, or other indicator of ventilatory adequacy, to alert staff of resident distress when not on the ventilator. The resident #1 was found unresponsive without a pulse or respirations. The resident was transferred to and died in the hospital. This resulted in actual harm that was Immediate Jeopardy. The findings are: The Policy & Procedure Titled Flow Sheet for Trache(ostomy) Resident dated [DATE] documented that a respiratory therapist was to check [MEDICAL CONDITION] and ventilator residents every 4 hours and should not be later that an hour if any emergency comes; to fill out a flowsheet each time the therapist checked a resident. Make sure that residents were ok and check if residents needed suctioning in between the flow sheet checks. Pulse oximetry was to be done with each check and oxygen saturation was to be documented in the flow sheet. The Policy and Procedure Titled Physician order [REDACTED]. The RT would make sure physician's orders [REDACTED]. The Policy and Procedure Titled Tracheolife dated [DATE] documented that the [MEDICAL CONDITION] physician or physician assistant would make decisions for the use of Tracheolife in residents. Monitor the oxygen saturation with pulse oximeter for ventilator weaning residents. No frequency of monitoring was designated. The facility lacked documented evidence of policies and procedures related to respiratory therapist assignments and scheduling. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set assessments dated [DATE] and [DATE], the resident had severely impaired cognitive status, required total assistance with activities of daily living (ADLs) and was receiving special treatments including oxygen therapy, suctioning, [MEDICAL CONDITION] care and ventilator use. The Comprehensive Care Plan lacked documented evidence of a care plan related to the resident's respiratory condition, ventilator use and interventions including weaning status. The resident had a physician's orders [REDACTED]. The Respiratory Ventilator Flowsheet (RVF) dated [DATE] documented the resident was on T/L (Traheolife) from 12PM- 5PM (5 hours) Respiratory Progress Notes (RPN) dated [DATE] at 5:44 PM documented that the resident tolerated weaning to Tracheolife until 5pm; desaturated to 70% (an indicator of poor oxygenation), was suctioned and was switched back to the ventilator on Synchronized Intermittent Mechanical Ventilation mode (SIMV, a mode allowing the resident to take additional breaths in between mechanical breaths delivered by the ventilator). The Medical Progress Notes (MPN) dated [DATE] at 12:08 PM documented that the [MEDICAL CONDITION] team recommended to advance ventilator weaning to daytime Tracheolife supported by nighttime ventilator from full support to intermittent mechanical ventilation. The MPN lacked documented evidence that the physician (MD) addressed the episode of desaturation on [DATE]. The RVF dated [DATE] documented that the resident was on Tracheolife from 10:20 AM - 1:20 PM with oxygen saturation of 98% and HR 108 beats/minute (elevated heart rate) and placed back on the ventilator at 1:20 PM. The RPN dated [DATE] at 4:11 PM documented that the resident did not tolerate the Tracheolife, shortness of breath was noted and the resident was placed back on the ventilator. A physician's orders [REDACTED]. The Respiratory Therapy Administration Record (RTAR) dated [DATE] documented that resident was on SIMV Ventilator setting of 6 breaths per minute from 6:00 PM-10:00 AM, as ordered. The RPN dated [DATE] at 6:38 PM documented that the resident failed Tracheolife with 4 Liter Per Minute (lpm) of oxygen. Desaturated and resumed to Ventilator setting of Assist Control (AC, mode of mechanical ventilation that provides support for every breath, whether it's initiated by the resident or the ventilator) 10 breaths per minute. The RVF documented the resident was on Tracheolife from 11:00 AM and was placed back to Ventilator setting of AC 8 breaths/minute from 1:00 PM-8:00 PM and AC 10 breaths/minute from 8:00 PM until 11:00 AM (on [DATE]). The RVF dated [DATE] at 11 AM documented the resident was on Tracheolife with 4 liters of oxygen, oxygen saturation of 97% and HR 78. The RVF lacked documented evidence that the resident's oxygen saturation, Heart Rate (HR), Respiratory Rate (RR) and oxygen setting was monitored after 11:00AM. According to the MPN dated [DATE] at 12:29 PM, the resident was noted with questionable abdominal distention on [DATE], enema was given with soft stool bowel movement; STAT Kidney/Ureter/Bladder (KUB) sonogram ordered to rule out pseudo-obstruction of abdomen from adhesions. All other systems status was stable. The MPN lacked documented evidence that the MD addressed the failed weaning on [DATE]. The [MEDICAL CONDITION] Progress Notes (PPN) by the pulmonologist dated [DATE] at 1:18 PM documented the resident was seen and examined. The pulmonologist documented that the resident had a failed weaning episode on [DATE] (hypoxemia), was now on AC mode, was being evaluated by the PMD (primary medical doctor) for abdominal distention, KUB was pending. On exam, resident was awake, non-verbal, no distress or shortness of breath. Resident was afebrile and rhonchi to bilateral lungs on auscultation. The pulmonologist recommended to hold weaning and keep the resident on AC (ventilator) mode around the clock (ATC). Maintain saturation to above 92%. Recommendation was discussed with RT (Respiratory Therapy) staff. There was no documented evidence of a physician's orders [REDACTED]. The RPN dated [DATE] at 4:58 PM entered by RT #1 documented weaning hours from 10AM-6PM. RT #1 documented the resident was placed on Tracheolife as ordered and weaning was well tolerated. The HR was 83, RR 16 and oxygen saturation 97%. The post weaning setting was documented as SIMV 6 breaths per minute. The RTAR dated [DATE] documented the resident was on Tracheolife (HME) from 10:00 AM-6:00 PM. The RTAR lacked documented evidence that resident was placed on a ventilator on [DATE] at 6:00 PM. The NPN dated [DATE] at 9:35 PM entered by the Licensed Practical Nurse (LPN #1) and the RPN dated [DATE] at 10:29 PM entered by RT #4 documented the resident was on Tracheolife, alert and responsive to verbal and tactile stimuli. At 7:52 PM the resident was found unresponsive by her assigned Certified Nurse's Aide (CNA #2) while making rounds. Resident assessed by RN, no palpable pulse was noted. Cardiopulmonary Resuscitation (CPR) was initiated at 7:55 PM and medical STAT and 911 were called and the resident was transported to the hospital at 8:25 PM. The facility investigative summary dated [DATE] documented the resident had been on ventilator weaning since (MONTH) (YEAR), was off the ventilator from 10:00 AM-6:00 PM and tolerated scheduled weaning most days without respiratory distress. On [DATE], the resident was weaned in the morning. The resident had abdominal distention, was given fleet enema with positive results, KUB was done and results indicated some fecal material present. The resident tolerated weaning despite abdominal distention. The RT documented at 4:58 PM that the resident was on the ventilator and had tolerated weaning well. At 7:50 PM the assigned CNA made rounds and found the resident unresponsive. The Registered Nurse (RN) initiated CPR, 911 was called, the resident was transferred to hospital at 8:25 PM where resident later expired. The facility investigative summary also documented statements from staff which indicated that the resident was not on the ventilator, no alarms were heard, no one acknowledged that pulse oximeter monitoring in place and pulse oximeter monitoring was the proper procedure. The facility's investigation noted that RT #1 documented the resident was placed back on the ventilator at 4:58 PM, however, when the resident was found unresponsive by CNA #2, the resident was not on a ventilator. RT #1 left the facility at 5:30 PM (RT #1 was scheduled to work until 5:00 PM). RT #1 claimed she gave a verbal report to the other RTs on duty. The other RTs denied getting any report from RT #1. The facility concluded that RT #1 failed to follow the policy and procedure of the facility which may have compromised the resident's condition. The facility lacked documented evidence of RTs assignments for continuity of resident coverage during scheduling gaps and breaks. The acting Director of Nursing (DON) who completed the facility investigation was interviewed on [DATE] at 2:11 PM and stated that the facility concluded that RT #1 did not follow the policy on face to face report, completing the flow sheet every 4 hours even if she had documented in progress notes and failed to log in the logbook which was an additional communication to the incoming shift documented after the shift ends of the resident's status. The DON stated the PA wrote her recommendations at 11:00AM on a piece of paper and handed her recommendations to the DRT at the end of shift about 3:00 PM which was the facility's practice prior to the incident. The DRT should have written the order. An undated, untitled piece of paper with 5 resident's names including Resident #1's documented AC, ATC recommendation for Resident #1. Upon interview with Director of Respiratory Therapy (DRT) and Physician Assistant (PA) noted below they stated the piece of paper had the recommendations that the PA had provided to the DRT. The recommendations included to place Resident #1 back on Ventilator on AC mode around the clock. The PMD was interviewed on [DATE] at 1:30 PM and stated he did not get any reports of the resident not tolerating weaning or desaturating on previous days or holding the weaning on [DATE]. The PMD stated that Resident #1 was not placed back to ventilator in a timely manner on [DATE]. The PMD further stated the Director of Respiratory Therapy (DRT) writes the vent orders in conjunction with pulmonologist who comes once a week and the RT team did not have to get the PMD's approval to write orders. RT #1 was interviewed via phone on [DATE] at 6:21 PM and stated that she was not scheduled to work on [DATE] and was asked to report to work from 7:00 AM-5:00 PM. She was assigned to Resident #1. RT #1 stated the resident was being weaned from ventilator as per the physician's orders [REDACTED]. She was supposed to be on Tracheolife between 10:00 AM-6:00 PM. RT #1 made her rounds around 8:00 AM and the resident was on the ventilator on AC mode and was stable. At 11:30 AM, RT #1 placed Resident #1 on Tracheolife. When RT #1 took Resident #1's oxygen off the ventilator, the ventilator oxygen monitoring was alarming. Resident #1 was not in any distress. RT #1 called RT #3 to help her reset the oxygen alarm and RT #3 fixed the alarm. RT #1 stated there were 2 pulse oximeters in Resident #1's room. One was attached to the wall (attached to call bell system) and one was portable. RT #1 stated Resident #1 was attached to both the pulse oximeters. At approximately 4:00 PM, Resident #1 was still on Tracheolife and RT #1 wanted to place Resident #1 back on the Ventilator before she left at 5:00 PM. RT #1 stated Resident #1 was stable and tolerated weaning at that time. RT #1 called RT#5 to ensure that oxygen alarm on the ventilator was enabled. RT #1, RT#2, RT #3 and RT #5 were in Resident #1's room. RT #1 fixed the ventilator oxygen alarm. RT #1 stated that she indicated to RT #2, RT #3 and RT #5 that she was placing the resident on the ventilator and needed help to adjust the oxygen. RT #1 stated she requested that RT #2, RT #3 and RT #5 place Resident #1 on the ventilator (did not recall their response). RT #1 stated RT #2, #3 and #5 knew she was leaving at 5:00 PM. RT #1 stated she left Resident #1's room at 4:30 PM because another resident's family member called her for assistance. RT #1 attended to another resident until 5:00 PM while the other RTs were still in Resident #1's room. RT #1 did not go back to Resident #1's room. RT #1 did not check if Resident #1 was placed back to ventilator before she left. RT #1 stated she left Resident #1's room and gave the other RTs the clip board for Resident #1. RT #1 stated she did not document on Resident #1's ventilator flow sheet after 11:00 AM because at 4:30PM she wanted to place Resident #1 back on the ventilator. RT #1 stated that she notified the other RTs and they should be the ones to document the resident's condition on the ventilator flow sheet. RT #1 stated RT #5 should pick up her assignment because he was the first person she called to help her with the ventilator. RT #1 entered the progress note for the resident but she did not document that Resident #1 was placed on the ventilator. A 7:00 AM-8:00 PM respiratory therapist (RT) #2 was interviewed on [DATE] at 1:52 PM and stated she went to Resident #1's room around 3:30 PM on [DATE]. RT #1 and RT #5 were in the resident's room and asked RT #2 to check the ventilator because the oxygen level alarm was disabled. Resident #1 was not on the ventilator, she was on Tracheolife and was not in distress. RT #2 could not remember if the resident was attached to the continuous pulse oximeter at that time. RT #2 stated RT #1 left the room, RT #2 enabled the ventilator oxygen monitoring. RT #2 did not place Resident #1 on the Ventilator and left RT#5 in Resident #1's room. RT #2 stated that was the last time she saw Resident #1. RT #2 stated RT #1 informed her when she left at 5:30PM however, RT #1 did not ask her to place Resident #1 back on the ventilator and did not give her a report. RT #2 stated normally the 2 RTs who were left on the duty would attend to the calls and alarms of residents assigned to RT#1. RT #2 stated she did not recall any alarms from Resident #1's room. RT #2 stated if a resident was weaning off the ventilator on Tracheolife, there was no alarm on the system to alert the staff. However, a continuous pulse oximeter with a cable connected to the call light system could be used. If a resident had a low oxygen saturation below 90% or increased heart rate, the pulse oximeter would alarm locally, a call light outside the door activated and it would alarm at the nursing station. RT #2 stated it was not the policy of the facility to use the continuous pulse oximeter when a resident was on Tracheolife, residents were attached to the continuous pulse oximeter monitoring most of the time, however, it was not a routine. RT #2 stated the Pulmonologist would inform the RTs if a resident needed to be on a continuous pulse oximeter by writing a note. At times, it depended on the RT's decision such as in cases when a resident was unstable. RT #2 stated, when on occasions she was assigned to Resident #1, she (RT #2) attached the continuous pulse oximeter because the resident had a history of [REDACTED]. RT #2 stated residents on Tracheolife were monitored every ,[DATE] hours but she would monitor Resident #1 more often because of reports from RTs that she desaturated on [DATE]. RT #2 stated she would know if a resident was desaturating from physically monitoring the resident if he/she was not connected to pulse oximeter. RT #2 stated the resident was supposed to be back on the ventilator by 6:00 PM as per the physician's orders [REDACTED].>7AM-7PM RT #3 was interviewed on [DATE] at 5:28 PM and stated she was aware that Resident #1 was on the ventilator from 6:00 PM-10:00 AM and on Tracheolife from 10:00 AM-6:00 PM. RT #3 stated she had the resident attached to the continuous pulse oximeter whenever she was assigned to her and that usually the DRT informed her if a resident needed to be attached to a continuous pulse oximeter and it was not her decision. RT #3 then stated that she usually placed residents, who were weaning by using Tracheolife, on continuous pulse oximeter to identify how a resident was tolerating the weaning. On [DATE] at approximately 10:30AM-11:00 AM, RT #1 called her to ask her assistance to reset the oxygen alarm on Resident #1's Ventilator. RT #3 reset the alarm and left Resident #1's room. RT #3 stated that was the last time she saw Resident #1. RT#3 stated she did not hear alarm from Resident #1. RT #3 stated she did not know that RT #1 left the facility early. RT#3 stated RT#1 supposed to give report to the other therapists and the remaining RTs were supposed to cover RT #1's assignment. The 3:00 PM-11:00 PM RN #2 was interviewed on [DATE] at 6:05 PM and stated she saw Resident #1 on Tracheolife, attached to oxygen concentrator, and she was not in distress during her rounds at 3:00 PM. RN #2 could not recall if Resident #1 was attached to the continuous pulse oximeter. At 7:55 PM, CNA #2 called for help, RN #2 responded and saw Resident #1 pale in color. Resident #1 was on Tracheolife in her bed attached to oxygen concentrator at that time. RN #2 could not feel a pulse and started CPR. RT #4 and LPN #1 responded to the room and helped with CPR. RN #2 stated she did not hear any alarms sound. The 3PM-11PM LPN #1 was interviewed on [DATE] at 7:05 PM and stated that he was assigned to Resident #1 on [DATE]. LPN #1 saw the resident on Tracheolife, not in distress, with no alarm sounding at 3:00 PM, between 4:00 PM - 5:00 PM and at 7:30 PM and he could not recall if the resident was attached to a pulse oximeter. LPN #1 stated, prior to the incident on [DATE], the resident was on a pulse oximeter because she had an episode of desaturation. At approximately 7:50 PM, CNA #2 called for help. LPN #1 stated RN #2, RT #4 and he responded. Resident #1 was observed pale in color, on Tracheolife, no pulse and they started CPR. LPN #1 stated that after the incident he heard Resident #1 was supposed to be on Ventilator. The 3:00 PM-11:00 PM CNA #2 was interviewed on [DATE] at 7:20 PM and stated that she was assigned to Resident #1 on [DATE]. CNA #2 stated the resident was okay, not on the ventilator when she washed her at approximately 4:30 PM and on rounds at 6:00 PM. CNA #2 stated she thought the pulse oximeter was in the room but she was not sure if it was attached. Between 7:,[DATE]:50 PM, she saw Resident #1's face was pale. CNA #2 stated she was not sure if the resident was on or off the ventilator at that time because she rushed out and screamed for help. CNA #2 stated there were some days Resident #1's pulse oximeter alarmed but that day it did not alarm. 7:00 PM-8:00 AM RT #4 was interviewed via phone on [DATE] at 8:26 AM and stated she was assigned to Resident #1 on [DATE]. She started work at 7:00 PM, received reports from other RTs regarding other residents but she did not get a report regarding Resident #1 and she did not ask about Resident #1 during the shift report related to ventilator or any other information. RT #4 assumed that Resident #1 had no issues and that was why she was not on the report. RT #4 stated she did not get to Resident #1's room and, at approximately 7:50 PM, RT #4 heard someone call for help in Resident #1's room. She responded and saw the resident on Tracheolife attached to oxygen 4 liters. The pulse oximeter was on the table. RT#4 could not recall if Resident #1 was attached to pulse oximeter. RT #4 stated Resident #1 was supposed to be on Ventilator at 6:00 PM and she was not on the ventilator. RT #4 stated she was supposed to make rounds and see every resident and answer the alarms. RT #4 did not hear any alarms for Resident #1. RT #4 stated the assigned RTs determined if a resident needed a continuous pulse oximeter monitoring such as in cases when a resident was known to desaturate or exhibit restlessness. RT #4 stated she did not receive reports that Resident #1 had episodes of not tolerating weaning. RT #4 stated Resident #1 should be attached on continuous pulse oximeter because she was restless at times and was pulling the Tracheolife. The DRT was interviewed on [DATE] at 10:15 AM and stated that residents weaning from ventilator to Tracheolife should have a continuous pulse oximeter attached and they should be checked every 4 hours and as needed. If a resident did not tolerate weaning, then the RT would stop the weaning. The DRT stated if a resident was with someone such as their family members, the resident did not need to be on continuous pulse oximeter. The DRT stated that on [DATE] Resident #1 desaturated during weaning, with oxygen saturation of 70% and she was placed back on the ventilator an hour earlier than scheduled. Resident #1 also failed Tracheolife weaning and desaturated on [DATE] and was placed back on the ventilator. The DRT stated that on [DATE] he did not accompany the PA (pulmonary physician assistant) and Pulmonologist on rounds. The DRT stated that he last saw Resident #1 at approximately 11: AM-12:00 Noon; Resident #1 was on Tracheolife and was not in distress. The DRT stated there were two types of pulse oximeter in Resident #1's room and he could not recall if the pulse oximeter was attached to Resident #1. The DRT stated he did not receive any verbal recommendations from the PA. The DRT stated that usually the PA would write her recommendations on a piece of paper and give it to the DRT to write the orders based on the recommendations. The DRT stated that on [DATE] he received the written recommendation on a piece of paper from the PA approximately at 2:00 PM-2:30 PM. The recommendation for Resident #1 was to place resident on the ventilator AC mode around the clock. The DRT stated that Resident #1 should have been placed on the ventilator around the clock and not on weaning schedule. The DRT stated he got busy and did not get a chance to write the order for Resident #1 to hold weaning and place back on the ventilator. The DRT stated he did not inform the assigned RT or any other RT on the unit to hold weaning for Resident #1. The DRT stated that RT #2, RT #3 and RT #5 knew RT #1 was leaving at 5:00 PM however, RT #1 did not inform them of the time she left. There was no RT staff assigned to Resident #1 for the 2-hour time when RT #1 left; Resident #1 was not checked by the assigned RT who came to work at 7:00 PM until Resident #1 coded at 7:50 PM. The DRT stated, according to Resident #1's flow sheet, RT #1 documented at 11:50 AM (last documentation on flow sheet was at 11:00 AM). RT #1 last saw Resident #1 at 4:00 PM. RT #1 should document in the flowsheet at 4PM of resident #1's Ventilator settings and assessment even though she was leaving at 5PM as per the facility policy. RT #1 should have endorsed to other RTs to place Resident #1 back on the ventilator. The DRT stated RT #1 documented the post ventilator setting (SIMV) for Resident #1 which indicated that RT #1 placed Resident #1 back on the ventilator at 4:58 PM. The DRT stated RTs worked 12-hour shifts and he did the staffing schedule monthly. The DRT stated there was no written assignment for each RT. The RTs would split their assignment amongst themselves. When an RT left at 5:00 PM or mid-shift, the RT who was leaving should give report and inform the remaining RTs that he/she was leaving. The leaving RT should also document the current Ventilator setting or changes made at the end of the shift. The remaining RTs then would decide themselves who would take the open assignment after the assigned RT left. The Pulmonologist was interviewed on [DATE] at 11:49 AM and he stated that Resident #1 was on Tracheolife on daytime and mechanical Ventilation at night time. Resident #1 was doing okay with weaning until the morning of [DATE] when the Pulmonologist was told that during that night ([DATE]) Resident #1 was placed back on the ventilator. The Pulmonologist came to the facility between 1:00 PM-1:30 PM. The Pulmonologist stated he did not examine Resident #1 and recommended to hold weaning and keep Resident #1 on the ventilator (AC mode) around the clock. The Pulmonologist and PA informed the DRT of the recommendations. The Pulmonologist stated he was told that Resident #1 was placed on the ventilator AC mode and was never in distress. The Pulmonologist stated he did not physically examine Resident #1 at that time and he was not informed at any time that Resident #1 was placed back on Tracheolife after the desaturation episode on [DATE]. The Pulmonologist stated that Resident #1 should have been on the ventilator at 6:00 PM. The Pulmonologist stated a resident who is being weaned should be on a continuous pulse oximeter if a resident is unstable and especially with an acute medical condition. The [MEDICAL CONDITION] PA was interviewed via phone on [DATE] at 12:59 PM and she stated that she saw Resident #1 on [DATE] between 9:00 AM-10:30AM and Resident #1 was on the ventilator, alert and was comfortable. The PA stated the DRT informed her that Resident #1 did not do well on weaning a day prior. The PA stated she was under the impression that RT staff was leaving Resident #1 on the ventilator because she failed weaning the day before, and she was not aware that Resident #1 was taken off the ventilator that day ([DATE]). The PA had written her recommendation to hold weaning. The PA stated the pulmonologist came in at 1:00 PM and both she and the pulmonologist discussed Resident #1's condition but did not physically examine Resident #1 at that time. The PA gave her recommendation to the DRT at 3PM in a piece of paper for Resident #1 which wrote AC ATC (assist control, around the clock). The PA stated she did not inform any other RT regarding her recommendation at that time. The PA felt that there was no urgency of the order because she knew Resident #1 was comfortable on the ventilator when she last saw her at 9:30 AM. The Medical Director was interviewed via phone on [DATE] at 3:40 PM and stated that he was made aware, but did not have the details of the incident, and he then reviewed Resident #1's chart. The Medical Director stated Resident #1 was supposed to be off the ventilator between 10:00 AM-6:00 PM but the RT staff took Resident #1 off the ventilator at 11:00 AM on [DATE] so the resident should have been placed back on the ventilator at 7:00 PM on [DATE] for an 8-hour weaning schedule. Resident #1 coded at 7:40PM and being off the ventilator for 40 minutes did not cause the resident's death. The Medical Director stated he was not aware the resident desaturated a day prior but stated the resident was fine and no issues with desaturation on [DATE]. The Medical Director stated while the resident was off the ventilator, the pulse oxygenation should have been monitored. He stated he did not know the protocol on frequency of pulse monitoring. The Medical Director stated that when the pulmonologist made recommendations, the PMD should be made aware and approve the order. He stated he was not aware the DRT wrote the orders. The Medical Director stated he was not responsible and did not review the policies and procedures related to respiratory. The Administrator was interviewed on [DATE] at 4:04 PM and she stated that she was made aware by the Director of Admissions on [DATE] that Resident #1's family had concerns about her passing away and her care. The Administrator forwarded an email to the ADNS to look into the issue. She also received an email from the DRT regarding respiratory staff issues and that the DRT was going to do an investigation. The facility concluded that RT #1 had falsely documented that she put Resident #1 back on the ventilator. RT #1 left her shift and did not give report. RT #1 left the entire log blank regarding Resident #1's ventilator setting. The Administrator stated there was a lapse in communication between the pulmonologist, the RT and the PMD. 415.12(k)(6)

Based on interview and record review during an abbreviated survey, the facility did not ensure that one of two residents reviewed for use of physical restraints was assessed, monitored and received care to prevent injury (Resident #1). Specifically, Resident #1 had bilateral mittens applied with the use of stretch gauze to secure the mittens, instead of the ties provided by the manufacturer. The resident was found with redness and swelling of both hands and blisters on the left hand secondary to use of the mittens and required emergency transfer to the hospital for evaluation. The facility lacked documented evidence that skin was assessed and that the mittens were released as per physician's orders [REDACTED]. Complaint ID #: NY 747 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a Brief Interview for Mental Status (BIMS) score dated 10/2/16, the resident was noted to have short and long term memory problems and severely impaired decision making. The Comprehensive Care Plan (CCP) dated 3/25/16 documented that the resident exhibits behavioral symptoms not directed towards others, hitting and scratching self, puts the resident at significant risk for physical illness or injury, significantly interferes with residents care. Interventions included ½ hourly visual monitoring, assess for unrecognized needs, preferences or illness. An undated consent for physical restraint form documented spoke with Resident #1's son agreed to continue using the bilateral hand mittens and will sign consent upon form when he comes to facility on 3/29/16. The facility policy titled Restraint, dated 5/2016, documented that the comprehensive care planning team will assess all residents at the time restraint use is being considered including completion of an initial restraint monitoring form by a licensed nurse and a restraint evaluation conducted by the comprehensive care plan team. The policy stated that, included in an evaluation will be an assessment of the resident's physical and cognitive abilities, indicate that less restrictive solutions have been implemented and evaluated prior to recommendation for use of physical restraint. All restraints should be properly applied allowing for some body movement and not impaired circulation. Patient should be checked every two hours (at the time of release of restraint) for any evidence of adverse effects. Manufacturer's instructions must be followed. For mittens secure with ties at wrist. Leave enough room to easily insert one finger between the device and the patient's limb. An Interim Physician order [REDACTED]. The CCP was revised dated 11/12/16 to add interventions for: hand mittens to be worn at all times, release every two hours for skin assessment. Check and remove x 15 minutes and with activities of daily living care. Diagnosis: [REDACTED]. The CCP dated 11/14/16 documented that the resident rejects evaluation or care as evidenced by non-compliance. Resident attempts to remove trach/gastrostomy tube at times secondary to cognitive impairment. Interventions included to assess resident's understanding of the situation, coping skills and support system. The Nursing Progress Note dated 11/23/16 at 1:31 AM documented that the resident removed her [MEDICAL CONDITION] and that the staff replaced it with a new tube. The facility Incident and Accident report dated 11/23/16 at 9:00 AM documented that the assigned CNA (Certified Nursing Assistant) observed the resident out of bed to a wheel chair with mittens to bilateral hands. Upon removal of mittens, resident's both hands were swollen and red at the wrist. Resident statement of occurrence: mucho dolor (much pain). The Nursing Progress Note dated 11/23/16 at 2:10 PM documented that the Certified Nursing Assistant assigned to the resident's care reported that, at about 9:00 AM she approached the resident to prepare her for her scheduled shower, the resident who has a history of restlessness was observed out of bed to her wheel chair and her eyes were closed. The staff started to move the mittens that were on resident's hands and noted that they were tight. The resident's hands were also swollen. The primary nurse and the nursing supervisor were summoned. An assessment was performed. Both hands were noted to be swollen and reddened at the wrist. Range of motion intact. Resident stated mucho dolor. At 3:05 PM resident to start on ½ hourly visual rounds from 7:00 PM-7:00 AM hand mittens to be on hold for 48 hours. If resident becomes agitated place at nursing station. The Interim Physician order [REDACTED]. The facility investigation summary for the incident of 11/23/16 completed on 11/28/16 documented resident's bilateral hands were noted to be swollen and reddened at the wrist. The assessment revealed that range of motion was intact to both hands. When resident was asked about the presence of pain or discomfort the resident stated mucho dolor. Resident who is cognitively impaired was unable to provide explanation of the circumstances. Physician was informed, pain medication was administered. Physician ordered to hold use of mittens and place resident for observation every 30 minutes to monitor for changes due to her history of interfering with her [MEDICAL CONDITION] appliance. The primary care physician ordered to transfer resident to the emergency room where resident's hands could be further examined to rule out [MEDICAL CONDITION]. The emergency room (ER) Physician note dated 11/23/16 at 6:46 PM documented that the ER Physician spoke with the Primary Care Physician (PCP) who stated patient is trached/peg'ed (has a breathing tube and feeding tube) and often pulls at tubes. Yesterday was tied down on hands. When removed this morning noted to have extensive swelling. Set for evaluation. Stable vital signs, afebrile. Bilateral redness to both hands, non blanchable. Not warm. Small petechia (small red or purple spot caused by bleeding into the skin) in left hand with two small <1 cm blister. Swelling worse in left then right. Patient likely had reduced venous flow secondary to [MEDICATION NAME] and ended up getting [MEDICAL CONDITION]. (Resident discharged from hospital ER and returned to facility on 11/23/16). The facility lacked documented evidence of assessment or the consideration of use of less restrictive devices or methods in lieu of physical restraints, or of specific restraint use care planning that addressed the potential to decrease and/or eliminate restraints. There was no documented evidence of monitoring every two hours to ensure that mittens were properly applied and in place or that restraint release or skin assessment was performed for the month of November 2016 according to the resident's physician's orders [REDACTED]. During an interview with Resident #1's private aide (an aide who attends the resident from 9:00 AM - 9:00 PM) on 12/16/16 at 10:30 AM, the private aide stated that she came in on the morning of 11/23/16 at approximately 9:00 AM and found Resident #1 with mittens on both of her hands. Resident #1 appeared to be in pain and pointed to her hands. The private aide stated that she tried to untie the mittens but was not able to do so as both mittens were tied very tightly. The mittens were tied in place with stretch gauze and not with ties that were made for the mittens and there were several loops of the stretch gauze around the resident's wrists to secure the mittens in place. The private aide stated that she had to cut the ties with a scissor. The private aide stated that after she removed the mittens she observed that both of Resident #1's hands were swollen, red and that some blisters were also noted. The resident's left hand was swollen more than the right and both wrists had indentations around the wrists and redness and that Resident #1 stated that she had mucho dolor. The private aide stated that she called the nurse on duty and notified her. During an interview with the 7:00 AM-3:00 PM Registered Nurse, Nurse Manager (NM) on 12/16/16 at 11:46 PM, the NM stated that Resident #1 has a [MEDICAL CONDITION] and a habit of playing with her hands and fingers a lot and tries to pull on her oxygen tubing. Resident #1 had mittens placed due to her behavior of pulling [MEDICAL CONDITION]. The NM stated that when a restraint is initiated, the doctor is informed, family consent form is signed and risks and benefits are discussed with the family. After the restraint is ordered the CNA (Certified Nurse Aide) accountability record (resident care guide) has to be updated to indicate use of the restraint. The NM stated that Resident #1 did not use the mitten restraints during the 7:00 AM-3:00 PM shift because she has a private aide with her from 9:00 AM to 9:00 PM. The mittens are placed when the private aide is not in attendance during the evening shift. The NM stated that the CNAs and nurses are to monitor residents utilizing restraints. Resident #1 was not on any scheduled monitoring but when Resident #1 is out of bed she is always monitored by placing her at the nursing station. The licensed nurses are responsible to release the restraint every two hours and as needed according to the physician's orders [REDACTED]. The NM stated that there was no documented evidence that the mittens were released for Resident #1. The NM stated that a comprehensive care planning team assessment was not done for restraint use prior to initiating the restraint until 11/23/16 when Resident #1 was found with swelling on her hands. The NM stated that a restraint monitoring form was not initiated or completed as per policy. The NM stated that, when the facility was utilizing paper records, the monitoring form was being utilized. As the facility moved to the computer record the monitoring form was not available and was not being utilized. During an interview with the Director of Nursing (DON) on 12/16/16 at 12:59 PM, the DON stated that a restraint assessment should be done that includes if resident is able to release the restraint her/himself. The DON stated that the clinical team should get together and evaluate and monitor the need for the restraint prior to placing the restraint on any resident. Every month the restraint necessity should be discussed with the team for continuation or discontinuation. A care plan should be initiated related to use of the restraint and updated monthly. The DON stated that the care plan should be specific to the restraint. The DON stated that the resident utilizing a restraint should be monitored and observed every two hours for release of the restraint and monitoring of skin integrity. The DON stated that the nurse on duty should make sure that the restraints are being released according to the physician's orders [REDACTED]. The documentation for the restraint is done on the electronic medical record, not on paper records. The DON stated that there was no indication that the restraint monitoring or evaluation was completed for Resident #1 until 11/23/16 when Resident #1 was found with redness and swelling of her hands. During a subsequent interview with the DON on 12/28/16 at 3:30 PM, the DON stated that the medical record did not have indication that Resident #1's restraints (mittens) were released every two hours as per the physician's orders [REDACTED]. During an interview with the 7:00 AM-3:00 PM Certified Nurse Aide (CNA #1, who also cares for the resident) on 12/16/16 1:15 PM, CNA #1 stated that she does not place restraints on Resident #1 as she does not need it. Resident #1 takes off the mittens as soon as it's placed on her. CNA #1 stated that, on 11/23/16, Resident #1 was in the lounge in her wheel chair when CNA #1 arrived on duty at 7:00 AM. CNA #1 stated that she did not observe the mittens at 7:00 AM. At 9:00 AM, when CNA #1 was taking Resident #1 for a shower, she noticed that the mittens were very tight on both hands. The regular string for the mittens was missing and the mittens were tied very tight with stretch gauze. CNA #1 stated that she was not able to open the ties and that Resident #1's private aide cut the ties. Both hands were blown up, very swollen. CNA #1 stated that she called the charge nurse and notified her. CNA #1 stated that, during day shift, the resident did not wear the mittens as she would take them off. CNA #1 stated that she didn't know why the mittens were placed on the resident. CNA #1 stated that restraints are to be monitored by the nurses and have to be taken off every two hours for 15 minutes by the nurses. CNA #1 stated that she was not sure who is supposed to sign for the release of the restraint. CNA #1 stated that she did not sign for the restraint as she was not placing the mittens on Resident #1. CNA #1 stated that she had notified the NM that the resident was taking the mittens off. During an interview with the 11:00 PM-7:00 AM CNA (CNA #2) on 11/23/16 at 1:30 PM, CNA #2 stated that Resident #1 was on 30 minute rounds. When CNA #2 made rounds at the beginning of the shift, Resident #1 did not have the mittens at the time. Resident #1 pulled [MEDICAL CONDITION], RN #1 was notified. CNA #2 stated that she went on her break and left RN #1 in Resident #1's room. After coming back from break, CNA #2 saw Resident #1 sleeping in the recliner with mittens on both hands. CNA #2 stated that, at approximately 5:00 AM, she changed Resident #1 and checked on her mittens by placing two fingers between the mittens and the resident's wrist. CNA #2 stated that she was not able to place her fingers in between the mittens and Resident #1's wrists. CNA #2 stated that she couldn't tell if Resident #1's hands were swollen as she was not able to open the restraints. CNA #2 stated that she tried to untie the mittens but couldn't do it as they were too tight. CNA #2 stated that she called RN #1 and asked her to check the Resident. CNA #2 stated that RN #1 told her that she checked the mittens and that she will release them. CNA #2 stated that she left RN #1 with Resident #1. CNA #2 stated that the instructions to release the mittens every two hours were not on the CNA accountability. CNA #2 stated that the nurse is supposed to be releasing the restraints and monitoring the resident's skin. During an interview with the 11:00 PM-7:00 AM Registered Nurse (RN #1) on 12/16/16 at 2:00 PM, RN #1 stated that she was assigned to Resident #1 on 11/22/16-11/23/16 night shift. Resident #1 pulled out her [MEDICAL CONDITION] at approximately 11:30 PM which was reinserted. Resident #1 was very agitated at the time of tube placement. RN #1 stated that she asked CNA #3 to assist her in placing the mittens on Resident #1's hands at approximately 12:30 AM. RN #1 stated that she was holding Resident #1's hand when CNA #3 tied the mittens. RN #1 stated that she had instructed him to tie the mittens. RN #1 stated that the mittens did not have strings available so RN #1 decided to use the stretch gauge in place of the ties. RN #1 stated that, after the mittens were placed, CNA #3 checked the mittens by placing his finger between the mittens and Resident #1's wrists and found the fit to be loose. RN #1 stated that she checked the mittens twice at approximately 3:00 AM and after 7:00 AM. RN #1 stated that CNA #2 had asked her to check Resident #1's mittens. RN #1 stated that she found the string to be too long so she cut it short. RN #1 stated that at the time of placement of mittens at 12:30 AM the string was not long. RN #1 stated that she also checked if the mittens were loose or tight. She was able to place her finger between the mittens and Resident #1's wrists indicating that the mittens were loose. RN #1 stated that she did not release the mittens to check the skin integrity because the mittens were see though (with mesh on top) and she was able to see the skin. RN #1 stated that she did not observe any [MEDICAL CONDITION] (swelling) and that Resident #1 was sitting comfortably without any complaints of pain. During an interview with the RN Risk Manager (RM) on 12/16/16 at 4:30 PM, the RM stated that he was called to assess Resident #1 on 11/23/16. Upon assessment, Resident #1 was noted with circumferential redness of both wrists without indentation. The left hand had more pronounced swelling than the right. The RM stated that the staff had already removed the mittens prior to him reaching the unit. The RM stated that Resident #1 complained of pain and stated mucho dolor. The physician was notified and the family was also notified. The resident was sent to the emergency room to rule out [MEDICAL CONDITION]. During an interview with the CNA #3, 11:00 PM-7:00 AM on 12/28/16 at 11:00 AM, CNA #3 stated that Resident #1 was not on CNA #3's assignment. RN #1 asked CNA #3 for help with Resident #3 while RN #1 was placing the mittens on her. CNA #3 stated that he was just holding Resident #1's hands so the nurse (RN#1) could place the mittens. CNA #3 stated that the mittens did not have the original ties and that is why RN#1 had used stretch gauze to secure the mittens. CNA #3 stated that, at the time, he was able to place two fingers between the mittens and Resident #1's wrists. CNA #3 stated that the nurse was responsible for checking the restraint every two hours to monitor skin integrity. During an interview with the Primary Care Physician (PCP) on 1/10/17 at 9:45 AM, the PCP stated that Resident #1 has behaviors of pulling her [MEDICAL CONDITION] out and that is why orders for mitten use were provided to staff. The PCP stated that he received a call from staff early in the morning that Resident #1 had bilateral hand swelling with blisters. The PCP stated that he gave orders to elevate both hands and to transfer Resident #1 out to the emergency room (ER) for further evaluation. The PCP stated that the swelling could have been caused due to either the mittens being too tight or due to Resident #1's hand movements in an effort to try to take off the mittens. 415.4(2-7)

Based on observation, record review and staff interviews, during the recertification and extended survey, it was determined that the Administrator failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practical well being and safety of each resident. Specifically, 1) the Administrator failed to identify the potential for entrapment risk with side rails (bed systems and components, as outlined in a New York State Department of Health Dear Administrator Letter (DAL) dated 6/19/15 NH15-05 (Zone 1)), despite having prior knowledge of these recommendations. This was evident for eleven of eleven residents reviewed for Accidents in a Stage Two Sample of 27 Residents for a total of 211 of 280 beds identified with gaps within the side rail exceeding the recommendation of 4 and 3/4 inches. This resulted in Immediate Jeopardy and Substandard Quality Care for Residents # 162, # 34, # 275, # 316, #346, #41, # 245, # 127, # 190, #371, and # 379. The findings of deficient practice are cited in F 323 L- Accidents and Supervision, and F 520 F - Quality Assurance Committee. The findings are: Between 7/11/16 and 7/14/16, an observation of Residents # 162, # 34, # 275, # 316, #346, #41, # 245, # 127, # 190, #371, and # 379 beds were made. The residents all had 1/2 side rails with spaces between the rungs within the side rail measuring 7 and 1/2 inches or exceeding 7.5 inches (Resident #316). Further observations of the facility revealed 200 additional resident beds using the same type of 1/2 side rails that had spacing that measured 7.5 inches within the rail. All 211 of the 280 beds had the potential to cause entrapment within the side rail, including the potential to cause serious injury or death. The Recommendations presented in a document Guidance for Industry and FDA (Food and Drug Administration) Staff, titled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on March 10, 2006 and presented in a Dear Administrator Letter from the New York State Department of Health to the New York State Nursing Home Administrators on June 19, 2015 documented that recommendations for Zone 1 (the area within the rail) of a (bedside) rail should not exceed 4 3/4 inches. The Administrator was interviewed on 7/14/16 at 2:00 PM and stated that he does not recall specifically details about DAL dated 6/19/15 NH 15 -05 titled Entitled Entrapment risk with bed systems and components, but he was aware of the recommended gap size of no greater than 4 and 3/4 inch space within the rail to prevent entrapment. The Administrator did not recall if there was a policy specific to the dimensions of the side rails, but acknowledged that there should have been and that he would have been responsible to ensure compliance. The Administrator stated that the Director of Maintenance would have been aware of the recommended measurements of 4 and 3/4 inches. The Administrator further stated that he does make rounds but was not aware that residents were actually using unsafe side rails. Additionally, the Administrator stated that the Director of Nursing Services (DNS) would not be aware of the recommended 4 and 3/4 inch space within the side rails. The Administrator did state that nursing was responsible for the authorization of side rails and that maintenance was responsible to install the rails. The Administrator was asked to provide any Quality Assurance (QA) that had been conducted on the use of side rails since July of 2015, any consultant notes regarding side rails and any maintenance logs with regards to side rail use. The Administrator was unable to provide any of the requested documentation. An interview was held with the Maintenance Director on 7/14/16 at 2:30 PM. The Director stated that he has worked in the facility for a few years and has never been informed either in writing or verbally that the side rail needed to be a certain size between the rail rungs to prevent the residents from becoming entrapped. Additionally, the Director stated that he had never received notification from any unit that there was a problem with side rails. On 7/18/16 the Immediate Jeopardy was removed after monitoring confirmed the facility had implemented a plan to remove the immediacy. The determination to remove the Immediate Jeopardy was based on the facility's Policy and Procedure development to include an interdisciplinary team approach for side rail assessment, education of staff regarding the revised Policy and Procedure, and removal of the side rails which exceeded the FDA recommended 4 3/4 inch space within the rail space. On 7/15/16 the outside consultant conducted an additional audit of all resident beds to validate that all unneeded side rails had been removed. 415.26

Based on observation, record review and staff interviews during the Recertification and Extended survey, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible; and that each resident received adequate supervision and assistive devices to prevent accidents. This was evident for eleven residents reviewed for accident hazards in a total Stage two sample of 27 residents. Specifically, 1) On 7/14/16 at 1:00 PM, 211 of 280 total beds, including the eleven sampled residents, were observed with unsafe side rails with gaps measuring 7.5 inches or more between the rail space. This measurement exceeded the Food Drug Administration (FDA) recommended space between rails of less than 4 3/4 inches. (Residents #316, #379, # 34, #371, #162, # 275, #41, # 245, #127, #346, and #190). This resulted in Immediate Jeopardy and Substandard Quality of Care for Residents #316, #379, #371, #162, #34, #275, #41, #245, #127, #346, and #190. Additionally, 2) the housekeeping closets located on 4 North and 2 North were observed to be unattended and left unlocked. Several liquid chemicals in one-gallon containers were stored in the closets. 3) The Elevator #2's saddle to saddle level on the elevator landing on the 4th Floor was not even with each other, with a 0.5 inch discrepancy. The elevator's landing height was higher than the hallway flooring. The findings include but not limited to: 1a) During a tour on 7/14/16 at 1:00 PM of all seven nursing units, it was observed that 211 of 280 resident beds had side rails attached to the beds with unsafe gaps greater than the FDA recommended space of 4.75 inches between the rails. In addition, both the facility's Administrator and the Director of Nursing Services (DNS) were unaware on 7/14/16 at 2 PM of the unsafe gaps in the side rails that existed for 211 of the resident's beds. On 7/16/16 at 11:00 AM a list of residents utilizing side rails was requested, including the cognitive status of each resident. On 7/18/16 at 10:00 AM, the Director of Nursing Services (DNS) provided a list of residents who were using side rails on their beds. There were 100 residents listed with cognitive impairment (BIMS score of 0-12) whose beds had unsafe gaps of the attached siderails. The side rails of these residents were assessed and replaced by the facility. The DNS stated on 7/18/16 at 10:00 AM that all of the side rails for these beds have been replaced. 1b) Resident #316 is a [AGE] year old with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented that the resident was severely impaired in cognition with the Brief Interview for Mental Status (BIMS) score of 5. It also documented that the resident required extensive assist of two people for bed mobility and total assist of two people for transfer. The resident was observed in bed on 7/14/16 at 10:45 AM. Both upper side rails were in the upright positions. The right side rail had a zone 1 gap that measured 7.5 inches. The left side rail had a zone 1 gap that measured 14 inches. In an interview with the Certified Nursing Assistant (CNA) #1 on 7/14/16 at 12:25 PM, the CNA stated that the resident's upper side rails are raised when the resident is in bed to assist in turning and positioning. The New York State Department of Health Nursing Home Dear Administrator Letter (NYSDOH NH DAL) 15-05 titled Entrapment Risk with Bed Systems and Components dated 6/19/15 documented to have the facility re-examine the nursing homes' systems to ensure that adequate safeguards are in place for all aspects of bed safety encompassing the function of the bed's use. In addition, the DAL also recommended the facility to review the Food and Drug Administration's (FDA's) Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment and use it as a resource for assessing bed systems safety. The recommendations presented in a document Guidance for Industry and FDA (Food and Drug Administration) Staff, Titled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on March 10, 2006 and presented in a Dear Administrator Letter from the New York State Department of Health to the New York State Nursing Home Administrators on June 19, 2015, documented that recommendations for Zone 1 the area within the rail should not exceed 4 3/4 inches. The Administrator was interviewed on 7/14/16 at 2:00 PM and stated that he did not recall specific details about the DAL dated 6/19/15 NH 15 -05 titled Entitled Entrapment risk with bed systems and components, but he was aware of the recommended gap size of no greater than 4 and 3/4 inch space within the rail to prevent entrapment. The Administrator did not recall if there was a policy specific to the dimensions of the side rails, but acknowledged that there should have been and that he would have been responsible to ensure compliance. The Administrator stated that the Director of Maintenance would have been made aware of the recommended measurements of 4 and 3/4 inches. The Administrator further stated that he does make rounds but was not aware that any resident was actually using unsafe side rails. Additionally, the Administrator stated that the Director of Nursing Services (DNS) would not be aware of the recommended 4 and 3/4 inch space within the side rails. The Administrator did state that nursing was responsible for the authorization of side rails and that maintenance was responsible to install the rails. An interview was held with the Maintenance Director on 7/14/16 at 2:30 PM. The Director stated that he has worked in the facility for a few years and has never been informed either in writing or verbally that side rails needed to be a certain size between the rail rungs to prevent the residents from becoming trapped. The DNS was interviewed on 7/14/16 at 5:30 PM and was unaware of the recommended FDA spacing between the siderail bars on resident's beds. She stated that the facility has no policy and procedure for the use of siderails. She further stated there were no incidents of entrapment involving siderails. 1c) Resident # 379 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory loss and severe cognitive impairment. The resident requires extensive assistance for 2 staff members for bed mobility and for transfers. On 7/14/16 at 11:30 AM, the resident was observed in bed with both sides of the resident's upper siderails raised with the resident's head near an observed 7.5 inch gap in zone 1 of the siderails (upper siderails). The Comprehensive Care Plan (CCP) developed for falls dated 3/16/16 identified the resident at risk for falls/injury/fracture related to: a history of falls, physical limitations, debilitated/weakness, anti-anxiety (medications), communication deficits, noncompliance with safety measures, impulsive or poor safety awareness, agitation, restlessness, cognitive impairment and incontinence. The interventions included bi-lateral half siderails up when the resident is in bed. The Certified Nurse Assistant (CNA) #2 was interviewed on 7/14/16 at 1:40 PM and was not aware of any concerns with the side rails. The CNA stated that the siderails were used to prevent the resident from falling out of bed. The Registered Nurse (RN) Manager was interviewed on 7/15/16 at 12:30 PM and stated that she was not aware of any safety concerns regarding the resident's side rails prior to 7/14/16. She further stated that the resident's side rails were also used as an enabler to use during care and that the side rails were not being used as a restraint. 1d) Resident #34, an [AGE] year old, with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The MDS dated [DATE] documented that the resident was severely impaired in cognition and required extensive assistance of two people for bed mobility and transfer. The CCP developed for Falls dated 7/13/16 did not document the resident's use of side rails (SR) as an intervention. The resident was observed in bed on 7/14/16 at 10:25 AM. The resident's bilateral upper SRs were in upright positions. The left upper SR had a zone 1 gap of 7.5 inches. The right upper SR had a zone 1 gap of more than 4 and 3/4 inches as recommended by Food and Drug Administration. An interview with the Certified Nursing Assistant (CNA) #3, that was assigned to Resident #34, was conducted on 7/14/16 at 1:30 PM. The CNA stated that the resident uses the side rail to prevent falls while in bed and also to assist in turning and positioning. 2) During a tour of 4 North Unit conducted on 7/11/16 at 9:30 AM, the following was observed: - the housekeeping closet was unattended and unlocked - inside the housekeeping closet, chemicals such as Fusion Coral baseboard stripper, Fusion Pink deodorizer, Fusion Violet multi surface cleaner and disinfectant, Fusion Denim spray buff/ shine maintainer, Fusion Green detergent cleaner, and Fusion Blue glass and window cleaner were stored with their containers' caps off. An interview was held with the facility's Engineering Supervisor on 7/11/16 at 9:45 AM. The Supervisor stated that he will report the unlocked housekeeping closet to the Director of Environmental Services. The Supervisor also stated that Housekeeping Closets are to be locked at all times when unattended. 2b) During a tour of 2 North Unit with the Registered Nurse In-service Coordinator conducted on 7/17/16 at 11:58 AM, the following was observed: -the housekeeping closet was left unattended with an unlocked door. - inside the housekeeping closet, chemicals such as Fusion Pink, Fusion Violet, Fusion Denim, and Fusion Green were stored without the caps on the containers. There was a tube placed in each container which led to a fixture on the wall. The tubing could easily be removed from the container. The Housekeeping Staff was interviewed on 7/17/16 at 12:03 PM. The Housekeeping Staff stated that the closet should have been locked. She thought that she had closed the door when she left the closet. An interview with the Director of Environmental Services was conducted on 7/15/16 at 1:00 PM. The Director stated that the housekeeping closet should be locked at all times. The Material Safety Data Sheet (MSDS) for these chemicals contain the following: - Fusion Violet is an eye irritant and may cause redness or swelling. It is also an irritant to the mouth, throat, and gastrointestinal (GI) system. - Fusion Pink is an eye irritant and may cause redness or swelling. It is also an irritant to the mouth, throat, and gastrointestinal (GI) system. The vapor can be an irritant to the nose, throat, and lungs. - Fusion Coral is an eye irritant and may cause redness or swelling. It is also an irritant to the mouth, throat, and gastrointestinal (GI) system. - Fusion Blue is both skin and eye irritant. It is also an irritant to the mouth, throat, and gastrointestinal (GI) system. - Fusion Denim is an eye, skin and GI irritant. - Fusion Fusion Green is an eye, skin, respiratory and GI irritant. 3) Observations on 7/11/16 at 10:00 AM, 7/12/16 at 11:00 AM, and on 7/13/16 at 11:00 AM revealed that Elevator #2 had uneven floor heights between the elevator floor and the floor outside the elevator. The elevator saddle level was 0.5 inch higher than the 4th floor saddle landing. The Director of Environmental Services was interviewed on 7/14/16 at 11:00 AM. The Director stated that he will have the elevator company fix the problem. The elevator company's service order dated 7/14/16 documented that the company made an adjustment to the elevator to adjust the alignment of the elevator stop on the fourth floor. 415.12(h)(1)