Every finding on record at Washington Center for Rehab and Healthcare

Based on record review and interviews conducted during the recertification and abbreviated survey (Case # 677094), the facility failed to ensure the residents' right to be free from neglect for one (1) (Resident #128) of six (6) residents reviewed for neglect. Specifically, Resident #128 was care planned for falls with intervention including the resident's bed being in the lower position, bolsters placed on both sides, and high-profile floor mats. On 02/12/2025, Certified Nurse Aide #2 left the resident unattended with the bed in a high position while providing care. The resident fell out of bed and sustained a hematoma (a localized pool of blood) on the head, and bruising in both knees. This resulted in actual harm to Resident #128 that was not Immediate Jeopardy. This is evidenced by:The facility policy titled, Abuse, last revised 07/18/2025, documented that the purpose was to prohibit the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone, including but not limited to staff, family, friends, and residents of the facility. The policy further defines neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or distress.Resident #128 was admitted to the facility with diagnoses of dementia with behavioral disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Minimum Data Set (an assessment tool) dated 02/01/2025, documented that Resident #128 sometimes made themselves understood, sometimes understands others, and had severe cognitive impairment.The Comprehensive Care Plan for falls, initiated on 08/21/2021, documented that Resident #128 was at risk for falls and has had an actual fall related to deconditioning, psychotropic drug use, progression of aneurysm, did not seek assistance with transfers, and had declining health related to dialysis stopping. Interventions included the resident's bed being in the lower position, bolsters placed on both sides, and high-profile floor mats. The facility's Investigative Report dated 02/13/2025, documented that Resident #128 was observed on the floor next to their bed on 02/12/2025 at 7:45 PM. The bed was observed in an elevated position, and only one (1) bolster and no floor mats were in place. The resident had been incontinent on linens, so staff stepped into the hallway to obtain fresh linens from the cart that was just outside the resident's room. Upon returning to the room, the resident was observed on the floor next to their bed. A hematoma (a localized pool of blood) was reported on the head, and a bruise was reported on both knees. A review of progress notes dated 02/12/2025 documented that at 7:45 PM, Licensed Practical Nurse #4 on the unit heard a sound followed by Resident #128 yelling, 'I am on the floor.' Upon entering the resident's room, they noticed the bed in an elevated position, no fall mat or bolster in place on the left side of the bed, the right-side bolster and mat were in place. A review of progress notes dated 02/12/2025 documented that Registered Nurse #2 was called to the resident's room to assess their injuries after the fall. They observed Resident #128 lying on the floor, next to their bed, on their back. Resident with complaint of pain on the left side of their head and a hematoma noted with bruising to their right and left knees.Nurse Practitioner #1's progress notes dated 02/13/2025 at 10:33 AM documented Resident #128 was evaluated for report of fall out of bed on 02/12/2025. Report hematoma left head but nothing visible at this time. No joint tenderness or swelling,Facility staff were educated on 02/13/2025 on care plan violation by Director of Nursing #1 and Assistant Director of Nursing #1. Education was conducted for all staff regarding understanding the importance of reading care cards and the potential consequences of not adhering to them.A review of investigation notes dated 02/13/2025 documented that Certified Nurse Aide #2 stated the resident was in bed getting changed when they had another bowel movement. They stated that they stepped out of the room to get a new pad, and upon returning, the resident was on the floor next to their bed. During an attempted phone interview on 09/11/2025 at 12:35 PM, Certified Nurse Aide #2 was contacted. A phone message was left, and no return phone call was received.During an interview on 09/11/2025 at 2:35 PM, Licensed Practical Nurse #5 stated they were working when they heard a noise from Resident #128's room, and the resident was found on the floor. They stated they observed the resident lying on their back on the floor with their head against the fall mat, and the bed was noted in an elevated position. They stated that they contacted the supervising nurse, who came down to assess the resident.During an interview on 09/12/2025 at 11:35 AM, Director of Nursing #1 stated they assessed the resident the day after the incident. They stated that the staff used a Hoyer lift to place the resident in bed on 02/12/2025 in the evening. They stated Certified Nurse Aide #2 was changing the resident when they became incontinent again and required a clean pad. They stated that the aide stepped out of the room across the hall to obtain a clean pad from the linen cart, and upon re-entering the room, the resident was lying on the floor next to their bed. Director of Nursing #1 stated that during the investigation, it was determined that the resident's bed was not in the lowest position, and only one (1) side floor mat and bolster was observed in place (to the side opposite of which resident fell out). They stated Registered Nurse #2 assessment findings of a hematoma to the forehead and bruising to both knees. They stated there was no skin abnormalities noted on their assessment on 02/13/2025.Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: Completed a full house audit to determine what residents required floor mats to be placed and to determine compliance. Developed and implemented education on 02/13/2025 for entire facility associated with the following of care plans, specifically for residents with safety and fall care plans. Developed and implemented a plan to ensure all residents were safe and free of potential neglect for staff not following care plans. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life for one (1) (Resident #22) of six (6) residents reviewed. Specifically, Resident #22 reported that some staff did not treat them with respect, they were impolite and mean to them. The resident expressed concern over being treated worse if they talked about it. This is evidenced by: The Policy and Procedure titled, Quality of Life/Dignity, revised 5/28/2024, documented each resident would be cared for in a manner that promoted or enhanced quality of life, dignity, respect and individuality. Residents would be treated with dignity and respect at all times. Treated with dignity meant the resident would be assisted in maintaining and enhancing their self-esteem and self-worth. Resident #22 was admitted to the facility with diagnoses of cerebral infarction (ischemic stroke and occurs because of disrupted blood flow to the brain) chronic diastolic (congestive) heart failure (heart does not fill with blood adequately), edema (swelling that occurs when fluid builds up in the body's tissues). The Minimum Data Set (an assessment tool) dated 07/06/2025, documented the resident had severe cognitive impairment, could be understood, and understand others. During an interview on 09/08/2025 at 1:49 PM, Resident #82 stated some staff were 'short and abrupt' especially with Resident #22. Resident #82 stated they were concerned for Resident #22 because the resident was afraid to speak up. Resident #82 stated some residents could not speak for themselves and emphasized the need for respectful treatment. During an interview on 09/08/2025 at 3:18 PM, Resident #22 stated some staff did not treat them with respect and were impolite and mean. They stated they did feared being treated worse if they reported their concerns and that care was not always provided timely. During an interview on 09/12/2025 at 10:37 AM, Licensed Practical Nurse #2 stated they had been told by Social Work Director #1 the prior week that Resident #82 had concerns about the treatment of Resident #22, who at the time reported no concerns. Licensed Practical Nurse #2 stated the expectation was for staff to treat residents respectfully and politely, asking residents what they wanted and respecting their choices. During an interview on 9/12/2025 1:17 PM, Director of Nursing #1 stated all staff were trained on treating residents with dignity and respect. They stated Licensed Practical Nurse #2 had spoken to Resident #22 and Resident #22 reported no concerns. 10 New York Code of Rules and Regulations 415.5(a)

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #2) of two (2) residents reviewed for respiratory care. Specifically, for Resident #2, the facility did not ensure the physician's order for oxygen administration was followed. This is evidenced by: The Policy and Procedure titled, Oxygen - concentrators, dated 8/14/2025, documented that oxygen equipment would be checked daily for the correct flow and concentration. The Policy and Procedure titled, Oxygen Policy, dated 8/13/2025, stated the oxygen flow rate must be adjusted by a Licensed Practical Nurse and administered according to the physician order. Resident #2 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), type two (2) diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet). The Minimum Data Set (an assessment tool) dated 08/07/2025 documented the resident was able to be understood, to understand others and was cognitively intact. The Physician's order dated 06/22/2025 documented the resident was to receive three (3) liters of oxygen per minute via nasal cannula to maintain oxygen saturation greater than 88 percent. During an observation on 09/09/2025 at 9:30 AM, Resident #2 was observed on oxygen. The oxygen concentrator was set to two (2) liters per minute. During an observation on 9/11/2025 at 12:10 PM, the oxygen concentrator in Resident #2's room was running with the flow meter set to two (2) liters per minute. Resident #2 was not in the room. When Licensed Practical Nurse #3 was alerted, they turned the concentrator off. During an observation on 9/11/2025 at 1:50 PM, Licensed Practical Nurse #3 turned on the oxygen concentrator for demonstration to the surveyor without the resident present. The oxygen rate was observed to be two (2) liters per minute. During an interview on 9/11/2025 at 1:50 PM, Licensed Practical Nurse #3 stated it was reasonable to assume the resident had been receiving the wrong liter per minute of oxygen when in bed, as the concentrator had still been running. During an interview on 9/11/2025 at 2:30 PM, Director of Nursing #1 stated that oxygen should only be administered by nurses and at the rate prescribed by the provider. 10 New York Codes, Rules, and Regulation 415.12(k)(6)

Based on observation and staff interview conducted during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was leaking and the area around was not clean. This is evidenced by: During observations on 09/08/2025 at 11:25 AM, a white and yellow fluid and a black fluid were leaking from the trash compactor. A food decomposition odor was detected in the area surrounding the compactor. During an interview on 09/08/2025 at 11:26 AM, Food Service Director #1 stated that they would place a work order with the maintenance department to contact the vendor to have the compactor replaced or repaired and to have the area cleaned. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on record reviews and interviews conducted during an abbreviated survey (Complaint #NY00304653), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #1) of 4 residents reviewed for abuse. Specifically, Resident #1 who required mechanical lift for transfers was transferred with a wheeled walker from a shower chair to bed by a Certified Nurse Aide. Resident #1's knees buckled, lowered to the floor, and sustained bilateral knees skin tears. This is evidenced by: Resident #1 Resident #1 was admitted to the facility with diagnoses of cellulitis, acute embolism, and thrombosis (blood flow obstruction) deep veins of an extremity, and chronic atrial fibrillation. The Minimum Data Set (an assessment tool) dated 11/1/2023, documented the resident could be understood and could understand others with a Brief Interview of Metal Status indicating significant intact cognition for decisions of daily living. The Policy and Procedure titled, Abuse, dated 2/2019 defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility's Investigation Form dated 11/3/2022 was reviewed and indicated the facility concluded there was reasonable cause to believe that resident abuse, neglect, exploitation, or mistreatment had occurred. The Investigation Form documented a Certified Nurse Aide transferred Resident #1 without using a sit-to-stand mechanical lift that resulted in injury to the resident. An undated written statement related to the Investigation Form dated 11/03/2022 documented that the Certified Nurse Aide stated they had been told verbally to try to use a walker with Resident #1. The Kardex (an electronic resident care card followed by Certified Nurse Aides) dated 10/28/2022 was reviewed and documented that Resident #1 was to be transferred with the assist of a sit-to-stand mechanical lift. A Progress note dated 10/31/2022 was reviewed and indicated Resident #1 had 2 skin tears as a result of a fall. The Progress Note indicated Resident #1 stated they fell with staff while transferring from the shower chair. During an interview on 12/28/2023 at 10:47 AM, Director of Rehabilitation #1 stated Resident #1 was care planned to be assisted by a sit-to-stand mechanical lift for all transfers. They stated that the goal of physical therapy was to improve a resident's functioning so the resident may have been working on transferring from surface to surface with a walker, for example, but until the change was made in writing to nursing, that was strictly a therapy plan. Director of Rehabilitation #1 reviewed the records, and further stated that the Resident #1 was working with a walker in therapy but there had been no submission to the nursing staff that the transfer status should be changed for daily care. During an interview on 12/28/2023 at 11:15 AM, Certified Nurse Aide #1 stated a resident's transfer status was listed on the resident's Kardex (an electronic resident care card followed by Certified Nurse Aides) and should be checked every day for changes. They stated that the Kardex (an electronic resident care card followed by Certified Nurse Aides) should be followed as that was the official list of tasks and assistance needed. During an interview on 12/28/2023 at 11:19 AM, Certified Nurse Aide #2 stated the assistance that the staff provided to a resident was listed in the resident's Kardex (an electronic resident care card followed by Certified Nurse Aides) and that's what should be followed. They further stated that the resident care card followed by Certified Nurse Aides for care was available on the electronic medical record and a paper copy was hanging in the resident's closet. They stated they checked the computer at the start of their shift and checked the paper copy; if the paper copy didn't match or wasn't there, they would notify the nurse to print out a new copy. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: - From 11/01/2022-11/22/2022, the facility completed a random audit for 4 weeks to ensure care plans were followed. - On 10/31/2022, the facility provided education to therapy staff regarding leaving assistive devices in the resident rooms if they are not care planned to use them outside of therapy. - The facility provided re-education on abuse, neglect, and mistreatment, and the accused Certified Nurse Aide was immediately suspended and re-educated regarding following care plans/cards. - At the time of survey, three resident incident reports were reviewed and there were no additional concerns with neglect. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review and interviews during the abbreviated survey (Case #NY00316364), the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 3 residents reviewed for CPR. Specifically, for Resident #1, whose advance directive status was a full code (full support including CPR, if the resident had no heartbeat and was not breathing), the facility failed to ensure CPR was initiated by Registered Nurse (RN) #1 in a timely manner upon recognition of cardiopulmonary arrest on [DATE] at 9:05 AM. This resulted in actual harm to Resident #1 and the likelihood for serious harm to the health and safety of 16 residents on the Midtown Unit in the facility that is Immediate Jeopardy and Substandard Quality of Care. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of post procedural respiratory failure (the need for ventilation for more than 48 hours after surgery), paralysis of vocal cord and larynx (a condition in which the movement of the vocal cord muscles cannot be controlled), chronic kidney disease (progressive damage and loss of function in the kidneys). The Minimum Data Set (MDS-an assessment tool) dated [DATE] documented the resident was cognitively intact, could understand others, and could make themselves understood. The facility policy and procedure (P&P) titled Code Blue/CPR, dated [DATE], documented the facility was to provide emergency cardiopulmonary resuscitation (CPR) with current standards of practice in accordance with resident end of life determination (MOLST- Medical Orders for Life Sustaining Treatment). The P&P documented in accordance with the resident's CODE status ( full code), CPR would be initiated upon recognition of cardiopulmonary arrest ( no pulse, no respirations, no audible blood pressure) and 911 would be activated. A Licensed Nurse certified in CPR/BLS (basic life support) would assume to the role of Code Leader. The leader would supervise the area of the CPR event, direct the code, summon appropriate personnel and discharge personnel from the area who were not longer needed. The MOLST form dated [DATE] documented the resident was a full code. The Comprehensive Care Plan (CCP) for Advance Directives dated [DATE], documented the resident had a MOLST/CPR ordered and no advanced directives. A Physician Order dated [DATE] documented the resident was a full code. A facility investigation dated [DATE], documented on the morning at approximately 9:05 AM, Resident #1 was observed unresponsive in bed with no pulse and no respirations noted by auscultation (listening to the sounds of the body). Resident #1's MOLST indicated they were a full code. The resident was pronounced dead at 9:40 AM by the physician via emergency medical services (EMS). The conclusion also documented the policy was not followed completely. RN #1 acknowledged they should have called a Code Blue immediately. The CPR Log dated [DATE] documented: - 9:20 AM, Code Blue was announced for Resident #1 - 9:25 AM, Staff arrived at the location - 9:10 AM, CPR was initiated - 9:25 AM, Application of automated external defibrillator (AED) - 9:25 AM, Notification of 911 system - 9:35 AM, Arrival of EMS - 9:40 AM, Physician notified (TOD- time of death) A Nursing Clinical Evaluation note dated [DATE] at 11:00 AM, written by the Director of Nursing (DON) documented the Date/Time of Event OR When Nursing Became Aware of Event: [DATE] 9:05 AM. The event type was documented as an unanticipated death. Vital signs documented at 9:05 AM were 0 Respirations and 0 Pulse. The Clinical Evaluation documented a Certified Nurse Aide (CNA) notified the RN on the unit of the resident who was noted to be unresponsive. During an interview on [DATE] at 9:42 AM, CNA #1 stated on the morning of [DATE], CNA #2 came out of Resident #1's room and told them the resident was not responding. CNA #2 went to get RN #1. CNA #1 stated RN #1 started chest compressions and then asked them to take over doing the chest compressions because they were also CPR certified. CNA #1 stated then all the other nurses in the facility came in the room because a Code Blue was called overhead. The CNA stated they were unsure of the time of the events and did not know when CPR had been started. CNA #1 stated when they did chest compressions no one else was in the room because the RN had left the room. CNA #1 stated they thought RN #1 left to go get the crash cart. During an interview on [DATE] at 9:47 AM, CNA #2 who was not CPR certified, stated they remembered looking at the clock when they went into Resident #1's room to get the resident up for the day, because they were the last resident to get up that morning. The clock said 8:57 AM. CNA #2 stated they called the resident's name and said Good Morning, but the resident did not respond. They removed the resident's CPAP (continuous positive airway pressure) mask and stated they knew something was not right as the resident was not responding. CNA #2 stated they told CNA #1 who was in the hallway that the resident was not responding, as they left the resident's room to get the nurse. CNA #2 stated they immediately notified RN #1 that Resident #1 was not responding. During an interview on [DATE] at 11:22 AM, RN #1 stated CNA #2 made them aware that Resident #1 was not responding at 9:05 AM. RN #1 assessed that the resident did not have a pulse or respirations. RN #1 stated they did not immediately perform CPR on the resident because they were unsure what to do in that situation. They had never been in that situation before. RN #1 stated they left the room, and first went to Licensed Practical Nurse (LPN) #3 on the other side of the unit to tell them about Resident #1. RN #1 stated LPN #3 told them to call the Supervisors. RN #1 stated before they called the Supervisors, they called the on-call physician's line. They were asked a lot of questions and were told they would be called back. RN #1 stated they, then, called the RN Supervisors who were on another unit in the facility. While making the calls to the RN Supervisors, they looked up the resident's code status in the computer and confirmed the resident was a full code. RN #1 was not aware of the resident's code status prior to that point. After they notified the RN Supervisors, they went back to Resident #1's room to start compressions, and CNA #1 came with them. RN #1 initiated compressions and then asked the CNA #1 to take over. RN #1 stated they left the room to see if staff were coming with the crash cart. RN #1 stated they were not sure of the exact time of when compressions started but stated they were notified that the resident was unresponsive at 9:05 AM, and compressions started between 9:15 AM and 9:20 AM after they had notified the Supervisors. RN #1 stated they did not call a Blue Code; one of the other nurses called the Code Blue at 9:20 AM, and staff began to come to the resident's room with the AED and crash cart. RN #1 stated compressions lasted about 20 minutes, and then the EMS called their physician, and the resident was pronounced deceased at 9:40 AM. The RN stated they did not know if they were supposed to call a Code Blue right away when they found the resident unresponsive or check the resident's MOLST form for their code status. During an interview on [DATE] at 12:20 PM, LPN #1 stated they were working in the facility on [DATE] on the Hillview Unit and had not heard a Code Blue called until a CNA came over from the Midtown Unit at 9:20 AM. LPN #1 stated as soon as they heard that there was a Code Blue on the Midtown Unit, another nurse on Hillview Unit overhead paged Code Blue throughout the facility, and staff grabbed the crash cart and the AED and went down to Resident #1's room. During an interview on [DATE] at 2:15 PM, the Assistant Administrator (AA) stated the protocol was that the first staff member who found a resident unresponsive was supposed to call out Code Blue and a nurse would go to the room to see the resident. At the same time, because a Code Blue was called, staff would bring down the medical chart with the MOLST, the AED, and the crash cart to the location, and call 911. The resident's code status should be verified using the MOLST to determine if the resident was a full code prior to initiating CPR. If the resident was a full code, compressions would be immediately initiated. The first nurse on the scene should be the Code Leader and would delegate responsibilities to other staff. Then the physician and the family would also be notified. During an interview on [DATE] at 11:40 AM, RNS #1 stated they were on the Country Meadow Unit passing medications when they received a phone call from RN #1 at 9:21 AM. RN #1 told them they found a resident passed away at 9:05 AM. The RNS stated they were not told the resident was a full code. RNS #1 told RN #1 to call RNS #2 who was also on Country Meadow Unit. RNS #1 stated they did not know why at 9:21 AM, they were just being notified of a resident who had passed away at 9:05 AM. RNS #1 stated after RN #1 told RNS #2 that the resident was a full code, they run over to the Midtown unit where Resident #1 resided. RNS #1 stated compressions had not been initiated prior to RN #1 calling the Supervisors. RNS #1 stated a Code Blue was called overhead at 9:25 AM. When the RNS #1 and RNS #2 arrived to the resident's room at 9:25 AM, RN #1 was performing chest compressions on Resident #1. RNS #1 switched with RN #1 to continue the compressions. During an interview on [DATE] at 2:44 PM, the DON stated the MOLST was the primary identification for code status of a resident and 100% of residents had a MOLST in their chart. The DON stated the investigation showed RN #1 initiated CPR before they called a Code Blue. The DON stated when a resident was found unresponsive, the staff who found the resident should call out Code Blue, get a nurse, and have the code paged in the facility. As soon as the nurse arrived to the location, the nurse was to verify the MOLST to determine whether to start CPR. During an interview on [DATE] at 3:00 PM, LPN #2 stated they worked on Hillview Unit and one of the CNAs from Midtown Unit came down around 9:20 AM, said there was a Code Blue on Midtown Unit. Another LPN on Hilltown Unit called Code Blue overhead. The staff from Hillview Unit grabbed the crash cart and went straight down to the resident's room. The LPN stated when they arrived someone was doing CPR on the resident, then another nurse took over. The staff continued compressions until EMS got there. The LPN stated they were asked to complete the CPR Log. The LPN stated they were not present when CPR was initiated, did not know when the compressions were initiated, and was not in the room at 9:10 AM, the time they documented that CPR was initiated. The LPN stated they tried to be accurate when they documented on the CPR Log and someone had said something about compressions started at 9:10 AM and that was what they wrote down on the log. The LPN stated they were not aware of the Code Blue until 9:20 AM. The LPN stated the nurses in the facility arrived to the resident's room around the same time, at 9:25 AM, and compressions had already been started. During an interview on [DATE] at 3:32 PM, RNS #2 stated they were notified at 9:22 AM by RN #1 that a resident was unresponsive and was a full code. The RNS stated a Code Blue had not been called as of 9:22 AM. The RNS heard the Code Blue being called just as they hung up the phone with RN #1 at 9:22 AM or 9:23 AM. The RNS did not know what time CPR was initiated, but stated they believed RN #1 had started compressions before they were called. The RNS ran to the unit and when they arrived to the unit at 9:25 AM, compressions were being done on the resident by RN #1. During an interview on [DATE] at 4:13 PM, the AA stated, with the Administrator also present, to their knowledge, RN #1 made one phone call to the RN Supervisors before performing CPR. The AA stated the code status was verified when RN #1 spoke with RNS #1 and RNS #2 and CPR was immediately started once the code status was verified. The AA stated during the investigation, they did not notice a gap in the time of events from 9:05 AM, when the resident was noted to be unresponsive to 9:22 AM, when RN #1 spoke to RNS #2. The AA stated through the investigation, they noticed that CPR was initiated prior to the Code Blue being called. During an interview on [DATE] at 9:50 AM, LPN #3 stated they were working on the North hallway of the Midtown Unit when the CPR event happened with Resident #1, who was a resident on the South hallway. The LPN stated RN #1 came over and told them that Resident #1 was unresponsive. LPN #3 told RN #1 to let the Supervisors know if they needed more guidance because RN #1 seemed unsure of what to do and they were busy. LPN #3 stated they told the RN to call the supervisors to come over and assess the resident. LPN #3 stated they were not aware of the resident's code status and Code Blue had not been called yet when they told RN #1 to call the Supervisors. The LPN stated when the Code Blue was called, they responded to the resident's room and saw RN #1 doing compressions on the resident. The LPN stated they could not remember what time RN #1 came over to them, but it was around t 9:00 AM. During an interview on [DATE] at 11:51 AM, the Medical Director (MD) stated a staff from the facility called them soon after the resident was pronounced deceased to notify them of the death. The MD stated they were told a CNA walked into the resident's room and found the resident unresponsive. The CNA notified the nurse, and the nurse confirmed the resident did not have any vital signs. The code status was confirmed, and the staff called on-call, but did not wait for on-call to call back before starting compressions. The timeline of events from 9:05 AM to 9:22 AM was reviewed with the MD. The MD stated they did not think that was accurate, but they were not in the facility at the time of the event. The MD stated they were told that CPR was initiated, 911 was called, but the resident could not be revived. The MD stated the protocol when a resident was found unresponsive, was for a Code to be called, the code status needed to be confirmed and if the resident was a full code, CPR would be initiated and 911 and on-call would be called. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on [DATE]. Based on the following corrective actions, the facility corrected the non-compliance as of [DATE]. (IJ past non-compliance indicates the facility had an IJ but the non-compliance was corrected prior to the survey staff entering the nursing home on [DATE]. A Statement of Deficiency will be issued but a Plan of Correction is not required given the facility had corrected the non-compliance). - The facility immediately investigated the incident on [DATE]. - The Registered Nurse involved was suspended pending the investigation and received individual re-education on [DATE] on Code Blue and the CPR Policy. - The facility reviewed the code status of each resident in the facility with no concerns identified. - Beginning [DATE], the facility began CPR drills to be conducted weekly for 4 weeks then monthly for 3 months. - The facility completed 90% of their facility-wide education on the Code Blue/CPR policy as of [DATE] prior to the state agency entering the facility and the education was on-going until 100% of staff were educated. 10 NYCCR 415.3 (e)(2)(iii)

Based on record review and interviews during the abbreviated survey (Case #NY00316364), the facility did not ensure allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for 1 (Resident #1) of 3 residents reviewed for neglect. Specifically, the facility did not ensure a thorough investigation was completed to rule out neglect when the facility investigation did not address the timeline of events for the Code Blue (emergency response) for Resident #1 on [DATE] and therefore, the investigation did not address that CPR (cardiopulmonary resuscitation) was not initiated timely by Registered Nurse (RN) #1 upon recognition of cardiac arrest on [DATE] at 9:05 AM. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of post procedural respiratory failure, paralysis of vocal cord and larynx, chronic kidney disease. The Minimum Data Set (MDS- an assessment tool) dated [DATE] documented the resident was cognitively intact, could understand others, and could make themselves understood. The facility policy and procedure (P&P) titled Abuse dated ,d+[DATE] documented neglect was the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or distress. The P&P documented allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. The conclusion must include whether the allegation was substantiated or not and what information supported the decision. A facility investigation dated [DATE], documented on the morning of [DATE] at approximately 9:05 AM, Resident #1 was observed unresponsive in bed with no pulse and no respirations noted by auscultation (listening to the sounds of the body). The investigation conclusion documented Registered Nurse (RN) #1 assessed and noted absence of pulse and respiration and notified the supervisors. CPR was initiated by RN #1, and Code Blue (emergency response) was called. The conclusion also documented due to the policy not being followed completely, a plan of correction was in place to prevent recurrence and RN #1 acknowledged they should have called a Code Blue immediately. During the review of the facility investigation, the conclusion did not rule out abuse, neglect, or mistreatment. The Timeline of Event for the Code Blue dated [DATE], documented the following: - 8:30 AM, Activity Staff was passing out chronicles and the resident was noted to be alive and breathing. - (Time Blank), CNA (Certified Nurse Aide) noted the resident unresponsive and notified the nurse. - (Time Blank), RN notified of resident unresponsive. Auscultated x 1 minute and no pulse noted. - (Time Blank), RN notified the LPN (Licensed Practical Nurse) on the unit - (Time Blank), RN notified Registered Nurse Supervisor (RNS) of resident being deceased - (Time Blank), RN Supervisor notified DON (Director of Nursing) of resident being deceased - (Time Blank), RN initiated CPR - (Time Blank), CNA took over CPR - (Time Blank), CNA from Midtown unit ran to Hillview unit and notified the LPN of the Code Blue on Midtown - 9:20 AM, Code Blue called by LPN - 9:25AM, CPR continued, AED (automated external defibrillator) applied, and 911 called - 9:35 AM, EMS arrived - 9:40 AM, Resident was pronounced deceased by the physician via EMS A Staff Statement by CNA #2 documented, the CNA walked in around 8:57 AM and found Resident #1 in their bed unresponsive. CNA #2 removed the resident's CPAP (continuous positive airway pressure) machine and immediately notified the nurse. A Staff Statement by RNS #2 documented, RN #1 notified them at 9:22 AM of Resident #1 being found unresponsive. The resident was verified to be a full code. CPR initiated. 911 called. DON notified. EMS arrived and deemed the resident deceased at 9:40 AM. A Staff Statement by RN #1 documented at 9:05 AM on [DATE], a CNA alerted me to a patient being unresponsive, having no pulse or respirations. The RN listened to the resident's heart for one minute. The RN ran to the other nurse and let them know. The RN called both Supervisors on Country Meadow. The RN documented they looked at the resident's code status and saw that they were a full code. The RN started compressions, someone called a code blue, grabbed the AED, and called 911. Time of death was 9:40 AM. A Nursing Clinical Evaluation note dated [DATE] at 11:00 AM, written by DON documented the Date/Time of Event OR When Nursing Became Aware of Event: [DATE] 9:05 AM. The event type was documented as an unanticipated death. Vital signs documented at 9:05 AM were 0 Respirations and 0 Pulse. The Clinical Evaluation documented a CNA notified the RN on the unit of the resident who was noted to be unresponsive. During an interview on [DATE] at 11:22 AM, RN #1 stated CNA #2 made them aware that Resident #1 was not responding at 9:05 AM. RN #1 assessed that the resident did not have a pulse or respirations. RN #1 stated they did not immediately perform CPR on the resident because they were unsure what to do in that situation. They had never been in that situation before. RN #1 stated they left the room, and first went to Licensed Practical Nurse (LPN) #3 on the other side of the unit to tell them about Resident #1. RN #1 stated LPN #3 told them to call the Supervisors. RN #1 stated before calling the Supervisors, they called the on-call physician's line. RN #1 stated they were asked a lot of questions and were told they would be called back. RN #1 stated they, then, called the RN Supervisors who were on another unit in the facility. While making the calls to the RN Supervisors, they looked up the resident's code status in the computer and confirmed the resident was a full code. RN #1 was not aware of the resident's code status prior to this point. After they notified the Supervisors, they went back to Resident #1's room to start compressions, and CNA #1 came with them. RN #1 initiated compressions and then asked the CNA #1 to take over. RN #1 stated they left the room to see if staff were coming with the crash cart. RN #1 stated they were not sure of the exact time of when compressions started but stated they were notified that the resident was unresponsive at 9:05 AM, and compressions started between 9:15 AM and 9:20 AM after they had notified the Supervisors. RN #1 stated they did not call a Blue Code; one of the other nurses called the Code Blue at 9:20 AM, and staff began to come to the resident's room with the AED and crash cart. RN #1 stated compressions lasted about 20 minutes, and then the EMS called their physician, and the resident was pronounced deceased at 9:40 AM. The RN stated they did not know they were supposed to call a Code Blue right away when they had a resident who was unresponsive or check the resident's MOLST form for their code status. During an interview on [DATE] at 2:10 PM, the Administrator stated through the facility investigation, they found that the Code Blue policy was not followed, but after reviewing everything for the investigation, and discussing it with the Assistant Administrator (AA), they determined it was not a reportable incident based on the New [NAME] State (NYS) Reporting Manual (A manual dated 2016 for reporting alleged violations of mistreatment, neglect, and abuse). During an interview on [DATE] at 2:18 PM, the DON stated they initiated the investigation on [DATE] as soon as they were notified of the Code Blue that took place. They came into the facility on [DATE] to initiate the investigation. Upon investigation it was determined the policy was not followed by RN #1. The RN was suspended, and had since been reeducated. During a subsequent interview on [DATE] at 2:44 PM, the DON stated the investigation showed RN #1 initiated CPR before calling the Code Blue. The DON stated when a resident was found unresponsive, the staff who found the resident should be calling out Code Blue, getting the nurse, and having the code paged overhead in the facility. The DON stated for their investigation they did not look at the timing of the events, they looked at the sequence of events and found that the order of events was not per policy. The DON stated they were not aware CPR was not started right away based on the investigation but they were aware the Code Blue was called after CPR was initiated. During an interview on [DATE] at 4:13 PM, the AA stated, with the Administrator also present during the interview, they were also confused when they did the investigation regarding the timeline of events, because they did not know the exact times and neither did the staff because they were not looking at a clock. The investigation focused on the order of the events, rather than the timeliness of events. The AA stated to their knowledge, RN #1 made one phone call to the supervisors before performing CPR. The AA stated the code status was verified when RN #1 spoke with the RN Supervisors and CPR was immediately started once the code status was verified. During the interview, the Timeline of Event for the Code Blue dated [DATE] was reviewed. The AA stated they were able to put together the order of events, but acknowledged the times of events on the timeline were left blank. The AA stated during the investigation, they did not notice a gap in the time of events from 9:05 AM, when the resident was noted to be unresponsive to 9:22 AM, when RN #1 spoke to RNS #2, but they did notice through the investigation, that CPR was initiated prior to the Code Blue being called. 10NYCRR 415.4(b)

Based on record review and interviews during an recertification and abbreviated survey (Case #'s NY 873, NY 351, NY 396, NY 095, NY 004, NY 838, and NY 513) conducted on 9/07 through 9/13/2022, the facility did not ensure that a Level II assessment was conducted as indicated on the DOH-695 (2/2009) Screen form, prior to admission for one (Resident # 117) of 18 residents reviewed for completion of PASRR (Preadmission Screen Resident Review). Specifically, for Resident #117, whose DOH-695 (2/2009) Screen form dated 6/9/2021 indicated the resident was to have a Level II Evaluation completed for determination of needed services due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: Resident #117 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 7/2/2022 documented the resident was sometimes understood and could sometimes understand others. Resident #117 had severely impaired cognition for daily decision making. The PASRR Screen form (DOH-695, (2/2009) for Resident #117 dated 6/9/2021, documented the following: 1. Question #26, Does this person present with evidence of cognitive deficits and/or adaptive skill deficits that may indicate the presence of mental [CONDITION(S)] or developmental disability? YES Guideline: If any items from question 24-26 are marked Yes, proceed to Categorical Determinations (items 27-30). 2. Question #27, Does this person qualify for convalescent care? NO 3. Question #28, Is this person seriously physically ill? NO 4. Question #29, Is this person terminally ill? NO 5. Question #30, Is this person to be admitted for a very brief and finite stay or a provisional emergency admission? NO Guideline: If any of the items 27-30 are marked YES, proceed to danger and self or other qualifiers (item 31). If all are marked NO, proceed to Level II referral (item 33). 6. Level II evaluation Item 33 not completed. Review of Resident #117's medical record did not include documentation that a Level II referral had been done. A preadmission screen dated 6/09/2022 documented the resident did not have dementia, mental illness, and did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Questions 27 thru 30 were answered no, indicating a Level II referral was required. The form was accepted by the facility. During an interview 09/09/22 10:36 AM, Registered Nurse Unit Manager (RNUM) #1 stated the resident was admitted on [DATE] for orthopedic aftercare for repair of fracture of a femur. The resident had health care support from the Manager of the Group Home and was to be discharged there after rehabilitation. Resident #117 had an Intellectual disability and [CONDITION(S)]. RNUM #1 could not provide a completed PASRR for the resident. RNUM #1 thought the Social Worker may have that information. During an interview on 9/9/2021 at 2:38 PM, the Director of Nursing (DON) stated the facility is responsible to ensure all residents have a PASRR screen completed per regulation before being admitted to the facility. The DON stated Social Services handles the Preadmission paperwork. Resident #117 had no services other than staff monitoring while at the facility. The DON could not find any evidence of a Level II referral for the resident. During an interview on 09/12/22 at 1:34 PM, the Director of Social Work (DSW) stated Resident #117 had been admitted to the facility from the hospital after a surgical repair of a fractured right hip. Aftercare was needed for the resident before returning to the group home setting. The hospital completed the PASRR Screen form but the facility was responsible to ensure it was correct. It had been determined that a Level II referral was not needed because Resident #117 had not been diagnosed with intellectual disability prior to the age of 22. After re-reviewing the PASRR, the DSW stated, based on the answers to the initial screen dated 6/9/2021, question 27 to 30 were answered no and a Level II referral should have been done according to the guidelines and was not done. The DSW has training in completing PASRR's and should have addressed this when it was reviewed at the facility on the day of admission. A Level II referral was not completed for determination of services. 10 NYCRR415.11(e)

Based on interviews and record review, during an abbreviated survey (NY 085) conducted from 2/9/2022 to 2/24/2022 the facility failed to development and implement policies and procedures (P&P) to ensure proper precautions to prevent the spread of COVID-19 by unvaccinated staff. Specifically, P&Ps did not include a contingency plan for staff not fully vaccinated for COVID-19. This was evidenced by: The facility P&Ps for COVID 19 - Staff - NY dated 1/4/2022, COVID Vaccine dated 10/26/2021 and COVID Vaccine - Staff dated 11/2021 did not document a contingency plan that addressed actions and consequences the facility would take for staff who indicated they would not get vaccinated and did not qualify for an exemption. During an interview on 2/10/2022 at 11:16 AM, the Administrator stated that a P&P had not been written for a contingency plan for unvaccinate staff because all their staff had been vaccinated. During a subsequent interview on 2/24/2022 at 8:54 AM, the Administrator stated that there was not a contingency plan for unvaccinated staff because they would not hire unvaccinated staff, and that there had been no changes made in their P&P to include a contigency plan. 10 NYCRR 415.19(a)(1-3)

Based on record review and interviews during an abbreviated survey (Case #s NY 890 and NY 287), the facility did not ensure a comprehensive care plan (CCP) was implemented for each resident for 2 (Residents #1 and #2) of 3 residents reviewed for care plan implementation. Specifically, Resident #1 was care planned for the assistance of 2 staff for bed mobility and personal hygiene. On 1/10/2021 a Certified Nurse Aide provided care by themself and Resident #1 fell out of bed. Additionally, Resident #2 was care planned to have bolsters for positioning in bed. On 4/27/2021 the bolsters were not placed on the bed. Subsequently, Resident #2 fell out of bed, sustaining a superficial scalp laceration. This was evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It also documented Resident #1 needed extensive assistance from 2 people for bed mobility and personal hygiene. The Comprehensive Care Plan (CCP) for Activities of Daily Living dated 10/14/2021, documented the resident needed the extensive assistance of two staff for bed mobility and personal hygiene. The Certified Nursing Assistant (CNA) care card as of 1/11/2021, documented the resident was the extensive assist of two staff for bed mobility and personal hygiene. The Accident/Incident Report dated 1/10/2021, documented that, at 8:25 PM on 1/10/2021 Resident #1 fell out of bed while evening care was being provided by CNA #3. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . An untimed statement dated 1/11/2021, written by CNA #3, documented they turned the resident over to provide care. The resident then rolled over out of the bed and fell on to the floor. CNA #3 documented it was the first time they had taken care of Resident #1, and they did not know the resident need the assistance of 2 staff until afterwards. During an Interview 12/20/2021 at 11:53 AM, the Director of Nursing (DON) stated that, on 1/10/2021, CNA #3 was doing care on the resident and the resident rolled out of bed. The DON stated the resident was a 2 assist for care and CNA #3 provided care by themself. CNA #3 told the DON they had done the resident's care alone. The DON stated staff were supposed to look at the resident's care card in their room whenever they went into a room to provide care because their care plan could change at any time during the day. Resident #2: The resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS tool dated 4/22/2021, documented the resident had severe cognitive impairment, could be understood, and could rarely/never understand others. The CCP for Risk for Falls, dated 4/20/2021, documented that on 5/7/2021, the resident was to have bilateral bolsters for positioning. The CNA care card as of 4/27/2021 documented the resident was to have bilateral bolsters in bed. An untimed Investigation Form for the 4/27/2021 incident, documented that on 4/27/2021, at 8:30 AM, the resident rolled out of bed onto the floor. A Registered Nurse (RN) assessment was done, and the resident had a superficial laceration to the back of their head. At the time of the incident, it was witnessed the resident's bolsters were leaning against the wall, instead of in the bed as the resident was care planned for. Licensed Practical Nurse (LPN) #4 reported they put the resident to bed at approximately 11:00 PM and did not place the bolsters in the bed with the resident. An RN Assessment note dated 4/27/2021 at 8:30 AM, documented Resident #2 was found on the floor by a CNA at 8:30 AM. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/21/2021 at 9:46 AM LPN #4 stated they got to the unit about 11:00 PM on 4/27/2021, and Resident #2 was wandering in the hall, even though they were not supposed to be walking by themself. LPN #4 stated they redirected the resident back to their room, asked them if they needed to use the bathroom, and then put the resident in their bed. LPN #4 stated they did not notice to bolsters in the room and had not looked at the care card. During an interview on 12/24/2021 at 9:23 AM, the DON stated that on 4/27/2021, Resident #2 had been observed on the floor by their bed. The resident was supposed to have bolsters in place, and LPN #4 admitted they did not place them on the bed. The DON stated the care plan was not followed because the bolsters were not in place and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 10 NYCRR 415.11(c)(1)

Based on interview and record review during an abbreviated survey (Complaint #NY 199), the facility did not ensure 1 (Resident #4) of 5 residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, after starting cardiopulmonary resuscitation (CPR), Licensed Practical Nurse (LPN) #1 assessed Resident #4 and determined continued CPR would have been futile. This is evidenced by: The facility's P&P titled, Code Blue/ CPR, last updated ,[DATE], documented if a resident was found either, turning blue, unresponsive, not breathing normally, not breathing, having no palpated pulse within 10 seconds or choking, the staff member was to stay with the resident, call for assistance have staff members checking for advanced directive and call Code Blue. Resident #4: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had a severe cognitive impairment. The Medical Order for Life Sustaining Treatment (MOLST), dated [DATE], documented an order for [REDACTED]. A Facility Investigation dated [DATE] documented Resident #4 had an order to attempt CPR. On [DATE] Resident #4 was found unresponsive, had no color, no pulse and no heartbeat. CPR was attempted the discontinued so the LPN then stopped CPR to get assistance from the on-call medical service. The facility concluded LPN #1 stopped CPR prior to arrival because the resident was already dead, and that resuscitation efforts were futile. While LPN#1 did not follow the facility Code Blue/CPR policy, the LPN's description of the resident's condition, including the fact that it was difficult to do compressions, lead her believe the resident was truly dead. In a verbal statement, documented by the Administrator, dated [DATE] at 8:00 AM, LPN #1 stated that, at 3:40 AM, CNA #s 1 and 2 reported to LPN #1 that Resident #4 was unresponsive. LPN #1 reported the resident was cool to touch, did not have a pulse or heartbeat, CPR was initiated then LPN #1 called the Director of Nursing (DON) and informed her Resident #4 had passed away. LPN #1 stated she was instructed to call the physician on call and inform him/her of the resident's death. In a written statement dated [DATE], as part of the facility's investigation, The DON documented LPN #1 called the DON at 4:00 AM and reported that Resident #4 had passed away. LPN #1 told the DON that the resident was cold to touch, unresponsive and mottled. The DON documented LPN #1 called and stated the MD did not return her call, and DON Instructed LPN #1 to call 911. During an interview on [DATE] at 7:56 AM, LPN #1 stated she was told Resident #4 did not look right and was unresponsive. When she entered the resident's room, the resident was cold, had no pulse or heartbeat, so she performed three cycles of CPR, but there was no response, so she stopped CPR. When LPN #1 contacted the DON, she was instructed to call the on-call MD. When she called the DON again, the DON instructed her to call 911. During an interview on [DATE] at 1:13 PM, the DON stated she received a telephone call from LPN #1 on [DATE], stating Resident #4 had passed away. The DON stated she instructed LPN #1 to call the on-call MD. The facility's investigation revealed LPN #1 had stopped CPR because the resident was cold, and that LPNs were not qualified to assess residents, but could only gather information and report it. During an interview on [DATE] at 3:42 PM, the Administrator stated LPNs were not qualified to assess residents. Although the resident may have been cold to the touch, LPN #1 should have continued CPR until emergency services arrived. 10 NYCRR 415.12

Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY 6), the facility did not ensure residents were free from physical abuse for 2 (Resident #'s 19 and 67) of 3 residents reviewed for abuse. Specifically, the facility did not ensure that Resident #'s 19 and 67 were free from physical abuse related to a resident to resident altercation. This was evidenced by: Resident #67: Resident #67 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 9/17/19, documented the resident had severe cognitive impairment, could usually understand others and was usually able to make himself understood. Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severe cognitive impairment, sometimes could be understand by others and usually was able to understand others. The facility policy and procedure (P&P) for Abuse, with a revision date of 2/2019, documented physical abuse was defined as any use of willful infliction of injury. Includes hitting, slapping, pinching, scratching, spitting, holding roughly, and kicking. It also includes controlling behavior through corporal punishment. Behavior Care Plan for Resident #67, date initiated 11/20/17, documented the resident exhibited behavior symptoms such as socially inappropriate verbal aggression/abuse, physically aggressive/abuse, hallucinations and delusions. Interventions; document all behaviors in attempt to identify pattern to target interventions, redirect negative behavior as needed and psychology evaluation as needed. Victim/Aggressor Care Plan documented the resident had cognitive impairment and was hard of hearing, had history of becoming physically aggressive if he perceived he was in danger or was being threatened or talked about. Behavior Care Plan for Resident #19, documented he had history of placing wet towels on the outside of his pants and then tell staff he urinated and needed to be changed. He makes animal noises to mimic/mock other residents and can become verbally/physically aggressive towards other residents if he feels provoked. Victim/Aggressor Care Plan, dated 9/18/19, documented resident had the inability to understand his surroundings related to cognitive impairment secondary to TBI, disruptive behavior such as making animal noises and mimicking others, physically abusive when he feels provoked by others such as calling him names and touching his chair in a threatening way. The facility investigation dated 9/18/19, documented a staff member witnessed Resident #67 attempting to pull Resident #19's wheelchair and was swinging a fist at the resident. Resident #19 used his reacher and struck Resident #67 twice in the head. The staff member immediately separated the residents and called for assistance. Resident #67 had slight pink discoloration to the back of his neck with some discomfort. He moved his head without difficulty. Investigation findings documented Resident #19 stated Resident #67 called him a bastard and grabbed his wheelchair so he could hit him. Resident #67 stated Resident #19 started it. The residents were roommates and were great friends until Resident #67 was recently hospitalized . There had been no reports of any trouble between them. They both have behavior careplans as they can become verbally aggressive with others. Resident #19 tends to instigate other residents by mimicking and laughing at them. Both have [MEDICAL CONDITION] and cognitive deficits. Resident #67 is very hard of hearing and has long history of thinking people are talking about him or misunderstanding what is said. He has declined any assistive device. He sees psychiatry regularly to help manage his behaviors and outbursts. Plan to prevent a reoccurrence was to move Resident #67 to another room as the residents continued to be angry with each other. The speech therapist statement dated 9/17/19, documented she approached the residents as they were in the middle of a physical and verbal altercation. Resident #67 was attempting to pull Resident #19's wheelchair and was swinging at him while Resident #19 was swinging his reacher twice down onto Resident #67's head. The residents were immediately separated and altercation was reported. Nursing Progress Note dated 9/17/19 at 4:15 PM, documented Resident #19 stated Resident #67 came up to him swearing at him and calling him names then grabbed his arm and kicked him. He denied pain/discomfort. No injury noted. Speech therapist reported that she heard the residents swearing at one another in the hallway. She observed Resident #19 hitting Resident #67 with his reacher. Resident #67 has history of resident to resident physical altercations. On 6/05/19 he grabbed Resident #17 by both arms, causing bruising to both forearms and a scratch to left forearm. Per investigation, Resident #70 had been signing God Bless America in the lunchroom, as he often does. Resident #67 was wheeling by and believed the resident was singing the death song so he grabbed him by both forearms. Resident #67 had history of delusions and receives psych services. Vision and hearing are impaired. After this incident, Resident #67 was seen by Psychiatry on 6/19/19, with consultation documenting resident had history of [MEDICAL CONDITION] with depression. Mood and behavior were stable. Stated he was doing fine, denies any problem with anyone. Continue with medications of Risperdone 0.5 milligram (mg) and [MEDICATION NAME] 50 mg every day. Psychiatric note on 9/23/19, documented Resident #67 had a recent resident to resident altercation. Recent [DIAGNOSES REDACTED]. Resident was preoccupied with not feeling well. Mood/behavior were at baseline, he can be redirected. Continue with current medications, Risperdone 0.5 milligram (mg) and [MEDICATION NAME] 50 mg every day. During an interview on 1/09/20 at 11:36 AM, the Director of Nursing (DON) and Administrator stated Resident #67 misunderstood what he was hearing. He refused a pocket talker and refused audiology. He had delusions and was frustrated when he misunderstood what was being said. The residents were immediately separated by a staff member who witnessed the physical altercation and were physically assessed. The residents were interviewed by the Administrator, DON and Unit Manager. The residents are best friends and recently both came to administration and begged to be in the same room again. They were told they cannot hit each other and are again roommates. Family is in agreement. Resident #67 has gained a trusting relationship with the day time receptionist, the DON and Administrator and reports if something bothers him before it goes too far. He had also been given a guitar which he enjoyed playing. 10 NYCRR 415.4 (b)(1)(i)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 2 (Resident #'s 80 and 115) of 3 resident reviewed for nutrition. Specifically, for Resident #80, the facility did not ensure a resident with a significant weight loss received adaptive equipment and assistance eating in accordance with the comprehensive care plan; and for Resident #115, the facility did not ensure the resident received a physician ordered supplement in accordance with the comprehensive care plan and the resident's preference. This is evidenced by: The Policy and Procedure (P&P) titled Care Plans dated 10/2019, documented care plan interventions were to be chosen after careful data gathering, proper sequencing of events, careful consideration of the resident's problem areas and their causes, and relevant clinical decision making. Resident #80: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 11/15/19, documented the resident had severely impaired cognition, could sometimes understand, and could make self understood. The facility did not have a policy and procedure (P&P) for adaptive equipement. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL's) last updated 1/6/20, documented the resident was to receive extensive assistance, a bent black handled spoon, and alternate liquids/solids at meals. The CCP for Nutrition last updated 1/6/20, documented the resident was to receive a bent spoon and limited assist at meal times. The certified nursing aid (CNA) caregiving instructions dated 1/9/20, documented the resident was to receive extensive assist with eating, a bend black handled spoon, and alternate liquids/solid foods. The weight record documented the following: - On 7/3/19 - the resident weighed 164.2 lbs. - On 12/1/19 - the resident weighed 138 lbs. - On 1/2/20 - the resident weighed 132.3 lbs, indicating a significant 31.9 lb (19%) weight loss over the past 180 days, and continued 5.7 lb (4%) weight loss over the past 30 days. During observations on 1/7/20: - At 11:53 AM, the resident's lunch tray was served with regular (not bent) built up utensils. - At 11:59 AM, staff in the dining room offered to cut the resident's main item (sloppy jo on a bun), moved the resident closer to the table, and then left the table. - At 12:21 PM, the Speech-Language Pathologist removed the resident's tray from the table. - Between 11:53 AM - 12:21 PM, there were no additional observations of staff assistance. During an observation on 1/8/20 at 12:08 PM, the resident was observed at lunch with regular (not bent) built up utensils. During an observation on 1/9/20 at 12:06 PM, the resident's lunch meal was served with regular cups and regular (not bent) built up utensils. The resident was seated at a table without a staff member seated beside her, and did not receive a sandwich with her meal. Finding #1: The facility did not ensure a resident with a significant weight loss received adaptive equipment. During an interview on 1/10/20 at 8:38 AM, the Registered Dietitian (RD) stated the Diet Technician (DT) documents the adaptive equipment the resident needs on his/her meal ticket, and Resident #80's meal ticket should have had bent utensils documented and did not. He/she stated there is no supervisor check for the trayline to ensure the adaptive equipment on the tray is accurate. During an interview on 1/10/20 at 10:14 AM, the Director of Nursing (DON) stated there was a disconnect between disciplines that led to confusion regarding the level of assistance the resident needed. The DON stated the staff in the dining room should be monitoring the residents and notify the interdisciplinary team if a resident requires more or less help than what is documented on the care card, and this did not occur. Finding #2: The facility did not ensure a resident with a significant weight loss received assistance eating in accordance with the comprehensive care plan. During an interview on 1/10/20 at 9:57 AM, Licensed Practical Nurse (LPN #2) stated he/she was familiar with the resident and the resident was to be supervised in the dining room, meaning the resident eats by him/herself after set up. LPN #2 stated the care giving instructions stated the resident was extensive assist and LPN #2 stated she was unsure why. LPN #2 called the Speech Language Pathologist, and LPN #2 stated the Speech Language Pathologist said the resident's level of assistance was changed because the resident needed assistance with the bent spoon, and the resident had difficulty picking the bent spoon up after setting it down. During an interview on 1/10/20 at 8:38 AM, the Registered Dietitian (RD) stated the resident's level of feeding assistance was increased after a significant weight loss in September. The RD stated the resident should receive extensive assist from staff for eating and the care plan interventions should have been consistent. Resident #115 The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 12/13/19, documented the resident was cognitively intact, could understand others and make self understood. The P&P titled Nourishments-Supplements-Snacks dated 10/2019, documented a list of residents receiving specific supplements was kept by the Food and Nutrition Department, reviewed as part of the resident's care plan update, and all supplements were provided by physician order [REDACTED]. The CCP for Nutrition last updated 12/28/19, documented the facility was to honor resident food preferences (including Nepro, a nutritional supplement, drinks). A physician order [REDACTED]. The Medication Administration Record [REDACTED] - On 12/12/19, the patient refused and ate all of her lunch. - On 12/13/19, the resident ate a good lunch. - On 12/14/19, the resident decline and ate all of her lunch. - On 12/16/19, the resident was not given the supplement and the facility did not have any. - On 12/17/19, nursing would discuss with dietary. - On 12/18/19, order discontinued due to resident received at [MEDICAL TREATMENT]. During an interview on 1/09/20 at 12:10 PM, the resident stated the [MEDICAL TREATMENT] center told her she needed more protein, and she liked the Nepro from the [MEDICAL TREATMENT] center. She stated she had asked for Nepro many times at the facility, and it was not provided to her. During an interview on 1/9/20 at 1:35 PM, Registered Nurse (RN #1) stated the Nepro order was discontinued because the resident was receiving Nepro at [MEDICAL TREATMENT], and the intervention to provide the Nepro was still on the care plan and should not have been. He/she stated the facility never received the Nepro to provide to the resident during the time the order was in place. During an interview on 1/10/20 at 9:03 AM, the facility Registered Dietitian (RD) stated the resident was receiving Nepro when she came to the facility, and the facility did not have it in stock. He/she stated that in order to get the Nepro, the nursing department would let central supply know they would need the Nepro once the physician placed the order, and the Food Service Director would complete the purchase order. During an interview on 1/10/20 at 9:37 AM, the [MEDICAL TREATMENT] Center Registered Dietitian (RD) stated the resident is scheduled to receive a protein bar at [MEDICAL TREATMENT] per her preference, however all residents are offered a choice at [MEDICAL TREATMENT] of a Nepro or a protein bar, so it is possible she has received Nepro on occasion during her treatments. He/she stated the resident's protein labs have been low. During an interview on 1/10/20 at 9:44 AM, Registered Nurse (RN) #1 stated when a supplement is needed for a resident, the physician order [REDACTED]. He/she stated if there was difficulty obtaining the product, administration should have been notified and the nurse should have notified the physician. He/she stated the notification should be documented by the nurse on the medicine cart. He/she stated a judgement call on whether or not to give the supplement based on intake should not been made without the physician being aware. He/she stated the in-house physician started a protein supplement due to the resident's [MEDICATION NAME] lab value being low (15.7 milligrams per deciliter), and the care plan should be updated with changes to the resident's supplement schedule by someone on the interdisciplinary team. During an interview on 1/10/20 at 10:14 AM, the Director of Nursing stated the physician agreed to provide the Nepro supplement to the resident and wrote the physicians order. He/she stated the facility finally made the determination that they were unable to obtain the supplement, and the order was discontinued. He/she stated the facility also needed to be fiscally responsible. He/she stated the documentation on the Medication Administration Record [REDACTED]. 10NYCRR415.12(i)(1)

Based on record review and interviews during the recertification survey, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice for 1 (Resident #115) of 1 residents reviewed for [MEDICAL TREATMENT] care. Specifically, the facility did not ensure there was ongoing communication with the [MEDICAL TREATMENT] treatment center. This is evidenced by: The Policy and Procedure (P&P) titled [MEDICAL TREATMENT] Management, dated 5/2019, documented the facility was to establish communication with the [MEDICAL TREATMENT] center using the [MEDICAL TREATMENT] communication form. The P&P documented the nurse would establish pre-[MEDICAL TREATMENT] vital signs, advanced directives, and any pertinent resident information and the nurse would review the communication when the resident returned from the [MEDICAL TREATMENT] center. Resident #115 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 12/13/19 documented the resident was cognitively intact, could understand others and make self understood. The Comprehensive Care Plan (CCP) for [MEDICAL TREATMENT] dated 12/28/19, documented the facility was to communicate with the [MEDICAL TREATMENT] Center as needed. A physician order [REDACTED]. During a record review on 1/09/20 at 9:56 AM, the resident's [MEDICAL TREATMENT] Communication Form sheets dated 12/11/19, 12/20/19, 12/23/19, 12/26/19, 1/6/20, and 1/8/20 did not include documentation of the resident's name or any other information from the nursing facility to the [MEDICAL TREATMENT] center. During an interview on 1/10/20 at 10:14 AM, the Director of Nursing stated the Licensed Practical Nurse or any of the nurses on the unit should have completed the facility portion (the resident's vital signs, medications, meal time, diet, fluid restriction, significant alerts, and signature) of the [MEDICAL TREATMENT] communication sheets prior to the resident leaving for [MEDICAL TREATMENT], the unit manager was responsible for oversight of the completion. 10NYCRR 415.12

Based on record review and interviews during the recertification survey, the facility did not ensure qualified staff were employed to carry out food and nutrition services. Specifically, the facility did not ensure that when a qualified dietitian was not employed full-time, the person designated to serve as the Director of Food and Nutrition met the requirements. This is evidenced by: The Facility Survey Report (FSR) dated 1/6/20, did not include documentation of the Food Service Director (FSD) qualifications. The FSR documented the qualified dietitian was part time. The facility assessment, reviewed by the Food Service Director (FSD) on 9/19/19, documented the Registered Dietitian position would be staffed as follows: 0.4 FTE's, 5 days a week, 2 shifts per week, 19 hours total. The facility assessment also documented the nutrition needs of the facility included individualized diet requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, and the facility was in process for Total [MEDICATION NAME] nutrition (TPN) implementation. During an interview on 01/09/20 at 1:38 PM, the FSD stated he did not have a certification or degree in food service management per regulatory requirements. He/she stated he was designated as the FSD for the facility after (MONTH) 28, (YEAR). During an interview on 1/10/20 at 8:38 AM, the Registered Dietitian (RD) stated she was employed by the facility 19 hours per week and her credential is a RD. During an interview on 1/10/20 10:51 AM, the Administrator stated the regulatory non-compliance was an oversight due to the FSD transfer from another facility. 10 NYCRR 415.14(a)(1)(2)

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 01/06/2020 at 1:00 PM, revealed fuel burning appliance in the basement boiler room, laundry room, and the kitchen without carbon monoxide detection. The Director of Maintenance stated in an interview on 01/06/2020 at 1:15 PM, that he will add carbon monoxide protection in all areas with gas fuel fired equipment. 483.70 (b); (YEAR) International Fire Code, Section 915

Based on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. Specifically, face masks were not properly worn by three employees while on resident units. This is evidenced by: Policy Statement on Influenza Vaccination of Health Care Personnel dated 8/09/19, documented it is recommended that health care personnel who do not receive an influenza vaccination must wear personal-protective masks when in direct resident contact during the influenza season (October through April). It is also recommended to target education to any health care personnel who do not receive an influenza vaccination. On 01/07/20 at 12:08 PM, an aide was observed feeding Resident #120 in the dining room with her face mask below her nose. On 01/07/20 at approximately 2:00 PM, Activity Personnel #5 was observed walking through Midtown Nursing Unit and then proceeded to [NAME]view Nursing Unit with her face mask below her nose. On 01/08/20 at 11:46 AM, Licensed Practical Nurse (LPN) #1 was observed walking onto the [NAME]view Nursing Unit with her face mask below her nose. During an interview on 01/08/20 at 11:46 AM, LPN #1 stated she was wearing it in that manner because she was just coming back from break. During an interview on 01/10/20 at 11:56 AM, the Assistant Director of Nursing (ADON) stated LPN #1 and activities personnel #5 are common culprits with wearing their face mask below their nose. LPN #1 has just received the flu shot. The ADON stated every department head gets a list of employees who are supposed to be wearing a mask. Nursing home policy is to inform the employee by verbal communication three times if they are wearing the mask incorrectly. After that, the employee is issued a written warning. Staff are inserviced how to correctly wear face masks. Employees who do not receive the flu shot sign a declination and are educated on the importance of wearing a mask 10NYCRR415.19(a)(1-3)

Based on record review and interviews during an abbreviated survey (Case # NY 460), the facility did not ensure a resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not ensure Resident #1, who had cognitive impairment, was free from physical abuse when he/she was assaulted by Registered Nurse Supervisor #1. This is evidenced by: The Facility Abuse Policy, last revised 2/2019 documented the facility prohibited mistreatment, neglect and abuse of residents by anyone, including staff. The Physical Abuse definition included holding roughly and controlling behavior through corporal punishment. Resident #1: Resident #1 was admitted to the facility [DIAGNOSES REDACTED]. The Admission assessment dated [DATE] documented Resident #1 was confused and had delusions. The Comfort Care Comprehensive Care Plan (CCP) dated 10/9/19, included the intervention to administer medications per MD orders, to provide comfort measures and honor preferences when possible. Review of Impaired Cognitive Function CCP dated 10/9/19 documented the intervention to provide a safe environment. A Physician order [REDACTED]. The undated Admission History & Physical by Physician (MD) #1 documented Resident #1 had some cognitive impairment. The Electronic Medication Administration Record [REDACTED]. A Nurse Progress Note dated 10/11/19 at 2:00 AM, written by Registered Nurse Supervisor (RNS) #1, documented Resident #1 had thrown [MEDICATION NAME] and [MEDICATION NAME] mixed in orange juice towards RNS #1 and stated, it's medicine. Licensed Practical Nurse (LPN) #1 and RNS #1 attempted to administer a syringe of [MEDICATION NAME] and Resident #1 again spit it out. RNS #1 documented she squirted the second syringe of [MEDICATION NAME] deeper into the throat of Resident #1. LPN #1 mixed the [MEDICATION NAME] with pudding and that they gave Resident #1 the [MEDICATION NAME] in pudding. RNS #1 documented she closed Resident #1's jaw so he/she could swallow the medication. A Written Statement dated 10/11/19, written by LPN #1, documented at 1:30 AM, RNS #1 instructed LPN #1 to crush Resident #1's [MEDICATION NAME] and mix the medication with orange juice and [MEDICATION NAME]. When LPN #1 handed the medications mixed with orange juice to Resident #1, he/she stated he/she did not want the drink and threw the orange juice on the floor. RNS #1 then instructed LPN #1 to get another dose of [MEDICATION NAME] ready and she would give the medication to Resident #1. RNS #1 then instructed LPN #1 to hold the hands of Resident #1 while RNS #1 administered the [MEDICATION NAME]. Resident #1 then spit out the [MEDICATION NAME], again. RNS#1 then administered a second dose of [MEDICATION NAME] by placing the syringe a little farther into the resident's mouth. RNS #1 then instructed LPN #1 to give Resident #1 the [MEDICATION NAME] crushed in pudding, then LPN #1 placed the crushed [MEDICATION NAME] mixed in pudding, in the mouth of Resident #1. RNS #1 put one hand on Resident #1's lower jaw and covered the resident's mouth. A Facility Interview dated 10/11/19 at 11:00 AM, documented the Assistant Director of Nursing (ADON) #1 interviewed RNS#1 who stated LPN #1 had a difficult time with Resident #1 and that Resident #1 would not take his/her medication. RNS #1 stated Resident #1 had thrown the orange juice mixed with [MEDICATION NAME] and [MEDICATION NAME] on the floor. RNS #1 then attempted to give Resident #1 [MEDICATION NAME] but the resident spit out the [MEDICATION NAME]. She then tried again by getting the second [MEDICATION NAME] syringe towards the back of his/her throat. RNS #1 stated she crushed a dose of [MEDICATION NAME] and put the medication in pudding. She asked LPN #1 and CNA #1 to hold Resident #1's hands while RNS#1 put the [MEDICATION NAME] crushed in pudding into the mouth of Resident #1. RNS #1 stated she held Resident #1's chin up, with her left hand, so the resident would swallow the medication. A Written Statement dated 10/11/19, written by the Staffing Coordinator, documented CNA #1 notified her that RNS #1 had instructed LPN #1 and CNA #1 to hold Resident #1's hands, then put medication into his/her mouth. When RNS #1 put the medication in Resident #1's mouth, she tipped his/her head back and put her hand in front of his/her mouth. A Facility Investigation dated 10/11/19 documented that at 11:10 am, RNS #1 was contacted on the telephone regarding the Nurse Progress Note dated 10/11/19 at 2:00 AM. RNS #1 stated Resident #1 had fallen at approximately 1:30 AM and she wanted to give him/her something to calm down. She admitted that she squirted the second syringe of [MEDICATION NAME] fast to the back of Resident #1's throat, gave him/her [MEDICATION NAME] mixed in pudding, and used her hand to close Resident #1's jaw. Review of physician orders [REDACTED]. During an interview on 10/31/19 at 12:55 PM, CNA #1 stated that when Resident #1 threw the orange juice, he/she stated that he/she did not want it, because there was medicine in it. CNA #1 stated RNS #1 attempted to give Resident #1 the syringe of [MEDICATION NAME] and Resident #1 spit it out. RNS #1 obtained another syringe of [MEDICATION NAME], tipped Resident #1's head back by picking up the resident's chin then squirted the syringe of [MEDICATION NAME] into his/her mouth, then covered Resident #1's mouth with her hand. CNA #1 stated that she verbally told RNS#1 that she could not do that, it was abuse and that RNS #1 replied it was not abuse, she was trying to medicate him. During an interview on 11/18/19 at 3:15 PM, RNS #1 stated Resident #1 had been anxious around 2:00 AM. RNS #1 stated that Resident #1 threw the orange juice mixed with medications at her, then spit out a syringe of [MEDICATION NAME], but she was able to administer the second syringe of [MEDICATION NAME] to Resident #1. She stated that she did close Resident #1's mouth after he/she was administered the crushed [MEDICATION NAME] in pudding, by cupping her hand around his mouth. RNS #1 stated that she later realized she should have obtained a Physicians order for an intramuscular medication. RNS #1 stated CNA #1 did tell her she needed to stop because that was abuse. During an interview on 10/31/19 at 2:45 PM, the Director of Nursing (DON) stated she would have expected the staff to recognize abuse and intervene, and that staff were able to contact contact her or the Administrator at any time with concerns. 10NYCRR483.12(a)(1)

Based on record review and interview during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for 5 (Residents #'s 6, 29, 31, 61, and 80) of 5 residents reviewed for hospitalization . Specifically, the facility did not ensure that there was documented evidence that the resident, the resident's representative, or the Ombudsman were notified in writing by the facility when the residents were admitted to a hospital. This is evidenced by: Resident #80 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident to understand, be understood and to be cognitively intact. A Progress Note dated 6/26/18 documented the resident was transferred to the hospital from [MEDICAL TREATMENT] earlier today. A Progress Note dated 7/4/18 documented that a call was received from the hospital reporting the resident would be return to the facility via ambulance at noon. The facility was unable to provide documentation showing the Resident, Resident's Representative, or the Ombudsman were notified in writing of the Resident's discharge to the hospital. During an interview on 9/12/18 at 12:29 PM, the Director of Nursing (DON) and the Administrator reported, residents, resident representatives, and the Ombudsman were not notified in writing when a resident was discharged to the hospital. Resident #6: The resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. He underwent an above knee amputation related [MEDICAL CONDITION], history of right extremity [MEDICAL CONDITION]. The Minimum Data Set of 5/11/18, documented the resident had moderate cognitive impairment and understood others and was able to understand. A Nursing Progress Note dated 4/22/18 at 10:00 PM, documented the resident had been vomiting on and off since after dinner with projectile vomiting initially. Resident continues to vomit bile. A Nursing Progress Note dated 4/24/18 at 3:58 PM, documented the resident continued to vomit. Initially he vomited bile and the last episode the resident vomited coffee ground emesis. The resident was transported to the hospital. Hospital Discharge Summary dated 5/01/18, documented the resident had [DIAGNOSES REDACTED]. During an interview on 9/12/18 at 11:36 AM, Social Worker #1 stated he had not notified the family and the ombudsman in writing of the resident's transfer to the hospital in 5/2018 and stated he was recently educated on this. Resident #31 The resident was admitted on [DATE] with a readmission on 5/31/18 after a hospitalization on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was able to understand and was understood with a Brief Interview for Mental Status (BIMS) of 9/15, moderately impaired for decisions of daily living. A Progress Note dated 5/24/18, documented the resident was transferred to the hospital directly from wound care for complaints of abdominal pain. A Progress Note dated 5/31/18, documented the resident was returned to the facility via ambulance in the afternoon and was readmitted to his room. The facility was unable to provide documentation showing the Resident, Resident's Representative, or the Ombudsman were notified in writing of the Resident's discharge to the hospital. During an interview on 9/11/18 at 12:00 PM, the Registered Nurse Unit Manager #3 (RNUM) stated the resident went out to the hospital from wound care on 5/24/18 and was readmitted to the same room he had been in when he returned the afternoon of 5/31/18. During an interview on 9/12/18 at 12:29 PM, the Director of Nursing (DON) and the Administrator reported, residents, resident representatives, and the Ombudsman were not notified in writing when a resident was discharged to the hospital. They had not developed a policy to address this but were working on it. They just had become aware recently that they needed to notify the resident or representative in writing. The social worker for the facility was the one responsible to notify the ombudsman of resident discharge and transfer. He had not done this. 10NYCRR 415.39(H)(1)(III)(a-c)

Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization . This was evident for 5 (Residents #'s 6, 29, 31, 61, and #80) of 5 residents reviewed for hospitalization . Specifically, there was no documented evidence the resident and the resident's representative were notified in writing of the bed hold policy when the resident was admitted to the hospital. This is evidenced by the following: Resident #80: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident to understand, be understood and to be cognitively intact. A Progress Note dated 6/26/18, documented the resident was transferred to Saratoga Hospital from [MEDICAL TREATMENT] earlier today. A Progress Note dated 7/4/18, documented the hospital called to report the resident was returning to this facility via ambulance at noon. The facility was unable to provide documentation showing the resident or Resident's Representative, were provided with a bed-hold notice at the time of hospitalization . During an interview on 9/12/18 at 11:36 AM, the Director of Social Services reported that bed-hold letters had not been sent because he was not aware until recently that this should be done. Resident #6: The resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. He underwent an above knee amputation related [MEDICAL CONDITION], history of right extremity [MEDICAL CONDITION]. The Minimum Data Set of 5/11/18, documented the resident had moderate cognitive impairment and understood others and was able to understand. A Nursing Progress Note dated 4/24/18 at 3:58 PM, documented the resident continued to vomit. Intially he vomited bile and last episode the resident vomited coffee ground emesis. The resident was transported to the hospital. Hospital Discharge Summary dated 5/01/18, documented the resident had [DIAGNOSES REDACTED]. During an interview on 9/12/18 at 11:36 AM, Social Worker #1 stated he had not notified the family in writing of the facility's bed hold policy when he was transferred to the hospital in 5/2018 and stated he was recently educated on this. Resident #31: The resident was admitted on [DATE], and readmitted on [DATE] after a hospitalization on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was able to understand and was understood with a Brief Interview for Mental Status (BIMS) of 9/15, moderately impaired for decisions of daily living. A Progress Note dated 5/24/18 documented the resident was transferred to the hospital directly from wound care for complaints of abdominal pain. A Progress Note dated 5/31/18, documented the resident returned to the facility via ambulance in the afternoon and readmitted to his room. The facility was unable to provide documentation showing the resident or Resident's Representative, were provided with a bed-hold notice at the time of hospitalization . During an interview on 9/12/18 at 12:29 PM, the Director of Nursing (DON) and the Administrator reported neither residents or resident representatives, were given a bedhold notification in writing when discharged to the hospital. They just had become aware recently they needed to notify the resident or representative in writing of the bed hold policy. The social worker for the facility was the one responsible to do this but had not done it. During an interview on 9/17/18 at 1:36 PM the Director of Social Services stated I did not notify in writing the resident or family of any bedhold policy whe he was transfered to the hospital. He further stated he was not aware of the regulation at the time. 10NYCRR 415.3(h)(4)(i)(a)

Based on observation, record review and interview during the recertification survey and abbrieviated survey (Case #NY 300), the facility failed to ensure the resident environment remained as free of accident hazards as was possible for ten (10) (Resident #'s 82, 3, 12, 18, 40, 48, 68, 69, 96, 156 and #201 ) of twelve (12) residents reviewed for bed rail use. Specifically, the facility failed to have an effective system in place to identify the potential for resident entrapment by bed rails. Subsequently, a resident became entrapped in a bed rail, requiring transfer to the hospital. An additional nine (9) residents used the same bed rails. This resulted in no actual harm with the potential for more than minimal harm and Substandard Quality of Care that was Immediate Jeopardy. Additional findings: For Resident #201, the facility did not ensure Resident #201 received the required care, when the Comprehensive Care Plan (CCP) and Certified Nurse Aide (CNA) Care Guide, were not updated with new interventions documented under the Conclusion section of the resident's post fall Incident and Accident Report Forms. Additionally, facility staff did not document the injuries that were sustained in one of the falls, on the careplan. This was evidenced by: This was evidenced by: The New York State Department of Health Dear Administrator Letter (DAL NH 15-05) documented that facilities should review the Federal Drug Administration's (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, and that they should use it as a resource for assessing bed systems safety. The FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment identified seven potential zones of entrapment in hospital-style beds, and set dimensional limits and test methods for the gaps and openings in zones 1 through 4. If an alternate approach was used by a facility to assess gap sizes, the dimensional limits used in any alternative approach must be at least as stringent as the ones described in this guideline. Specifically, the FDA defined zone 4 as the area under the rail at the ends of the rail. This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of the rail. The dimensional limit was to be less than 2 3/8 inches measured between the mattress support platform and the lowest portion of the rail at the rail end to prevent neck entrapment. During an interview on 9/11/15 at 11:50 am, the Director of Maintenance (DoM) provided the surveyor with a manual entitled, Bed System Measurement Device Instructions, and stated that this was the Policy and Procedure (P&P) for how to check the bed rails for safety. The Bed System Measurement Device Instructions P&P (National Safety Technologies; Revised 5/9/11) documented the use of a cone and cylinder tool for ensuring bed rails were applied safely to beds. The P&P explained four tests corresponding to potential entrapment zones 1 through 4. It was also documented that, using the tool, the four tests could be done in any order as long as all the tests were done on all of the rails. Resident #82: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented that the resident had moderately impaired cognition, and was able to make herself understood and was able to understand others. She was also assessed to require the extensive assistance of two people for bed mobility and transfers. The Fall Risk assessment dated [DATE], documented that the resident had balance and weakness problems, and was unable to understand or follow direction. The resident was assessed to be a fall risk. Review of the Comprehensive Care Plan (CCP) revealed there was no documentation of the use of an enabler bar (bed rail) on the resident's bed. The Activities of Daily Living (ADL) Care Plan/Nurse Aide Care Card dated 7/14/15, documented that the resident was at risk for falls and had bed and chair sensors in place. She required the limited assistance of one person with a gait belt because the resident's legs buckle quickly. The Bed Mobility Devices portion of the form was blank. There was no documentation of the use of a bed rail. Review of Incident and Accident Reports (I&A's) for 7/8/15 and 7/17/15, documented that on these dates, this resident had fallen out of bed while attempting to self-transfer. A Work Order (a ticket sent to the Maintenance Department) dated 7/14/15, documented a request for bed rails to both sides of this resident's bed. A Therapy Functional Status Roster dated 7/17/15, documented this resident would benefit from enabler rails (bed rails) to assist with bed mobility. A Nurses Note (NN) dated 7/19/15, for the evening shift, documented the resident had some dementia, was attempting to get out of bed, and was combative. The 24 Hour Report dated 7/22/15, documented that at 10:45 pm, this resident had been found on the floor and was sent to the hospital. A NN dated 7/22/15 at 10:45 pm, documented the Licensed Practical Nurse (LPN) was called to the resident's room by a CNA. The resident was half out of bed and her head was stuck between the side rails. The resident was flaccid (the original word used was unresponsive which had been crossed out) and a Registered Nurse (RN) was called to the room. 911 was called and the resident was sent to the hospital. This note was not attached to the I&A dated 7/22/15. A NN dated 7/22/15 at 10:45 pm, documented that the RNS went into the resident's room and her upper body and head were on the bed, and the enabler bar (bed rail) was close to the resident's head and neck area. The resident stated that she had hit her head, and her left arm and leg were limp. When the RN lifted the resident's arm, there was no resistance, and when released, the resident made no attempt to stop her arm from dropping. It was difficult to engage in purposeful movements to the left side of her face, arm or leg. Emergency Medical Services was called, and the resident was transported to the hospital. An Incident and Accident Report (I&A) dated 7/22/15, documented that at 10:45 pm, the lower half of the resident's body was on the floor and her head was on the mattress below the bed rail. The resident had reported she hit her head, and her left side was flaccid. The physician was notified and the resident was sent to the hospital. The Registered Nurse Supervisor (RNS) Form attached to the 7/22/15 I&A, documented at the question Was the Care Plan followed? was answered both yes and no. The explanation was documented that the therapy roster said the resident would benefit from an enabler bar (bed rail, or also known as side rail) for mobility. The resident had stated she had hit her head. Her left side was flaccid. The resident was questioned about a family member, and she had no verbal response, which was a change for her. The resident was sent to the hospital. A Written Statement from Certified Nursing Assistant (CNA) #1, who initially discovered the resident, was also attached to the 7/22/15 I&A. CNA #1 documented when she arrived in this resident's room, the resident's lower body was on the floor and her head was on the side rail. The resident had hit her head. The facility Summary/Conclusion Form dated 7/23/15, was attached to the 7/22/15 I&A. It documented the care plan was not followed. The narrative section of the form documented that the lower half of the resident's body was on the floor mat and her head was on the mattress below the enabler. The resident had stated she hit her head, and was sent to the hospital. The Care Plan Updates/Changes section documented that the enabler bars were discontinued due to risk versus benefit. According to staff, the resident did not use the enabler bar. A Hospital Physician's Note dated 7/23/15 at 3:51 am, documented this resident had been at the nursing home when she was found on the floor with her head turned in an odd manner. Staff suspected she might have gotten her head caught in the side rails. Staff were concerned she had suffered a neck injury. A computerized tomography scan (CT Scan) revealed no new injuries. During an interview on 9/10/15 at 3:54 pm, LPN #1 stated when she found this resident in the bed, her neck and shoulder were under the bed rail between the bottom of the side rail and the top of the bed, and her face was pushed against the bed rail. She was moaning, but was otherwise unresponsive and flaccid. She stated she had changed her note from unresponsive to flaccid, because the RNS had told her to. She stated the RNS said because the resident was moaning, that meant she was not unresponsive. She also stated she and the CNA had slightly adjusted the resident's position prior to the RNS arriving. The LPN stated this resident had several falls while at the facility. She stated it was usually because she had Dementia and tried to self-transfer from bed. During an interview on 9/10/15 at 4:24 pm, CNA #1 stated a bed alarm was sounding and when she entered the resident's room she found the resident with her lower body on the floor. Her neck was under the side rail (enabler bar) and her head was trapped with her face smushed on the rail. She was able to speak, but her body was limp. The CNA described the resident as having a portion of her neck pinned under the side rail. She immediately called for help and when the LPN arrived they adjusted the resident's position a little before the RN got there, because they could not leave her trapped that way. The CNA also stated while this resident was at the facility, she frequently attempted to get out of bed on her own, and that was why she fell a few times. Resident #69: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, required one person physical assistance with transfers and was independent with bed mobility. The resident was also assessed to have one-sided range of motion limitations to her arm and leg. The Physician's History and Physical for the 5/28/15 admission, documented the resident had a history of [REDACTED]. The Activities of Daily Living (ADL) Care Plan/Nurse Aide Care Card dated 8/20/15, documented the resident had enabler bars on her left side. The Comprehensive Care Plan (CCP) for Enablers dated 5/29/15, documented the resident had an enabler bar due to limited upper body strength and difficulty moving from lying to sitting in bed. Documented interventions included that safety measurements on Zones 1, 3 and 4 were to be done by the maintenance department. The CCP for Impaired Mobility dated 5/28/15, documented the resident had a stroke six months before that date, and a second stroke two weeks before that date. The resident was to use assistive positioning devices. The CCP for Assistance to Complete ADLs dated 5/28/15, documented the resident required extensive assistance with transfers. physician's orders [REDACTED]. During an observation on 9/10/15 at 4:40 pm, there was the same type of bed rail as Resident #82 attached to this resident's bed. Resident #12: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact, required the extensive assistance of one person for bed mobility, and transfers had not occurred during the assessment period. The Activities of Daily Living (ADL) Care Plan/Nurse Aide Care Card dated 7/9/15, documented the resident was dependent on two staff for transfers by mechanical lift and used side rails/able risers to assist with bed mobility. The Comprehensive Care Plan (CCP) for History of Falls, with a review date of 9/2/14, documented the resident had a mobility deficit, impaired judgment, Dementia/confusion and required assistance with ADLs. It also documented the resident had [DIAGNOSES REDACTED], and received psychoactive medications. The resident's bed was to be placed against the wall. The CCP for 2 Head of Bed Side Rails, with a revision date of 2/21/12, documented the resident used the side rails for mobility and they were not a restraint. The CCP for Risk for Falls, with a revision date of 2/21/12, documented the resident was at risk for falls and injury due to [DIAGNOSES REDACTED]. A Siderail Evaluation dated 2/27/15, documented the resident used side rails for mobility. During an observation on 9/10/15 at 4:40 pm, there was the same type of bed rail as Resident #82 attached to this resident's bed. Additional Interviews: During an interview on 9/10/15 at 4:35 pm, the Administrator stated the Quality Assurance Committee (QA) had audited all the bed rails in the facility at that time, and they were all found to be 100% in compliance. She stated she did not know for sure what was tested at the time of that audit, but knew that it was about measuring the distance between side of mattress and enabler bar on all of the beds. She also stated the maintenance department were the only staff that applied bed rails to the beds. She stated residents were evaluated by Physical Therapy (PT) for appropriateness and the need for a bed rail, and it was PT's responsibility to re-evaluate residents as needed, based on a change of condition and at least for the quarterly care plan review. During an observation on 9/10/15 at 4:40 pm, all the beds in the facility were observed with the following results: Resident #'s 3, 12, 18, 40, 48, 68, 69, 96 and #156 had beds with the same type of enabler bars as Resident #82 from above. During an observation and interview on 9/10/15 at 5:03 pm, the Director of Maintenance (DoM) was asked to demonstrate what he checks when he puts siderails on a bed. The DoM took the device and tried to wedge it through the siderail (zone 1), it did not go through the openings. He then laid the device on the mattress next to the siderail (zone 3), it did not move. The DoM stated he did not routinely test the gap where the siderail met the mattress at the end of the rail (zone 4). During an interview on 9/11/15 at 11:28 am, the Director of Therapy (DT) stated every new resident was assessed for bed mobility. If it was determined that enabler bars were beneficial for the resident, that would have been documented in their assessment. Their assessment that a resident would benefit from enabler bars was then sent to the nursing units, and nursing was responsible for requesting the bars from maintenance. The DT stated if they thought a resident was at risk for entrapment, they would not recommend enabler bars. He stated Therapy sent functional status sheets to nursing which they used for care planning. The Therapy Department did not write the care plans for enabler bars. The DT also stated Therapy did not routinely reassess the use/need of enabler bars for residents not on therapy services. He stated they re-assessed residents, if nursing put in a request. He stated their department was not responsible for any QA (Quality Assurance) monitoring on the enabler bars. During an interview on 9/11/15 at 11:50 am, the DoM stated during the 7/16/15 QA audit, he audited the bed rails on all the beds in the facility and found that they were in 100% compliance and reported this to QA. He stated during the audit zones 1 and 3 were tested , and that zones 2 and 4 were not tested . He also stated the maintenance department tested on ly zones 1 and 3 when a bed rail was applied to a bed, and that zones 2 and 4 were not tested . The reason for only testing zones 1 and 3 was because these were the zones that had been identified by the corporation as the zones that had been the focus of previous concerns at another facility. During an interview on 9/11/15 at 12:07 pm, the Registered Nurse Manager stated she had been employed at the facility for approximately three weeks, and in that time she did not request any enabler bars. She also stated maintenance was responsible for attaching the bars to beds, and for performing the measurements on the bars to ensure safety. Immediate Jeopardy identified on 9/10/15, was removed effective 9/11/15. The facility implemented the following measures to abate the immediacy: The bed rails in question were removed from resident beds, then modified and tested for Zones 1, 2, 3, and 4 prior to reapplying; 100% of maintenance staff were educated on the proper use of the Cone and Cylinder Tool used to measure bed rails zones for safety. Additional finding: The facility did not ensure Resident#201's Comprehensive Care Plan and Care Card were updated with new interventions documented on post fall Incident and Accident Forms. Resident #201: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13/15; mild cognitive impairment, . The Incident & Accident (I&A) Report dated 2/17/15 at 2:45 am, documented the resident was observed sitting on left arm, on floor, in front of bed, next to chair with the chair alarm sounding. Safety devices in use; wheelchair (wc) lapbelt and chair alarm. The I&A Conclusion documented; unwitnessed fall out of wc, left sided facial swelling, seen by Nurse Practitioner, x-ray completed and negative. Careplan followed. The Comprehensive Careplan (CCP) dated 10/31/14, and titled Potential for Accidents/Incidents, documented a high risk of falls secondary to Parkinson's, history of falls, and decreased safety awareness. Goals included; fall mat left side, and bed low position, dated 12/10/14. Interventions included; resident impatient will not wait for assistance, encourage resident to call for assist, mattress alarm in bed, chair alarm out of bed (oob), mats on left side of bed dated 12/10/14, wc seat belt dated 2/4/15, complete fall assessment on admission, readmission, quarterly, change of condition, and as needed. The CNA Care guide dated 2/5/15, documented; bed sensor, chair sensor, wc seatbelt on when in wc, seatbelt to be padded at all times and fall mats to left side of bed while in bed, bed in low position. The I&A report dated 3/4/15 at 4:00 am documented, resident observed lying on left side on fall mat next to bed. No injury, careplan followed, no new interventions. I&A Conclusion documented, unobserved fall (oob) onto fall mat on floor. No injury. Careplan followed. No new interventions. Review of CCP revealed there were no changes or additions to the careplan. Review of the CNA care guide dated 2/5/15, revealed no changes to the care plan. The I&A report dated 3/4/15, documented, at 6:40 pm, heard resident's chair alarm, ran to room and he was lying on his left side. There was a small amount of blood on the floor, next to his head. RN Supervisor (RNS) called immediately to assess. Resident was transferred to hospital for evaluation. The I&A Report for Conclusion documented, unobserved fall out of wheelchair. Laceration to left temple area with bleeding, swelling, transfer to hospital. Care plan followed. There were no new interventions documented. Hospital radiology reports dated 3/4/15, documented for first report; x-ray, three views of the left hand, subtle oblique fracture of the diaphysis of the fourth proximal phalanx (middle of the bone at tip of finger). The second report documented; CAT (computerized axial tomography) scan, imaging through the cervical spine, nondisplaced dens (cervical spine) fracture, may be nonacute. The third report documented; CAT scan, axial images of the head, left lateral subdural hematomas above. Review of CCP revealed there were no changes or additions to the careplan in regards to the injuries sustained with the fall. Review of the CNA care guide dated 2/5/15, revealed no changes to the care plan. Nurse note dated 3/5/15 at 2:30 pm, documented received resident to room 3A via rescue squad. Wife arrived with him. (resident was readmitted from hospital) The I&A report dated 3/5/15 at 9:20 pm, documented unobserved fall, safety devices in use, bed alarm and fall mat. I&A statement form documented, resident was on his knees on the mat with elbows still on the bed. I&A report for Conclusion, documented unobserved fall oob, onto fall mat on floor. Care plan followed. No injury. No new interventions. Physical Therapy Referral documented, MD order for evaluation dated 3/2/15 for pain in neck and back. Therapist response dated 3/6/15, documented, positioning devices changed to high back wheelchair and seat belt for prevention of falls. The seat belt with an alarm was implemented to alert the staff quicker. Review of CCP revealed there were no changes or additions to the careplan in regards to the injuries sustained with the fall, the high back wc or the alarm seat belt. Review of the CNA care guide dated 2/5/15, revealed no changes to include the high back wc or the alarm seat belt. The I&A report dated 3/9/15 at 5:15 pm, documented unobserved fall, safety devices in use, lap belt and wc alarm. I&A statement form documented, I walked in the room and he was laying on his right side, I help to get him up with the gait belt. The I&A for Conclusion documented, unobserved fall out of wc, no injury, careplan followed. Added velcro alarm seat belt. Review of CCP revealed there were no changes or additions to the careplan in regards to the injuries sustained with the fall, the high back wc or the velcro alarm seat belt. Review of the CNA care guide dated 2/5/15 revealed no changes to include the high back wc or the velcro alarm seat belt. The I&A dated 3/9/15 at 8:15 pm, documented unobserved fall, safety devices in use, bed alarm. No injury. The I&A statement form documented, when I got to resident's room he was halfway off the bed, knees on mat and arms on bed. The I&A for Conclusion documented, unobserved fall out of bed. No injury, careplan followed. Wide bed placed for resident. Review of CCP revealed there were no changes or additions to the careplan in regards to the injuries sustained with the fall, the high back wc, the velcro alarm seat belt, or the wide bed. . Review of the CNA care guide revealed no changes to include the high back wc, the velcro alarm seat belt or the wide bed. Observation on 3/18/15 at 3:12 pm, CNA #1 entered Resident #201's room and left the room within one minutes time. DOH Surveyor entered room and noted resident in wheelchair, at the side of the bed. The alarm velcro seatbelt on the resident was unclasped and the alarm was not sounding. CNA #1 entered the room at 3:15 pm and stated to the surveyor that she had unbuckled the belt and turned off alarm, then left the room to get a second CNA to help transfer the resident into bed. During an interview on 3/18/15 at 3:25 pm, CNA #1 stated she entered the room to transfer the resident into bed. When she unbuckled the belt, the wife told her she needed a second person to transfer the resident. CNA #1 then left the room to get another staff member to help transfer the resident. CNA #1 stated she should not have left the resident with the seatbelt unbuckled. CNA #1 stated she usually looks at the care guide before caring for a resident, but did not this day. (CNA care guide documented for transfer, extensive assist of one with Gait Belt and rolling walker). During an interview on 3/19/15 at 3:25 pm, the MDS Clinical Registered Nurse (CRN) stated she was covering the Midtown Unit in March, due to the Nurse Manager's absence. CRN stated, after the I&A's are signed off, she would enter any new information onto the care plans. The careplans should have been updated with new interventions, and the injuries should have been careplanned, after the resident returned from the hospital. During an interview on 3/19/15 at 10:15 am, LPN #1 stated the CNAs should always go to the care guide before providing care to a resident. CNA #1 should not have left the alarm belt opened and left the room. During an interview on 3/19/15 at 10:40 am LPN #2 stated the alarming seat belt for Resident #201 was fairly new, and the care card should be checked by the CNA before delivering care. LPN #2 stated there was a Communication Binder for all resident changes, that contained the new care card with the changes highlighted. The binder was for CNAs and LPNs to review daily for changes in resident care. Review of the Communication Binder revealed resident care cards from 12/2014 thru 3/2015, however, there were no care cards in the binder for Resident #201. 10 NYCRR 415.12(h)(1)

Based on observation, record review and interview, it was determined the facility Quality Assurance Committee did not develop and implement appropriate plans of action to correct identified of quality of care issues. Specifically, the facility failed to have an effective system in place to identify the potential for resident entrapment by enabler bars. Subsequently, a resident became entrapped in an enabler bar, requiring transfer to the hospital. An additional nine (9) residents used the same enabler bar. This resulted in no actual harm with the potential for more than minimal harm and Substandard Quality of Care that was Immediate Jeopardy. This was evidenced by: Refer to F 323 - Quality of Care - Scope/Severity K The New York State Department of Health Dear Administrator Letter (DAL NH 15-05) documented that facilities should review the Federal Drug Administration's (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, and that they should use it as a resource for assessing bed systems safety. The FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment identified seven potential zones of entrapment in hospital-style beds, and set dimensional limits and test methods for the gaps and openings in zones 1 through 4. If an alternate approach was used by a facility to assess gap sizes, the dimensional limits used in any alternative approach be at least as stringent as the ones described in this guideline. Specifically, the FDA defined zone 4 as the area under the rail at the ends of the rail. This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of the rail. The dimensional limit was to be less than 2 3/8 inches measured between the mattress support platform and the lowest portion of the rail at the rail end to prevent neck entrapment. During an interview on 9/11/15 at 11:50 am, the Director of Maintenance (DoM) provided the surveyor with a manual entitled, Bed System Measurement Device Instructions, and stated that this was the Policy and Procedure (P&P) for how to check the bed rails (enabler bars) for safety. The Bed System Measurement Device Instructions P&P (National Safety Technologies; Revised 5/9/11) documented the use of a cone and cylinder tool for ensuring bed rails (enabler bars) were applied safely to beds. The P&P explained four tests corresponding to potential entrapment zones 1 through 4. It was also documented that, using the tool, the four tests could be done in any order as long as all the tests were done on all of the rails (enabler bars). During an interview on 9/10/15 at 3:15 pm, the Administrator stated that she chaired the Quality Assurance Committee (QA). The members of the Committee included the Director of Nursing, Nurse Managers, all Department heads and the Medical Director. During an interview on 9/10/15 at 4:35 pm, the Administrator stated the Quality Assurance Committee had audited all the bed rails (enabler bars) in the facility at that time, and they were all found to be 100% in compliance. She stated she did not know for sure what was tested at the time of that audit, but knew that it was about measuring the distance between side of mattress and enabler bar on all of the beds. She also stated the maintenance department were the only staff that applied bed rails (enabler bars) to the beds. She stated residents were evaluated by Physical Therapy (PT) for appropriateness and the need for a bed rail (enabler bars) and it was PT's responsibility to re-evaluate residents as needed, based on a change of condition and at least for the quarterly care plan review. During an observation on 9/10/15 at 4:40 pm, all the beds in the facility were observed with the following results: Resident #'s 3, 12, 18, 40, 48, 68, 69, 96 and #156 had beds with the same type of enabler bars as Resident #82 from above. During an observation and interview on 9/10/15 at 5:03 pm, DoM was asked to demonstrate what he checks when he puts siderails (enabler bars) on a bed. The DoM took the device and tried to wedge it through the siderail (enabler bars) (zone 1), it did not go through the openings. He then laid the device on the mattress next to the siderail (enabler bars) (zone 3), it did not move. The DoM stated he did not routinely test the gap where the sidereal (enable bars) met the mattress at the end of the rail (zone 4). During an interview on 9/11/15 at 11:50 am, the DoM stated that he was on the QA committee and during the 7/16/15 QA audit, he audited the bed rails (enable bars) on all the beds in the facility and found that they were in 100% compliance and reported this to QA. He stated during the audit zones 1 and 3 were tested , and that zones 2 and 4 were not tested . He also stated the maintenance department tested on ly zones 1 and 3, when a bed rail was applied to a bed, and that zones 2 and 4 were not tested . The reason for only testing zones 1 and 3 was because these were the zones that had been identified by the corporation as the zones that had been the focus of previous concerns at another facility. NCR(a-ac)

Based on medical record review and interview during complaint investigation (NY 927), the facility did not ensure that the resident's physician was notified in a timely manner of a change in the resident's condition. Specifically for 1 (Resident #1) of 2 residents reviewed, the facility did not notify the physician (MD) of changes in the resident's condition. This resulted in actual harm that was not immediate jeopardy. This was evidenced by following: Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident had severely impaired cognition and long and short term memory loss. A laboratory report dated 12/15/11 documented the resident's Blood Urea Nitrogen (BUN, a test to measure the amount of nitrogen in the blood that comes from the waste product urea) value of 24 milligrams to deciliter (mg/dL), normal BUN ranges from 7-24mg/dL. The Physician order [REDACTED]. Resident's food and fluid acceptance documented that beginning at breakfast on 9/23/12 through dinner on 9/25/12, the resident refused all breakfast, lunch and dinner meals and fluids, with the exception of a documented poor acceptance on 9/23/12 at breakfast. Laboratory Report dated 9/24/12 at 6:30 am documented that the lab contacted the facility and spoke with Licensed practical Nurse #1 (LPN) to advise that Resident #1 had a critical blood urea nitrogen (BUN) value of 134 milligrams per deciliter (mg/dL, the normal range of BUN is 7-24 mg/dL). Laboratory report also documented the following blood test results: Sodium 151 millimoles per liter (mmol/L, the normal range was 136-145 mmol/L), potassium 5.9 mmol/L (normal range was 3.5-5.1mmol/L), and creatinine 4.6 mg/dL (normal range was 0.6-1.3 mg/dL). It was also documented that the resident's [MEDICATION NAME] level (a value that indicates the level of protein in the blood) was 2.9 grams per deciliter (g/dL)( normal 3.5- 5.4). Nurse's note 9/24/12 signed by LPN #1 documented that the Registered Nurse Manager (RNM) had requested vital signs after receipt of the critical lab value via phone. Note documented that the resident was combative and resisted blood pressure, apical pulse, and oxygen saturation test and that the resident had cold hands and his nail beds were blue. The note further documented that the Registered Nurse (RN) was aware and that the Certified Nurses Assistant (CNA) reported that the resident was refusing food and fluids. Nurse's note dated 9/24/12 at 6:30 pm signed by the RN Supervisor #1(RNS) documented that the resident was noted with mottling (a discoloration of the skin as a result of lowered blood flow to the surfaces of the skin) from his knees to his feet, bluish/purple in color and the RNS was unable to obtain an oxygen saturation level. Nurse's note dated 9/24/12 at 6:45 pm signed by the RNM documented that the resident's son was contacted and was advised of his father's declining status. Nurse's note dated 9/24/12 at 9:15 pm signed by LPN #2 documented that the RNS asked that the resident be administered a Tylenol suppository for comfort. Further noted was that at 8:00 pm, the resident's knees and feet were mottled. Nurse's note dated 9/25/12 at 8:00 pm signed by RNS #2 documented that resident's oxygen saturation (the concentration of oxygen in the blood) was 80% (normal saturation is 95 - 100%), fingernails, ankles and knees were purple and a call was placed to the physician and an order received to have the resident transferred to the hospital and the family was contacted and made aware. The hospital History and Physical (H&P) dated 9/26/12, documented that the resident was admitted on [DATE] for low oxygen saturation and "not breathing". On arrival to the hospital, the resident was lethargic (a state of physical slowness and mental dullness), and had low blood pressure. The hospital physician assessed the resident and found him to have dry mucous membranes and that he was cachectic (a state of generally poor heatlh, [MEDICAL CONDITION], and weight loss) and in septic shock. It was also documented on the hospital H&P that the hospital began treating the resident with one liter of saline solution, intravenous [MEDICATION NAME] (a medication used in emergency situations to constrict the blood vessels to increase blood pressure), two antibiotics and [MEDICATION NAME] (a medication used to dilate the airway passages). The resident was in acute [MEDICAL CONDITION] and was given glucose and insulin intravenously (glucose and insulin given to decrease the level of potassium in the blood), sodium [MEDICATION NAME] intavenous drip (a medication used to treat an acidic condition in the blood due to kidney failure [MEDICAL CONDITION]), and an indwelling urinary catheter was placed and the resident had off-white milky urine. The kidney doctors were notified and it was likely that the resident would require urgent [MEDICAL TREATMENT] once the resident's blood pressure was stabilized. The hospital H&P also documented that the resident's family was at the bedside and reported that for the past several days the resident has refused food, symptoms had worsened and they had requested that the resident be evaluated at the hospital the night before but were told that there would not be any change in the management of the resident's condition and requested that he be transferred again today (9/25/12). The hospital H&P also documented the following blood test results: Sodium 150 millimoles per liter (mmol/L, the normal range was 136-145 mmol/L), potassium 7.5 mmol/L (normal range was 3.5-5.1mmol/L), blood urea nitrogen 172 milligrams per deciliter (mg/dL, normal range was 7-24 mg/dL), and creatinine 7.4 mg/dL (normal range was 0.6-1.3 mg/dL). Additionally, the hospital H&P Problem List included: septic shock of a urine source, acute [MEDICAL CONDITION],and a markedly high level of potassium in the blood. The resident was admitted to the hospital Intensive Care Unit in a guarded, life threatening, critical condition with potential for rapid deterioration to death. The resident short and long-term prognosis was documented as being very poor. During an entrance interview on 10/3/12 at 9:00 am with the Administrator and Director of Nursing (DON), the DON stated that he was investigating an issue related to quality of care that he had just learned about on 10/2/12 when he overheard a family member upset talking with the RNM. The DON stated that the family member thought that the resident should have been sent to the hospital sooner. The DON stated that he was still investigating the case and he believed that nursing staff could have handled the situation better, but did not believe that neglect had occurred because the resident was sent to the hospital less than twenty-four hours after the noted change in condition. During an interview on 10/3/12 at 9:45 am, the resident's physician stated that he was very concerned about the handling of the resident's condition. The physician stated that he had seen the resident on 9/21/12 and was trying to investigate new symptoms and behaviors and had ordered a series of blood work. The physician stated that he learned on 9/26/12 while completing routine rounds that the resident had been sent to the hospital on [DATE]. The physician stated he reviewed the resident's medical chart and found that as a result of his 9/21/12 orders, the facility was notified of critical lab values on 9/24/12 but the resident was not transferred to the hospital until the evening of 9/25/12, "almost 36 hours after the labs were returned." The physician stated that in review of the medical chart, there were no nursing notes regarding his discussion with the RN and inadequate and sporadic nursing documentation regarding the resident's condition. The physician stated that another physician was in the facility on 9/24/12 however, he was unsure of the involvement of that physician based on the chart notes available. The physician stated that he was very concerned about the case and that he documented and forwarded his concerns to the DON for further investigation on 9/26/12. During an interview on 10/3/12 at 10:30 am, LPN #1 stated that she took the call from the laboratory on 9/24/12 regarding the critically high BUN level and other out of range lab values and immediately reported them to the RNM who instructed her to get vital signs on the resident. LPN #1 stated that she returned to the RNM's office and informed the RNM that she was unable to get vital signs because the resident was being resistive and reported that the resident's nail beds appeared blue. LPN #1 stated that physician #2, who she hadn't seen in months in the facility, was in the office at the time talking with the RNM. LPN #1 stated that she was given no further instruction related to the resident. During an interview on 10/3/12 at 11:00 am, the RNM stated that she was made aware of the critical BUN level by LPN #1 on 9/24/12 and she believes that she would have addressed the issue with physician #2. RNM stated on that day, physician #2 held two medications for the resident assuming that the two medications were causing a problem and ordered a review at the next physician visit. When asked by the surveyor if she assessed the resident after being made aware of the critical BUN and the report from LPN #1 that the resident's nail beds were blue, the RNM stated "I looked at him, I didn't see any blue, I didn't know what she was talking about." When asked by the surveyor if she had assessed the resident or called the physician after getting the report of mottling from the knees to the feet, the RNM stated that she had not. The RNM stated that she believed the resident was on comfort care and through discussions with the resident's daughter believed the family wanted the resident to be comfortable, didn't want aggressive treatment like tube feeding and that is why she didn't contact the physician. The RNM stated that comfort care is documented in the resident's chart, however, upon review of the resident's medical chart, the RNM stated that there was no documentation that the resident was on comfort care. During an interview on 10/3/12 at 1:00 pm, the resident's daughter stated that on 9/24/12 her brother who lives out of state received a call that her father was failing and showing signs of mottling and that the family should come to the facility. The resident's daughter stated that she and her brother and his family went to the facility and observed their father and felt that he was in pain. She stated that the family requested that the resident be transported to the hospital for evaluation and treatment and were told by the RNS#1 "what can they do at the hospital that we can't do here, why don't we give him a Tylenol suppository to keep him comfortable." During an interview on 10/3/12 at 1:30 pm, the resident's son stated that he responded to the facility after receiving a call from his brother stating that their father was getting bad. The resident's son stated that he and his family arrived and observed his father was in pain and the RNS#1 stated that the pain could be from his feet as it appeared as though his "feet were dying". The resident's son stated he asked the RNS#1 to have the resident transferred to the hospital and was told "what do you think they are going to do at the hospital." The resident's son stated that it felt to him "that they were just going to let him die." The resident's son stated that he visited his father the next day and RNS #2 noticed that the resident wasn't himself. The resident's son stated RNS #2 started to examine the resident and asked him if he wanted to have the resident sent to the hospital. The resident's son said, "yes, that's what we all wanted last night." During an interview on 10/9/12 at 12:00 pm, RNS #1 stated she is contracted through an agency and was working at the facility on 9/24/12 when she was called to the resident's room by staff because they were concerned with the color of the resident's skin. RNS #1 stated that when she examined the resident, she noted that he was mottling from his knees to his toes and he was very cold but was not experiencing respiratory distress. RNS #1 stated that she reported the changes in the resident to the RNM who called the resident's family to come into the facility. RNS #1 stated that she asked the family if they wanted the resident to go to the hospital and they declined and RNS #1 denies that she told the family that nothing more could be done in the hospital than was being done in the facility. RNS #1 stated that typically, she would have contacted the physician, however, she spoke with RNM and was told that the physician was already aware of the situation. During an interview on 10/9/12 at 1:30 pm, RNS #2 stated that he went to the nurse's office, saw the nursing notes that documented blue nail beds and mottling from the knees to the feet and reviewed the critical lab values from the day before. RNS #2 stated "it didn't appear that anyone was doing anything" so he went to the resident and obtained an oxygen saturation level of 80%, spoke with the family and immediately contact the physician to send the resident to the emergency room . RNS #2 stated "he didn't even make it to the supervisor's report, I didn't know he was sick." RNS #2 stated that he spoke with the resident's family before the resident was transferred and the family informed him that they wanted the resident sent out last night but were told that nothing more could be done in the hospital than at the facility. The RNS #2 stated that he was very upset with the situation, on 9/25/12, he copied the nurses notes and left the information for the DON to alert him of the problem but no one has spoken to him about the issue. During an interview on 10/9/12 at 3:00 pm, physician #2 stated that she did not have much recollection of the resident. She stated that she recalls that the resident had a critical lab value but was under the impression that this was a chronic condition for the resident. She stated that she does not recall formally examining the resident but with the critically high BUN level and in the absence of comfort care, she would have sent the resident to the emergency room . Physician #2 stated "essentially, it sounds like he was crashing, I just don't think I had all of the information." 10NYCRR 415.3(e)(2)(ii)(b)

Based on record reviews, and staff interviews conducted during a partial extended abbreviated survey (Complaint # NY 800) it was determined the facility did not ensure that 20 ( #'s 1, 5, 6,11,12,18,19, 29, 30, 39, 40, 47, 72, 76, 80, 88, 93, 94, 96, and 118) of 20 residents reviewed were free of any significant medication errors. Specifically, residents were not administered all of their physician ordered medications. Staff interviews revealed that they understood the facility's policy & procedure regarding medication misses to mean that a resident may miss up to 3 doses of a medication(s) before reporting it to a physician. Also, Resident #40 was found to have three of the same medication patches on her skin at the same time. Additionally, the facility failed to have an effective system and policy & procedure for ordering missing medications in place to ensure the timely acquisition of medications. This had the potential to effect all 115 residents in the facility. This resulted in no actual harm with potential for more than minimal harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This was evidenced by: The Policy and Procedure (P&P) for Administration of Medications with a revision date of 9/2011 documented that medications were to be administered as ordered by the physician. If a medication administration was missed on a resident for three consecutive doses, the physician was to be notified. At the nurses discretion, the physician was to be notified in person, through a fax, by telephone, or a notation could be made in the Physician Flag Book for an update on the physician's next in-house visit. The P&P for Medication Errors with a review date of 6/2010, documented that when an error occurred, the Supervisor, Registered Nurse (RN) in Charge, Attending Physician, and/or Nursing Administration was to be notified. The nurse who made the error or found the error was to complete a Medication Error Incident/Accident Report (MEIA). A Nursing Supervisor was to review the report, obtain signatures and written statements from all staff member involved in the error and forward to Nursing Administration. Resident #18: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment. The Admission History and Physical (H&P) dated 7/14/10, documented that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record (MAR) dated 3/2012, documented that the resident was to receive 30 mg [MEDICATION NAME] morning. It was documented on the following dates that the medication was not available and the resident did not receive the medication: 3/4/12, 3/5/12, 3/8/12, 3/17/12, 3/18/12, 3/19/12, 3/20/12, 3/21/12, 3/22/12, 3/23/12, 3/24/12, for a total of 11 doses, 8 of those doses consecutively. There was no further documentation on the MAR as to actions taken due to the medication not being available. Review of the Nurses Notes (NN) from 3/1/12 through 3/24/12, revealed no documentation of the resident missing doses of Imdur. Review of the 24 Hour Shift Reports for 3/4/12, 3/5/12, 3/8/12, 3/17/12, 3/18/12, 3/19/12, 3/20/12, 3/21/12, 3/22/12, 3/23/12 and 3/24/12, revealed there was no documentation of this [MEDICATION NAME] being available. There was also no documentation of missing medications for any resident under the Pharmacy and Medication Follow-Up section of the forms. An MEIA dated 3/25/12 at 6:00 am, documented that the resident missed 8 doses [MEDICATION NAME] which he was supposed to receive 50mg every day. There was no apparent harm to the resident and his vital signs were stable. The medication was not given and not re-ordered, and was found in the wrong place on the medication cart. The medication had been entered on the MAR as not available. The MEIA documented that no violation had occurred and the report was signed by a Registered Nurse Supervisor (RNS). The MEIA was also signed by the physician who wrote that the error was not significant. There were no statements attached from the involved nurses. During an interview on 3/26/12 at 12:39 pm, the Director of Nursing (DON) stated that she was not aware that this resident had missed any doses of his medication until she saw the MEIA on 3/25/12. She stated that she was not aware that staff were using the code number "2" to document that a medication was not available. It was important for this resident to receive [MEDICATION NAME] he had such an extensive cardiac medical history. She stated that the facility's P&P was that it was okay for a resident to miss three doses of a medication before the physician had to be notified, but that there still should have been follow-up with the pharmacy to get the medication delivered. The DON stated that the physician did not consider this to be a significant medication error, but she considered it significant because of the number of days that the resident did not receive the medication. During an interview on 3/27/12 at 9:50 am, the physician stated that he should have been notified that the medication had not been given, an RN should have assessed the resident and an MEIA should have been completed on each occurrence that the medication was not available. Resident #40: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have severe cognitive impairment. The physician's orders [REDACTED]. The MAR dated 3/2012, documented that the resident was to receive a new 9.5mg [MEDICATION NAME] patch applied to her skin every day. It was documented on the following dates that the patch was applied to the resident, with the location of the patch: 3/17/12 on the forearm, 3/22/12 on the left side of the chest, and 3/23/12 on the right side of the chest. Review of the NN's from 3/9/12 through 3/23/12, revealed no documentation regarding [MEDICATION NAME]es. A NN dated 3/24/12 at 10:00 am, documented that three [MEDICATION NAME]es were found on the resident and the resident's vital signs were stable. The physician and the DON were notified. An MEIA dated 3/24/12 at 7:30 am, documented that the resident was found with three [MEDICATION NAME]es on her body. There was a copied image of the patches attached to the MEIA. One patch was dated 3/17/12 and was found on the resident's forearm, another was found on the left side of the resident's chest and was dated 3/22/12. The third patch was dated 3/23/12 and had been located on the right side of the resident's chest. There were no statements attached from the involved nurses, or other staff that may have bathed, dressed or otherwise cared for the resident. During an interview on 3/26/12 at 12:39 pm, the DON stated that she was not aware that this resident had been found with three [MEDICATION NAME]es on until a nurse reported this to her on 3/24/12 at approximately 9:30 am. She stated that nurses were expected to remove the previous days' patch prior to applying a new patch and the location of patch placement was documented on the MAR so nurses would know where to find them. She also stated that this was potentially a serious medication error because the resident's agitation levels could have gotten worse and may have lead to an accident or some other adverse incident. During an interview on 3/27/12 at 9:50 am, the physician stated that this medication error was potentially serious because [MEDICATION NAME] built up in the blood stream and could have increased the resident's agitation. Finding: During an interview on 3/26/12 at 12:00 pm, LPN#8 stated that if a physician ordered medication was not available in the medication cart, as long as the resident had not missed three consecutive doses, it was not necessary to notify the physician. When asked what she was supposed to do if she could not find a medication, she stated that she would have to look through the medication cart to see if it had been misplaced. If the medication could not be located, she was supposed to write the number "2" in the box. The number "2" was the MAR code for medication was not available. She stated that she was not aware of any further action that needed to be taken. During an interview on 3/26/12 at 12:39 pm, the DON stated that she did not know that when a resident's medication was not available, staff were writing a number "2" in the initials box of the MAR and were not following up on getting the medication from the pharmacy. After reviewing MARs that had multiple "2s" in the initial boxes, the DON stated that this showed a pattern of lack of accountability on the part of each of the individual nurses. She stated that the P&P was to call the physician if three consecutive doses of a medication were missed but there were not a lot of medications that residents could miss that many times consecutively. She stated that when that part of the P&P was written, she strongly disagreed with it, but the Quality Assurance RN and the Medical Director wrote it and said that was the way the policy should read. She stated that she believed that when the policy was written, it was intended to be more about residents missing less significant medications such as daily vitamins. The DON also stated that there was no P&P that outlined for staff exactly what to do if a medication was not available in the medication cart. There was also no system in place for tracking medications ordered from the pharmacy and whether or not they had arrived from the pharmacy. During an interview on 3/26/12 at 2:17 pm, LPN#9 stated that if a resident's medication was not in the medication cart, she checked the pharmacy website to see if the medication had already been ordered. If it had been, she documented a number "2" on the MAR, meaning that the medication was not available. She stated that she did not have to notify a physician of a missed dose of medication until three consecutive doses had been missed. When asked if there was a list of medications that a resident could not miss or could not wait until three consecutive doses had been missed to contact the physician, she stated that there was no such list but nurses should use their judgment to know if a medication was significant enough to notify the physician immediately. She also stated that she did not think a nursing supervisor had to be notified of a medication being unavailable until the resident missed three consecutive doses. During an interview on 3/26/12 at 2:22 pm, LPN#10 stated that an unavailable medication was documented on the MAR as a number "2". She also stated that the P&P for the facility was that a resident could miss up to three consecutive doses of a medication before she had to notify the physician. LPN#10 also stated that she did not know how to order a medication from the pharmacy other than faxing a new order. If a medication was missing, she stated she would probably have to ask a supervisor to get it from the pharmacy but that would only be if the resident had missed three consecutive doses. During an interview on 3/26/12 at 2:34 pm, LPN#3 stated that she had never been instructed on what to do if a resident's medication was missing. She stated that she would write on the back of the MAR that the medication was unavailable. She had been told by other nurses in the facility that it was okay for a resident to miss up to three consecutive doses of medications but that she would probably not be comfortable with that so she would probably notify a supervisor to get an unavailable medication ordered from the pharmacy. She stated that she was an employee of a temporary staffing agency, and sometimes there were no facility-employed nurses on a unit she might work on, which meant that there had been times when there would not be anyone available who really knew how to get medications from the pharmacy. During an interview on 3/26/12 at 9:53 am, LPN#11 stated that she was a temporary staffing agency nurse and that when she was oriented to the facility, she was told that if a resident's medication was not available she was to write the number "2" in the box on the MAR. She was also told that a resident could miss up to three consecutive doses of a medication before anyone had to be notified including the physician and the nursing supervisor. She stated that she was not instructed on how to order medications from the pharmacy. During an interview on 3/27/12 at 10:45 am. the Staff Education RN (SERN) stated that medication administration was not covered with regular staff or temporary agency staff during the core orientation to the facility. She stated that new nurses were to be supervised by a floor nurse until it was certain that a nurse could accurately administer medications and manage passing medications on a team of residents. She stated that the orienting nurse was responsible for getting the orientation checklist signed off by a floor nurse and that prior to passing medications without supervision, the nurse had to be audited by another nurse. She was aware that some nurses worked independently on the medication carts on the same day as the core orientation. She stated that LPN#12 was supposed to be audited prior to passing medications on her own, but to the best of her knowledge this had not happened. She stated that she had no record of the audit for LPN#12 and that this LPN was responsible for at least nine medication errors on 3/20/12. She also stated that there was a lack of training and orientation related to medication administration in the facility and had reported this to the DON. She stated that she was not aware of any changes in the training and orientation of nurses to medication administration after reporting this to the DON. The SERN also stated that the P&P did document that a resident could miss up to three consecutive doses of medication and the staff seem to understand that to mean that it did not need to be reported to anyone, not just the physician, until three doses were missed. She stated that the staff stuck to the P&Ps period, that whatever the P&P said, that was what they did without question or thinking any further. There was no list of medications that could not be missed for three doses and the P&P seemed to include all medications, and staff did not consistently report any medications until after three consecutive doses were missed. The SERN also stated that there was no P&P on how to order missing medications from the pharmacy. During an interview on 3/27/12 at 11:00 am, Registered Nurse Manager (RNM) #1 stated that there was no P&P to instruct staff what to do if a medication was missing. Residents were allowed to miss up to three consecutive doses of a medication before the physician had to be notified and staff also took that to mean that it was okay for a resident to miss three doses before it was a problem. She stated that the majority of the problems appeared to have been occurring on Unit #2 which had no RNM since sometime in 1/2012. There was no direct oversight of the staff on that unit. During an interview on 3/27/12 at 11:00 am, the Medical Director stated that he was not aware that some medications were not being given to some residents due to medications were not available. He stated that it was not acceptable to wait until a resident missed three doses and that it should not have been part of the P&P. He also stated that nurses should have used their judgment as to whether the physician should have been notified immediately or not if a resident's medication was not available. During an interview on 3/27/12 at 12:42 pm, the Administrator stated that he did not know why there had been so many medication errors. He stated that he was aware that the P&P documented that a resident could miss up to three doses of a medication, and that it was not a good policy. He also stated that missing three doses of a medication was part of the P&P until, "last week." Resident #6 The resident was admitted to the facillity with [DIAGNOSES REDACTED]. The MDS dated [DATE] and 1/26/12 documented the resident to be severly impaired cognitively and sometimes able to be understood and usually understands. Finding #1 The physician's orders [REDACTED]. The MAR dated 3/2012, documented that the resident was to receive 10 mg of [MEDICATION NAME] 1 tablet by mouth every day, take with food or meal, the medication was given at 6am every morning. It was documented on the following dates that the medication was not available and the resident did not receive the medication: 3/21/12, 3/22/12, 3/23/12, 3/24/12, and 3/25/12 for a total of 5 doses, consecutively. There was no further documentation on the MAR as to actions taken due to the medication not being available. The NN from 3/21/12 through 3/25/12, revealed no documentation of the resident missing doses of [MEDICATION NAME]. There was no documentation in the medical record that the physician was notified. An MEIA dated 3/25/12 at 6:00 am, documented that the resident missed 5 doses of [MEDICATION NAME] of which he was supposed to receive 10mg every day. It is documented no apparent harm to the resident and he offered no complaints. There is no documentation that an assessment was completed on the resident. The medication was not given and not re-ordered. The medication had been entered on the MAR as not available. The MEIA documented that no violation had occurred and the report was signed by a RN. The MEIA was also signed by a physician. The DON wrote that the error was not significant. There were no statements attached from the involved nurses. During an interview with the Medical Director on 3/27/12 at 9:50am, he stated that he was unaware that the resident did not receive his medication. He stated that a RN assessment should have been completed and [MEDICATION NAME] should not be abruptly stopped if the resident has taken it for longer than 7 days. The MAR documented that resident received 10 mg of [MEDICATION NAME] for 20 consecutive days. The physician stated that the resident ' s medical care is complicated and any symptoms of withdrawal could increase his pain. During an interview on 3/26/12 at 12:00 pm, LPN#8 stated that if a physician ordered medication was not available in the medication cart, as long as the resident had not missed three consecutive doses, it was not necessary to notify the physician. When asked what she was supposed to do if she could not find a medication, she stated that she would have to look through the medication cart to see if it had been misplaced. If the medication could not be located, she was supposed to write the number "2" in the box. The number "2" was the MAR code for medication was not available. She stated that she was not aware of any further action that needed to be taken. During an interview on 3/27/12 at 4:08pm, the DON stated that she was not aware that this resident had missed any doses of his medication until she saw the MEIA on 3/25/12. She stated that she was not aware that staff were using the code number "2" to document that a medication was not available. She stated that she instructed staff to circle their initials if the medication was not given, and to write a NN to document why. She stated that the facility's P&P allowed for a resident to miss three doses of a medication before the physician had to be notified, but that there still should have been follow-up with the pharmacy to get the medication delivered. . . Finding #2 Physician order [REDACTED]. Maximum daily dose (MDD) of 4 tablets. Clarification of the order by the MD documented 1 [MEDICATION NAME] tablet for pain 4 out of 10, 2 tablets [MEDICATION NAME] if pain 5-10 of 10 being the highest. A review of the nursing notes dated 3/10/12 documented that the resident received 2 [MEDICATION NAME] at 4:10 am for complaint of pain to left shoulder. There was no documentation of pain scale noted in the notes or the MAR. Nursing notes dated 3/10/12 timed 9:45pm documented the resident complained of rib/flank pain. Medicated at 4:15pm with prn [MEDICATION NAME] per request of pain 8/10. Review of the Controlled Substance Record (CSR) documented the resident received 2 tablets at 4:10am, 2 tablets at 4:15pm and 2 tablets at 11:35pm. There was no documentation in the nursing notes that the resident received medication at 11:35pm. The label on the CSR documented 1 tab by mouth 2x a day, maximum daily dose 4 and 1 tablet by mouth every 4 hours prn. The label did not match the physician orders. A medication error form was not completed for the resident receiving 2 extra [MEDICATION NAME] 3/10/12. The physician was not notified. NN dated 3/21/12 documented the resident complained of pain meds not working and the physician wrote new orders for 1 dose 5/325 [MEDICATION NAME] to be given from the emergency kit now. The MAR documented it was given at 11:30am. A new order was written to discontinue [MEDICATION NAME] 7.5/500 and change to [MEDICATION NAME] 10/325mg 2 tablets, three times a day, and to update MD on pain as needed. Review of the MAR for [MEDICATION NAME]([MEDICATION NAME]) 10/325 documented 2 tablets were given at 8:00pm on 3/21/12, and at 6:00am on 3/22/12. There is no documentation of pain scale recorded. NN dated 3/21/12, 3-11 shift documented the resident complained of muscle pain across chest and was given [MEDICATION NAME](no dose documented) for pain. The CSR is documented that at 8:00pm the resident received one 7.5/500mg.tablet A MEIA was completed on 3/22/12 stating the resident received one 7.5/500 tablet instead of two 10/325 [MEDICATION NAME] tablets, noted documented on the outcome section of the report, no adverse effects noted at this time. The MD signed the report on 3/23/12 and noted that the dose was significant, with no outcome. On The CSR labeled [MEDICATION NAME]([MEDICATION NAME]) 10/325 tablets, 2 tablets, three times a day, MDD daily dose 6 tabs, documentation indicated that the resident received the first dose of [MEDICATION NAME]([MEDICATION NAME]) 10/325 on 3/22/12 at 8:00am and received 1 tablet. Additionally, on 3/25/12 the CSR was documented for 1 tablet given at 7:36pm. A MEIA was completed on 3/25/12 at 7am stating at 6am noted that the resident only received 1 tablet at 8pm on 3/25/12. Documented under Outcome to Resident, No relief of pain. During an interview with the DON on 3/26/12 at approximately 12:40pm she stated that the nurses should be accountable for the controlled substances that they dispense, and there should be no margin for error, the physician should be notified immediately and an A&I should be submitted. If the nurse is an LPN they should notify an RN as soon as the mistake is noticed, for a resident assessment to be completed. Additionally, she stated that the narcotic given should be documented in the nursing notes, time, date and amount and another note should be documented for the effects of the medication given. The DON was asked if the facility had a Medication Error Tracking System, she responded sometimes Quality Assurance documents and sometimes she does not. It consists of documenting the nurses name and after three medication errors they will be disciplined. The QA person checks for trends then reports to the DON, which she stated was not being done. The DON stated about 6 weeks ago she developed a new tracking system taking the job away from the QA person. She stated she found inaccurate data reported from the QA nurse and took on the job herself. Additionally she stated that the facility requires a medication audit and an audit is not being completed. The pharmacy consultant was interviewed by telephone on 3/28/12 at approximately 10:30am, she stated that when they come to the facillity they ask for a sample of the residents MARS. She stated that they look for correct orders, omissions and administration times. Additionally she stated that they did not look for numbers in the MARS, ie: 2,3's and any consistant non administration of medication should be reported immediately. During an interview with the attending physician on 4/6/12 at approximately 11:30am, he stated that the orders were confusing and difficult to read and he rewrote them. Additionally he stated the pharmacy should have sent new narcotic count sheets when the dose and order were changed . The way they are now can only lead to confusion and errors. 10NYCRR 415.12(m)(2)

Based on record review and staff interview, the administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for each resident, during a partial extended abbreviated survey (Case # NY 800). Specifically, the administrator failed to ensure that residents were free of any significant medication errors, and that the facility had an effective system and policy & procedure for ordering missing medications in place to ensure the timely acquisition of medications. Additionally, the administrator failed to ensure that the facility had a Quality Assurance(QA) program that readily identified issues involving medication errors and had the potential to cause serious harm to residents. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to the health and safety of residents. This had the potential to effect all 115 residents residing in the facility. This was evidenced by: Medication Errors refer to - F 333 Scope/Severity = L During an interview on 3/27/12 at 12:42 pm, the Administrator stated that he did not know why there had been so many medication errors. He stated that he was aware that the P&P documented that a resident could miss up to three doses of a medication, and that it was not a good policy. He also stated that missing three doses of a medication was part of the P&P until, "last week." Quality Assurance refer to F 520 Scope/Severity = L Quality Assurance meeting minutes for the months of 9/11, 10/11, 11/11, 12/11, 1/12 and 2/12 documented that no member of the governing body had attended the QA meetings held in those months. During an interview on 3/27/12 at 12:42 pm, the Administrator stated that he did not know if the QA Committee tracked and/or monitored medication error reports to determine if there was any identifiable trends. During an interview on 3/28/12 at 10:03 am, the Administrator stated that the QA Committee met monthly. He stated that he had been the Administrator since the summer of 2011 and that no member of the governing body had attended the QA meetings in that time, and that he was not aware that this was a requirement. He stated that in 12/11, the QARN was asked not to attend QA meetings because there were concerns that her reports of QA audits and initiatives were not accurate and it was recognized that it was not beneficial to have the QARN at the meetings. He stated that he did not know what the QARN had been auditing since 12/11, and that he and the DON, "worked around her," because she was not beneficial to the QA program. 10NYCRR 415.26

Based on record review and staff interview, the facility failed to have a Quality Assurance(QA) program that readily identified issues that had the potential to cause serious harm to residents reviewed during a partial extended abbreviated survey (Case #NY 800). Specifically, the facility failed to have a QA program that readily identified issues involving medication errors and had the potential to cause serious harm to residents. This resulted in Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents and had the potential to effect all 115 residents residing in the facility. The findings were as follows: Quality Assurance meeting minutes for the months of 9/11, 10/11, 11/11, 12/11, 1/12 and 2/12 documented that no member of the governing body had attended the QA meetings held in those months. During an interview on 3/27/12 at 12:42 pm, the Administrator stated that he did not know if the QA Committee tracked and/or monitored medication error reports to determine if there was any identifiable trends. During an interview on 3/28/12 at 8:41 am, the Quality Assurance Registered Nurse (QARN) stated that she did not track and analyze medication errors. She stated that she used to track medication errors but no longer did so and that she did not know why. She had been instructed by the DON to check the Medication Administration Records (MAR) to ensure that there were no blanks left where nurses were supposed to have signed the MAR indicated [REDACTED]. She stated that Quality Assurance initiatives were assigned to her by the DON, and that she did not review the MARs for anything more than "blanks" because she was not told to do so by the DON. The QARN also stated that she no longer attended the QA meetings because on 12/14/12 she received an electronic message (e-mail) from the DON notifying her that she was no longer to attend the meetings. During an interview on 3/28/12 at 9:12 am, the DON stated that medication error reports were supposed to go to the QARN who was supposed to log the report and do an analysis for trends in medication errors. She stated that she was not being accurately updated on medication error trends by the QARN, so she took that responsibility away from the QARN. The QARN would not do anything that she was not specifically told to do and that if the DON did not specifically tell her a particular detail, the QARN would not do it on her own. The QARN was removed from the QA Committee in 12/2011 because she was a negative influence on the meetings and often reported inaccurate data to the committee. She stated that the QARN was left out of the QA program and was only responsible for performing audits as directed by the DON and/or the Administrator. The DON stated that the QA Committee met monthly and consisted of herself, the Administrator, the Medical Director, two Licensed Practical Nurses (LPN), two Certified Nurses Aides (CNA) and a representative from housekeeping. She stated that no member of the governing body (Board Member) had attended the QA Committee meeting in many months and that she did not know a Board Member was required to attend the QA meeting quarterly. During an interview on 3/28/12 at 10:03 am, the Administrator stated that the QA Committee met monthly. He stated that he had been the Administrator since the summer of 2011 and that no member of the governing body had attended the QA meetings in that time, and that he was not aware that this was a requirement. He stated that in 12/11, the QARN was asked not to attend QA meetings because there were concerns that her reports of QA audits and initiatives were not accurate and it was recognized that it was not beneficial to have the QARN at the meetings. He stated that he did not know what the QARN had been auditing since 12/11, and that he and the DON, "worked around her," because she was not beneficial to the QA program. 10 NYCRR 415.27(a-c)

Based on observation, staff interviews and medical record review, it was determined during the extended recertification survey and complaint investigations (Cases # NY 392, NY 07 and NY 749) that the facility failed to have evidence that all alleged violations are thoroughly investigated and that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law. Specifically, for 6 ( #'s 61, 63, 75, 78, 85 and 118) of 34 residents reviewed the facility failed to investigate events of resident self mutilation, failed to investigate medication errors, failed to report allegations of verbal abuse and neglect. Additionally, the facility failed to investigate why a six inch serrated knife remained in the possession of a resident with cognitive impairment and who resided on a locked dementia unit. The failure to thoroughly investigate to determine a root cause placed all of the 122 residents in the facility at risk for injury. This is a repeat deficiency from the [DATE] and [DATE] recertification surveys. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to residents health and safety and Substandard Quality of Care. This is supported by the following evidence: Resident # 75: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) and Nurse Aide Care Card, dated [DATE] and most recently updated on [DATE] documented the resident's room needed to be checked daily for items which may be sharp and /or cause harm to the resident or to others, that is, pins/needles/scissors, etc and to remove immediately. The CCP for behaviors dated [DATE] documented a problem statement as the resident picks at "dry skin" on hands with fingernails, and other items (pins, brooches). The goal statement was resident will not experience complications or infections secondary to picking at skin. Approaches for this problem included: remove non-personal sharp objects, educate/remind of dangers related to behaviors, monitor hands daily for signs/symptoms of infection/complications, administer medications per physician order [REDACTED]. A Psychological Services note (PSN) dated [DATE] documented presenting and ongoing symptoms as: adjusting to illness/decrease in function, agitation, attention seeking (demanding), aggressive (verbal), inappropriate behavior, isolation/withdrawal, memory/cognition/decision making, non-compliance (medical, medical care) and easily annoyed/short tempered. The PSN further documented the resident will begin the session fairly benignly but agitation level escalates quickly. The resident will state over and over "I hate it here" (residence in the facility) and does not respond to validation or redirection. The PSN further documented it is unlikely the resident will derive any more benefit from psychotherapy, is unwilling to engage, and refuses psychological services. The psychology provider discharged the resident [DATE]. The Physician's Progress Note dated [DATE] documented the major issue of concern to the nurses was that the resident continues to pick at the skin of her hands with certain pins which have been removed from the room, but the resident has a couple of brooches that have needles on them. The Physician Progress further documented the following on [DATE]; that this behavior does not sound like a classic obsessive compulsive behavior. The resident has a cream for use on these areas. The physician documented that given the fact that she is already on [MEDICAL CONDITION] medications, " I would not prefer to add more drugs:. She is very fragile with advanced age. Since the nurses check these areas every day to make sure they are not getting infected and this does not bother the resident per say that she is doing I think we can observe and follow. If her behavior gets worse we could then consider behavior modification attempts with medications. The nurse's notes dated [DATE] documented that the resident continued on 15 minute checks for safety and that the resident was noted to be sticking her hand with a safety pin. The nurse's note also documented that when approached the resident hid the pin and wouldn't let the nurse look for it. Nurses note dated [DATE] documented that a safety pin was removed from the resident's room while she was in the bathroom with the pin being under the pillow. The nurses note from [DATE] further documented that the resident was seen picking at her left hand moments before. Nurses note from [DATE] documented that a safety pin was removed from the resident ' s room. During an interview on [DATE] at 12:40 pm the Registered Nurse Manager (RNM) stated that the resident was using the pointed ends of safety pins to stick the skin on her left hand. The RNM stated the resident has a condition which seemed to make her want to stick the skin of her left hand. The RNM stated no determination could be made as to where the resident was obtaining the safety pins. During an interview on [DATE] at 3:30 pm the Certified Nursing Assistant (CNA) that worked the 3:00pm-11:00pm shift stated that the resident will at times pick at her hands with safety pins or the pin of a brooch. The CNA stated that the care card (CCP for Activities of Daily Living) directed nursing staff to remove sharp items immediately when found. During an interview on [DATE] at 11:50 pm the Director of Nursing (DON) stated there were no Incident and Accident (I and A) reports completed to document where the resident was obtaining the safety pins to stick the skin of her left hand on [DATE], [DATE] and finding a safety pin in the resident's room on [DATE]. The DON stated that if there were no I and A reports completed then there was no investigation completed to determine where the resident was obtaining the safety pins. The DON stated that an investigation of this should have been completed . Resident # 61: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having moderately impaired cognition. The Policy and Procedure for Resident Abuse Prevention dated ,[DATE], documented that suspected resident abuse was to be immediately reported to the nurse in charge of the building, both verbally and in written form. If alleged abuse involved a staff member toward a resident, that staff member was to be immediately removed from that resident ' s care pending investigation. All occurrences involving residents were to be appropriately documented on an Incident/Accident form, Resident Complaint form, or Behavior Tracking form, and a supervisor was to be immediately notified. An In-House Investigation dated [DATE] at 4:00 pm, documented that Certified Nursing Assistant (CNA) #1 verbally abused this resident. On [DATE] at 6:30 am, CNA#1 stated in front of the resident and CNA#2 that she could not stand this resident and that she would not care if she died right now. CNA#1 continued to work until leaving at 10:52 am. The investigation was signed by the Director of Nursing. The Timecard dated [DATE] through [DATE], documented that CNA#1 left work at 10:52 am on [DATE]. Review of the Nurses Notes revealed no documentation of the incident or assessment of the resident on [DATE]. During an interview on [DATE] at 11:00 am, the Director of Nursing (DON) stated that she was investigating a case of verbal abuse involving this resident and CNA#1. At 6:30 am on [DATE], CNA#1 had said to CNA#2, in front of the resident, that she did not like this resident and that she would not care if this resident died right then. The DON stated that the resident's health had recently been declining and that she did not believe the resident was cognitive enough to hear or understand what the CNA had said. She also stated that she did not learn of the incident until [DATE] at approximately 4:00 pm and that CNA#2 should have immediately reported the incident to the RN on duty or some other supervisor or manager. CNA#2 should not have waited until after CNA#1 left for the day to report the incident. During an interview with CNA#1 on [DATE] at 1200 pm, she stated at approximately 6:30 am on ,[DATE] /12 she went into this resident's room to assist CNA#2 in transferring the resident. She said in front of the resident and CNA#2 that she could not stand this resident and that she would not care if she died right now. CNA#1 stated that she knew saying something like this was wrong, but she was frustrated and just said it without thinking. She worked the rest of her shift and nobody from the facility said anything to her about the incident until 4:00 pm when the DON called her and told her she was suspended pending investigation. During an interview on [DATE] at 10:46 am, CNA#2 stated that CNA#1 had come into this resident 's room to assist her with transferring the resident out of bed. CNA#1 stated, in front of the resident and loud enough for the resident to hear, that she could not stand the resident and that she would not care if the resident died right now. CNA#2 told CNA#1 that it was not nice to say such a thing and that she liked the resident. CNA#2 also stated that the resident did not seem to be cognitively intact enough to understand what CNA#1 had said and that she had no reaction to the statement. CNA#2 also said that she knew she would have to report this as verbal abuse but did not do so immediately because she did not think anyone would do anything about it. She stated that the incident was bothering her and at 11:00 am, she told Registered Nurse (RN) #1 and the Administrator about the incident. At approximately 12:50 pm, CNA#2 was returning from a break, saw RN#1 and told her that she had reported two incidents to the Administrator, one of the incidents being the verbal abuse toward this resident. During an interview with CNA#3 on [DATE] at 12:50 pm, she stated that on [DATE] at approximately 10:15 am, CNA#2 told her about CNA#1's verbal abuse of this resident earlier that day. She stated that she did not immediately report this to a nurse, management or administration because she was busy performing care on other residents. She stated that at approximately 11:00 am, she( CNA (#2) reported abuse allegations and allegations of neglect to the Administrator and to RN#1. When the CNA was asked by the surveyor if she was sure she reported this incident to the Administrator and RN#1 at 11:00, she stated that she was 100% sure that she reported the other allegation (neglect) involving CNA#1, but that she was not 100% sure about reporting this allegation of verbal abuse. During an interview on [DATE] at 1:26 pm, the Administrator stated that he did not learn of the incident involving this resident until between 3:00 pm and 4:00 pm on [DATE], and that when he learned of it he reported it to the DON. He stated that CNA#2 should have reported the verbal abuse by CNA#1 immediately and CNA#1 should have been removed from resident care. During an interview on [DATE] at 4:10 pm, RN#1 stated that on [DATE] at 11:00 am, CNA#2 and CNA#3 reported an incident to her involving CNA#1 and Resident #63. At 12:50 pm, she was working in the dining room when the CNAs came to her and told her that the incident involving Resident #63 and this incident involving CNA#1 verbally abusing this resident had been reported to the Administrator. Because the CNAs told her that the Administrator had already been notified of the incident, she did not think she needed to do anything about it. She did not report this to the RNM, DON or Administrator and did not discuss it with anyone until [DATE] at approximately 1:00 pm when the facility called her for an interview. Resident # 63: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having severely impaired cognition. The Nurse Aide Care Card (which the CNAs used to know what care each resident required) dated [DATE], documented that the resident required the extensive assistance of two staff members for transferring, and was to be offered position changes every two to three hours off buttocks. Staff were to encourage the resident to get out of bed every day. The resident also required the extensive assistance of one staff member for rolling in bed, extensive assistance of two for being pulled up in bed and for changing position from lying to sitting. The Comprehensive Care Plan (CCP) for Skin Breakdown dated [DATE], documented that the resident was to be changed promptly after episodes of incontinence and was to be turned and positioned every two hours when in bed. An undated In-House Investigation documented that on [DATE] at 10:40 am, two CNAs noticed that it did not appear that this resident had received care for that day. At 10:50 am, CNA#1, who had been assigned to this resident on that day, had reported to RN#1 that she was leaving work and that she had completed her care on residents. At 11:45 am, CNA#2 performed care on the resident and found that the resident brief was soaked with urine and the resident had slid down low in the bed. Investigation Findings documented that there was insufficient credible evidence that this resident had been neglected. In an Employee Statement dated [DATE] at 4:00 pm, RN#1 documented that on [DATE] at 11:00 am, two CNAs reported to her that CNA#1 had left for the day and had not performed care on five residents including Resident #63. RN#1 documented that she took notes of what was being said and told the CNAs that she would report this to the RNM. She stated that she did not see the RNM before 12:15 pm when she went to assist residents in the dining room. While in the dining room, CNA#3 came into the dining room and reported to her that she had told the Administrator about the complaint against CNA#1. During an interview on [DATE] at 4:10 pm, RN#1 stated that on [DATE] at 11:00 am, CNA#2 and CNA#3 reported an incident to her involving CNA#1 and another resident (61). At 12:50 pm, she was working in the dining room when the CNAs came to her and told her that the incident involving another resident and this incident involving CNA#1 verbally abusing this resident had been reported to the Administrator. Because the CNAs told her that the Administrator had already been notified of the incident, she did not think she needed to do anything about it. RN#1 stated that she did not speak to supervisory, managerial or administrative staff about the incident until she was called by the DON at approximately 1:00pm on [DATE]. RN#1 stated that when the CNAs reported the lack of care on this resident to her, she recognized it as an allegation of neglect but did not immediately report it to the RNM, DON or Administrator because she did not know if the care had been done or not. Her impression of the situation was that CNA#1 had not done care on any residents, and it just sounded like CNAs grumbling about another CNA. During an interview on [DATE] at 2:36 pm, CNA#3 stated that [DATE] was a hectic day. At 7:00 am she saw this resident and she was lying on her right side. When she saw the resident again at 10:50 am, the resident was lying in bed in the same position on her right side. The night shift puts linens in the rooms for the day shift to use for the resident's bed baths and linen changes. This resident's linens were still in her chair and had not been used. The resident's hair was still messed up and it did not appear that the resident had received any care that morning. When CNA#3 gave care to the resident, the resident's adult briefs were soaked through to the bed with urine. She reported to RN#1 at 11:00 am that CNA#1 had left for the day without providing care to this resident, and reported this to the Administrator at 12:15 pm. At 2:00 pm, CNA#3 reported to the RNM that CNA#1 had not provided care to the resident and was told to write a statement. During an interview on [DATE] at 4:15 pm, the DON stated that she learned of the allegation of neglect of this resident by CNA#1 on [DATE] at 11:50 am. She stated that upon hearing of an allegation of neglect from CNAs, RN#1 should have immediately begun to obtain statements and to report the allegation to the RNM whether she believed she had proof or not. She also stated that RN#1 should have immediately performed and documented a thorough physical assessment of the resident. During an interview on [DATE] at 2:00 pm, the Administrator stated that on [DATE] at 11:00 am, two CNAs reported to him that CNA#1 had left for the day without doing care on this resident. He stated that he could not recall what care the CNAs said had not been done and that within an hour after hearing this he reported it to the DON. He also stated that RN#1 should have immediately reported the allegation of neglect and should not have waited for the CNAs to report it. Resident # 118: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented the resident was mildly cognitively impaired and had short and long term memory mildly decreased. The hospital discharge summary dated [DATE] documented the resident needed 24 hour supervision to provide setup for activities of daily living, had explosive behaviors and should have with no access to dangerous objects. The resident showed a decrease in short term memory and impulsivity with decreased concentration. The nurse's notes (NN) dated [DATE] at 6:30 pm," resident daughter #2 called and left message with medication nurse that this afternoon she gave resident a knife and some donuts." The nurse entered the residents room and asked for the knife. The resident said "Leave me the hell alone. You ain't getting my knife." The supervisor was made aware. At 7:45pm the nurse asked the resident again for the knife and the resident stated "get out now God damn you." At 9:45pm the nurse entered the resident's room and the resident stated "Did you come to do my treatment, just do that and then leave I know what you're trying to get. NN at 11:00pm documented the medication nurse was made aware and the resident requested and received a beer at 8:00pm. The next NN is dated [DATE] at 11:05am, the Director of Nursing (DON) and the Unit Manager (UM) met with the resident to discuss the knife. The resident repeatedly would not give up the knife. The DON educated the resident that other residents on this unit could be at risk for injury if they were to get ahold of it. The resident stated he would give it to the Licensed Practical Nurse (LPN) when he was done using it. The DON updated the LPN, Social Services (SS) and directed them to ensure the knife was obtained by the end of the shift. A SS note dated [DATE] documented under Action Taken: ,[DATE] writer called family to educate on why no "sharps" are allowed on the unit. SS suggested to DON/Administrator that nursing conduct a search of the room and remove the knife for the family to pick up. Writer called daughter/guardian #1, who stated she had already educated family. She stated she had already spoke to a nurse this weekend and was told the knife was "already removed", the daughter#1 stated she was unhappy that he still had it and daughter #1 stated she would like a follow up of the knife issue. A review of the Comprehensive Care Plan (CCP), untitled, with the problems/needs listed as: impaired problem solving, limited insight/judgement, sad or anxious mood, problems with relationships and non compliance with health issues. The CCP documented that the resident will have fewer episodes of problem behaviors. There was no documentation of the incident involving the knife on [DATE]. A review of the resident's care card (used by the CNAs to provide care to the resident), last updated [DATE] documented under Special Instructions: when the resident is out of his room for breakfast check his room for old food and remove every day. There was no update to check resident's room for items that may place the resident at risk for his safety. An Accident and Incident Report was requested of the DON and Administrator and none was provided. During an interview on [DATE] at approximately 1:30 pm the UM stated the resident did not have the knife. They kept it in the medication cart. The Surveyor asked to see the knife and there were two six inch serrated steak knives in a cup for this resident. The LPN stated that they give it to him when he asks. He was unsupervised with it's use on a locked dementia unit. During an interview on [DATE] at 3:30pm the DON and the Administrator stated that they were unaware of the situation the date it occurred [DATE]. There was no communication over the weekend that the resident still had a knife. It was not until Tuesday [DATE] that the knife was removed from the resident. They stated that a thorough investigation was not completed because they considered it closed because they thought the knife had been removed. The continued use of the knife unsupervised was discussed. The DON stated that the resident really did not belong on the dementia unit, he is only there for his behaviors. Resident # 78: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severely impaired cognitive abilities. The physician's Information/Fax Sheet (information to the resident's attending physician) dated [DATE] documented a report to the physician that the order for [MEDICATION NAME] ,[DATE]mg three times daily and every four hours as needed with a maximum dose of 6 tablets in a 24 hour period had been incorrectly transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was administered this medication on [DATE], [DATE] at 3:30 pm and 7:30 pm, [DATE] at 4:00 pm and 8:30 pm, [DATE] at 7:50 pm, [DATE] at 8:45 am, [DATE] at 4:00 pm, [DATE] at 8:00 am, and [DATE]. The MAR indicated [REDACTED].) tablet by mouth every four hours as needed until gone then discontinue. During an interview on [DATE] at 12:40 pm the Registered Nurse Manager (RNM) stated the resident has been receiving [MEDICATION NAME] ,[DATE] mg's. three times daily and every four hours as needed for a prolonged period of time. When the resident returned from a hospital admission on [DATE] the physician's orders [REDACTED]. The RNM was uncertain as to whether a medication error investigation sheet had been completed. During an interview on [DATE] at 9:30 am the Director of Nursing stated that no medication error investigation sheet could be found. Since there was no incident report there was no investigation. The DON stated that a medication error investigation should have been completed. 10NYCRR 415.4(b)(1)(ii)

Based on medical record review, observation, and staff interview the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 4 ( #s-6, 75, 85,118) of 32 residents reviewed during the extended recertification survey and complaint investigation (#NY 505). Specifically, the facility did not remove items (brooches/ pins/ knives) which had the potential to injure residents, the facility did not have a procedure in place to monitor residents oxygen tank levels'. Additionally, the facility did not provide adequate supervision of a resident with known suicidal ideation with attempts. This resulted in no actual harm with the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This evidenced by the following examples: Resident # 85: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS documented the resident was severely cognitively impaired with long and short term memory loss. The facility policy titled " Suicidal Precautions " last revised 9/11 , documented : All reports of actual/potential suicidal actions shall be immediately reported to the Nurse Manager/Supervisor. Nursing shall immediately complete a " Suicide Risk Evaluation " .and determine if the resident is low or high risk. If the resident is high risk remove all lethal items of self injury from room, use plastic dishware and utensils and contact the Physician (MD) to review the risk assessment. Obtain order to transfer to the ED for immediate evaluation and keep resident in direct supervision until resident is transferred. During a review of the medical record on 3/13/12 it was documented in the nursing notes (NN) that on 8/31/11 at 5:40 pm the resident stated she wanted to slit her throat while talking to her son on the phone. A suicide risk assessment (SRA) was completed by the Licensed Practical Nurse (LPN) on 8/31/12 and the resident was considered to be low risk. On 9/1/11 on the 7:00am-3:00pm shift a NN documented a new order from the MD for an in house psychological evaluation. A Social Service Referral form was completed on 9/1/11 documenting the resident expressed thoughts of suicide to family and staff. The Social Work Assistant documented that she met with the resident who does not recall expressing suicidal thoughts or intent. NN's on 9/3/12 documented that the resident stated "I'm gonna kill myself". A suicide risk assessment (SRA) was not completed. On 9/6/12 a SRA was completed and the resident was placed as low risk. The NN documented the resident stated she did not remember any threats, but would tell staff if she wanted to commit suicide. The resident was placed on 15 minutes checks. A psychological services diagnostic screening form completed on 9/9/11 documented that the resident made suicidal ideations earlier in the week and that the family stated that the resident had a suicide attempt years ago with pills. The psychologist (PHD) documented the resident had severe cognitive impairment and does not meet the criteria for counseling. The resident continued with behaviors October 2011, November 2011 and December 2011. The behaviors included, verbally aggressive, crying and non-compliant, up and down from bed, refusing meals being demanding , and swearing at staff. A NN on 12/28/11 documented the resident stated that she was afraid, but could not articulate why. A NN on 1/3/12 at 4:30 pm, documented that the resident was very upset and demanding to speak with her family, while on the phone with family she stated "If you don't come and get me right now I'm going to slit my throat and die." Social Services came to speak with resident about her statement but all the resident had to say was that she had a plan. The resident was yelling at someone to open the door and when the person would not, the resident placed herself on the floor and played dead. The RN supervisor was called to do an assessment, and the resident stated she hit her head. The resident was later witnessed hitting herself in the head. A SRA was completed, unsigned and not dated, placing the resident at low risk. The MD on 1/4/12 evaluated the resident and new orders were noted. An order was received for a psychiatric evaluation and to start Xanax 0.5mg three times a day. On 1/5/12, a NN documented the resident was very demanding, ambulating unassisted, kicking the medication cart, and found turning her chair alarm off. On 1/5/12 the PHD saw the resident and noted that "the resident threatens self-harm as a way to express her emotional distress. Coping mechanisms are quite limited and behavior can be quite demanding. " On 1/6/12 the medication nurse saw the resident attempting to cut her left wrist with a knife, the nurse tried to take the knife from the resident with the assist of a CNA. The Resident resisted but eventually gave up knife. The RN notified the supervising RN and placed the resident on 15 minute checks, a 4cm red abrasion occurred from the knife. The MD was not notified. A written statement dated 1/6/12 at 9:00pm from CNA #1 documented " she helped the RN take the knife from the resident, and kept the resident in the dining room where she could see her. The resident continuously tried to take other residents knives and resume cutting her arm. The resident was very agitated and continued to state she wanted to go home and was violently pinching and smacking me. She even tried to find knives in the kitchen drawers. " The RN stated she was not aware of the facility policy for suicide precautions On 1/8/12 a nurse was reading the NN and found the entry that the resident attempted to cut self with knife. The DON was notified at this time and updated on the incident and they discussed interventions. At the conclusion of the call the interventions were documented to notify the MD of the attempt, to remove all sharp and harmful items from the resident's room, and to complete a suicide risk assessment. A SRA was completed on 1/8/12 and again the resident was placed at low risk. An undated and unsigned Suicide risk evaluation documented the resident stated" The lady in my room is going to be sorry when she wakes up and I killed myself". She was also stating "you can't watch me all the time you have to sleep." A NN, dated 1/9/12 at 9:00 am, documented the Resident continues with behaviors, The MD ordered Haldol and a behavioral unit evaluation. Orders were received to send the resident to the Emergency Department. A NN dated 1/10/12 at 12:50 pm documented that the Certified Nurses Aide(CNA) reported to the nurse while she was toileting the residents after breakfast, she noticed that the resident had a butter knife hidden under the blanket on her lap. The LPN stated the resident said " she wanted to cut her throat." Social Services(SS) was notified to come over and assess the resident. A SS note dated 1/10/12, untimed, stated "Called to assess resident re: verbalization of desire to inflect self-harm. The resident was found with a knife hidden under her blanket stating she wants to die and be with her parents. The resident stated she does not want to be here." The resident was placed on 1:1 and the MD ordered the resident be sent to the Emergency Department (ED). SRA completed and the resident was placed at high risk and sent to the ED. The NN from 1/10/12 through 1/18/12 documented that the resident continued to have weepy episodes. A NN, dated 1/18/12, documented the resident was found scratching lower arms and top of hands, stating I"m trying to make myself bleed, if I hurt myself I can go to the hospital and then go home." A NN dated 1/21/12, 7:00am -3:00pm shift documented that a CNA sat down next to the resident and noticed the resident had a knife on her lap. The knife was removed, the resident was very upset and stated that the knife was hers. A search of the resident's room was conducted to remove anything harmful. Also documented in the NN "the resident is already on precautions for suicidal ideations which include plastic silverware and 15 minute checks." The resident was again sent to the hospital for evaluation, and returned 1/21/12 on the evening shift. A NN dated 1/23/12 documented "a plan to send to Samaritan for evaluation/admission." The resident was sent out to the crisis center and admitted to the facility for 7 days. During an interview on 3/13/12 at approximately 2:00pm the Unit Manager LPN stated that she became aware of the situation when she came into work on Sunday 1/8/12, started reading the resident ' s NN, and found an entry that the resident attempted to cut self with a knife. The DON was called at that time and was updated on the incident and they discussed interventions. At the conclusion of the call the interventions were documented to notify the MD of the attempt, to remove all sharp and harmful items from the resident's room, and to complete a suicide risk assessment. A SRA was completed on 1/8/12 and the resident was placed at low risk. The LPN was asked why the resident was placed as low risk, and she stated that the incident occurred 2 days ago. During an interview on 3/14/12 at 11:30 am the DON stated that she was made aware of the incident on 1/8/12. She stated that she should have been made aware immediately on 1/6/12. During an interview on 3/15/12 at approximately 2:30pm the MD on call stated that he should have been called the evening of 1/6/12, the resident should have been placed on 1:1 supervision, and sent to the ED for an evaluation. During an interview on 3/15/12 at 3:00pm RN#1, stated and documented in the NN 1/6/12 that she was passing meds and observed the resident trying to cut wrist with a butter knife. She called a certified nursing assistant (CNA) for assistance to get the knife away from the resident. RN#1 stated she called the supervising RN#2 and made her aware. She was asked if she called the MD and she stated no. She stated she assumed the RN #2 would have done that. She was asked if the room was searched and harmful objects removed she stated no, I probably should have done that. Additionally, she was asked if a RN assessment was completed and she stated she did not do one, she was passing meds and assumed the other nurse did it. RN#1 stated she was not aware of the facility policy for suicide precautions. A written statement dated 1/6/12 at 9:00pm from CNA #1 documented " she helped the RN take the knife from the resident, and kept the resident in the dining room where she could see her. The resident continuously tried to take other residents knives and resume cutting her arm. The resident was very agitated and continued to state she wanted to go home and was violently pinching and smacking me. She even tried to find knives in the kitchen drawers. " The RN stated she was not aware of the facility policy for suicide precautions During an interview on 3/15/12 at approximately 4:00pm RN#2 stated that she did not call the MD, DON or do an RN assessment because she thought that RN #1 would do it. She was asked, as the house supervisor, if the facility policy was followed and she stated no a Suicide Risk assessment should have been completed at the time and the MD should have been called. RN#2 stated she was not aware of the facility policy for suicide precautions. Resident # 118: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented the resident was mildly cognitively impaired and had short and long term memory mildly decreased. The hospital discharge summary dated 6/24/11 documented the resident needed 24 hour supervision to provide setup for activities of daily living, had explosive behaviors and should have with no access to dangerous objects. The resident showed a decrease in short term memory and impulsivity with decreased concentration. The nurse's notes (NN) dated 2/25/12 at 6:30 pm," resident daughter #2 called and left message with medication nurse that this afternoon she gave resident a knife and some donuts." The nurse entered the residents room and asked for the knife. The resident said "Leave me the hell alone. You ain't getting my knife." The supervisor was made aware. At 7:45pm the nurse asked the resident again for the knife and the resident stated "get out now God damn you." At 9:45pm the nurse entered the resident's room and the resident stated "Did you come to do my treatment, just do that and then leave I know what you're trying to get. NN at 11:00pm documented the medication nurse was made aware and the resident requested and received a beer at 8:00pm. The next NN is dated 2/28/12 at 11:05am, the Director of Nursing (DON) and the Unit Manager (UM) met with the resident to discuss the knife. The resident repeatedly would not give up the knife. The DON educated the resident that other residents on this unit could be at risk if they were to get ahold of it. The resident stated he would give it to the Licensed Practical Nurse (LPN) when he was done using it. The DON updated the LPN, Social Services (SS) and directed them to ensure the knife was obtained by the end of the shift. A SS note dated 2/28/12 documented under Action Taken: 2/25 writer called family to educate on why no "sharps" are allowed on the unit. SS suggested to DON/Administrator that nursing conduct a search of the room and remove the knife for the family to pick up. Writer called daughter/guardian #1, who stated she had already educated family. She stated she had already spoke to a nurse this weekend and was told the knife was "already removed", the daughter stated she was unhappy that he still had it and daughter #1 stated she would like a follow up of the knife issue. A review of the Comprehensive Care Plan (CCP), untitled, with the problems/needs listed as: impaired problem solving, limited insight/judgement, sad or anxious mood, problems with relationships and non compliance with health issues. The CCP documented that the resident will have fewer episodes of problem behaviors. There was no documentation of the incident involving the knife on 2/25/12. A review of the resident's care card (used by the CNAs to provide care to the resident), last updated 2/9/12 documented under Special Instructions: when the resident is out of his room for breakfast check his room for old food and remove every day. There was no update to check resident's room for items that may place the resident at risk for his safety. An Accident and Incident Report was requested of the DON and Administrator and none was provided. During an interview on 3/15/12 at approximately 1:30 pm the UM stated the resident did not have the knife. They kept it in the medication cart. The Surveyor asked to see the knife and there were two six inch serrated steak knives in a cup for this resident. The LPN stated that they give it to him when he asks. He was unsupervised with it's use on a locked dementia unit. During an interview on 3/15/12 at 3:30pm the DON and the Administrator stated that they were unaware of the situation the date it occurred 2/25/12. There was no communication over the weekend that the resident still had a knife. It was not until Tuesday 2/28/12 that the knife was removed from the resident. They stated that a thorough investigation was not completed because they considered it closed because they thought the knife had been removed. The continued use of the knife unsupervised was discussed. The DON stated that the resident really did not belong on the dementia unit, he is only there for his behaviors. Resident # 75: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs)/ Nurse Aid Care Card most recently updated on 2/8/12 documented the resident's room needed to be checked daily for items which may be sharp and /or cause harm to the resident or to others, that is pins/needles/scissors, etc and remove immediately. The CCP for behaviors dated 11/10/11 documented a problem statement as the resident picks at "dry skin" on her hands with her fingernails and other items (pins, brooches). The goal was the resident would not experience complications or infections secondary to picking at her hands. Approaches for this problem included: remove non-personal sharp objects, educate/remind of dangers related to behaviors, monitor hands daily for signs/symptoms infection/complications, medications per physician, social service referral as needed and 15 minute checks as needed. A Psychological Services note (PSN) dated 10/6/11 documented under the area of Mood/Cognition/Behavior; that the presenting and ongoing symptoms are, adjusting to illness/decrease in function, agitation, attention seeking (demanding), aggressive (verbal), inappropriate behavior, isolation/withdrawal, memory/cognition/decision making, non-compliance with medical care and easily annoyed/short tempered. The PSN further documented the resident will begin the session fairly benignly but agitation level escalated quickly. The resident will state over and over "I hate it here" and does not respond to validation or redirection. The PSN further documented it is unlikely the resident will derive any more benefit from psychotherapy. The psychology provider discharged the resident 10/6/11. Nurse's notes dated 11/10/11 documented the resident was picking at her hand with a pin on a broach. The nurse had taken the pin away then gave it back. The resident was upset and slapped the nurse across the face. Nurse's notes from 11/10/11 further documented the resident was approached about a previous incident at which time the resident stated she was upset and packed her jewelry away. Another nurses's note from 11/10/11 further documented that the resident was reassured that the staff did not want to have to take her items away but the staff were also concerned for her that she would not get an infection in her hand. The resident seemed to understand but she said she had been doing this for "years" because of "dry hands" and never had an "infection yet" and she began to get upset again. The resident was left on 15 minute checks to continue to assure safety. Nurse's notes dated 11/13/11 documented that the resident continued on 15 minute checks for safety and that the resident was noted to be sticking her hand with a safety pin. The nurse's note also documented that when approached the resident hid the pin and wouldn't let the nurse look for it (the safety pin). Nurses note dated 12/1/11 documented that a safety pin was removed from the resident's room while she was in the bathroom with the pin being under the pillow. The nurses note from 12/1/11 further documented that the resident was seen picking at her left hand moments before. Nurses note from 12/16/11 documented that one safety pin was removed from the resident ' s room. The Physician's Progress Note dated 11/11/11 documented the major issue of concern to the nurses was that the resident continues to pick at the skin of her hands with certain pins which have been removed from the room, but the resident has a couple of brooches that have needles on them. The Physician Progress note dated 11/11/11 documented the following that this behavior does not sound like a classic obsessive compulsive behavior. The resident has cream for use on these areas. These areas (skin of left hand) are observed every day. Since the nurses check these areas every day to make sure they are not getting infected and this does not bother the resident, I think we can observe and follow. If her behavior gets worse we could then consider behavior modification attempts with medications. During an interview on 3/14/12 at 12:40 pm the Registered Nurse Manager (RNM) stated that the resident was using the pointed ends of safety pins and brooches with pins to stick the skin on her left hand. The RNM stated the resident has a condition which seemed to make her want to stick the skin of her left hand. During an interview on 3/15/12 at 3:30 pm the Certified Nursing Assistant (CNA) stated that the resident will at times pick at her hands with safety pins or the pin of a brooch. The CNA stated that the care card (CCP for Activities of Daily Living) directed nursing staff to remove sharp items immediately when found. During an interview on 3/15/12 at 11:50 pm the Director of Nursing (DON) stated she was aware of the resident continuing to have possession of her brooches with the pins. The DON stated the resident was allowed to continue to have possession of the broaches as these (the broaches ) were the resident's personal property. Resident #6: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have severe cognitive impairment. The Policy and Procedure (P&P) for Oxygen Administration with a revision date of 2/2012, documented that oxygen was to be applied to residents according to physician orders. Maintenance was to check the storage and safety of oxygen cylinders, and oxygen supply daily. Nurses were to document on the Medication Administration Record (MAR) how much oxygen a resident was to receive every minute, how often, for how long and how they were to receive the oxygen. A physician's orders [REDACTED]. The Medication Administration Record (MAR) dated 2/2012, documented that the resident was to receive O2 at a rate of 3L every minute through a mask and was to have humidity. A Resident Complaint Form dated 2/15/12 at 8:30 am, documented that the resident reported to Licensed Practical Nurse (LPN) #1 that he had asked LPN #2 to check his O2 at 6:40 am and to get him some more O2. He asked LPN#2 again at 7:00 am and he still did not get the O2. At 7:00 am, the resident asked LPN#1 to get him O2, which she did. The resident stated that he felt like he waited too long to get O2. There was a note written on the Complaint Form that on 2/17/12 that Registered Nurse Manager (RNM) #1 was going to obtain a statement from LPN#2. There was also a note written on the form that the issue was, "Resolved per team," on 2/17/12. The complaint form was signed by the resident, LPN#1 and by the Social Work Assistant (SWA) #1. An Employee Statement written by LPN#2 and dated 2/15/12 at 6:45 am, documented that Certified Nursing Assistant (CNA) #4 came to her that morning and told her that the resident had stated that he ran out of O2. She told CNA#4 to ask the resident to meet her by the O2 room, which he did and she replaced his O2 tanks. During an interview on 3/14/12 at 1:10 pm, SWA#1 stated that LPN#1 filed the complaint on behalf of the resident on 2/15/12. On 2/17/12 she gave the complaint to RNM#1 and sent copies to the Director of Nursing (DON), and the Administrator, and documented on the complaint form that the issue was resolved because this was a nursing issue and by giving it to the RNM she thought it would be handled. She stated that she did not interview the resident or any of the staff involved in the complaint. During an interview on 3/14/12 at 1:13 pm, Certified Nursing Assistant (CNA) #5 stated that when she gives care to a resident with O2 she looked to make sure there was O2 in the tank. If the tank was empty she would tell a nurse and the nurse would get a new tank for the resident. She stated that she had never been instructed to monitor an O2 tank and that she was not aware of any interval that the O2 tanks were to be monitored. She could not recall if she had ever found this particular resident's O2 tanks empty. During an interview on 3/14/12 at 1:22 pm, Certified Nursing Assistant (CNA) #6 stated that she looked at O2 tanks anytime she saw one and if it was empty she would tell a nurse so a new tank could be applied to the resident. She stated that she had never been instructed to monitor an O2 tank and that she was not aware of any interval that the O2 tanks were to be monitored. She could not recall if she had ever found this particular resident's O2 tanks empty. During an interview on 3/14/12 at 1:56 pm, the DON stated that she knew about this complaint and believed that it had been handled by a part time nursing supervisor. She stated that the nurses on the night shift were supposed to change any O2 tanks that had a low volume in them, and then report the status of the O2 tanks to the day shift nurses at change of shift. During the course of the day, the nurses check the volume of the O2 tanks in use with residents, but there was no set interval for checking the tanks and no place to document the checking of the tanks. There should never have been an empty O2 tank on a resident and it was a standard for nurses to know how much O2 was in tanks in use with residents. During an interview on 3/15/12 at 10:34 am, Licensed Practical Nurse (LPN) #4 stated that when she first comes onto shift she was in the habit of doing rounds to check where her residents were, make sure they were positioned safely and that she would check to make sure residents on O2 had O2 in their tanks and that the O2 was running. She stated that in the past week she had found residents who were supposed to be on oxygen and either their tank was empty or just was not turned on. She did not realize this needed to be reported and that she just corrected the situation by starting the O2 or replacing an empty tank. LPN#4 also stated that when the O2 is on the MAR, it was to be signed once a shift that the resident was receiving O2 as ordered. She was not aware of any requirement for monitoring the O2, just that if one was low or empty, it needed to be replaced. During an interview on 3/15/12 at 11:45 am, LPN #3 stated that she had come across empty O2 tanks on residents who were supposed to be receiving O2. She had not found any of those residents to be in respiratory distress, so she retrieved a new tank and restarted the O2. LPN#3 stated that she was not aware of any policy that outlined an interval in which the O2 tank volumes were to be checked and that there was no place to document that the O2 tanks had been monitored or checked. She stated that at the beginning of a shift she signed on the MAR that a resident was receiving O2 and through the course of a day, it was her practice to glance at any O2 tank that was in use on a resident, but that there was no systematic checking or monitoring. During an interview on 3/15/12 at 12:13 pm, Registered Nurse (RN) #2 stated that she had occasionally found this resident and others connected to an O2 tank that was empty. She stated that she did not normally report empty O2 tanks or complete an Incident Form or Medication Error Report because she had not found any of the residents in respiratory distress. She stated that she tried to look at O2 tanks that residents were on throughout the day, but that if she did not happen to see any particular resident during the course of the day she would not seek them out to check the O2 level in the tank. She was not aware of any particular interval that the tanks were to be monitored and that she would have to rely on the resident or other staff to report to her if an O2 tank was low or empty. During an interview on 3/15/12 at 3:01 pm, LPN#5 stated that at midnight on 3/12/12, this resident came up to her and stated that he did not feel like he was getting O2. When she checked his O2 tanks (the resident had two O2 tanks on the back of his wheel chair), both were empty so she put him on a new tank. She stated that she did not document or report this because it was just a matter of his O2 tank running empty and she replaced it. The resident was not in respiratory distress at the time. LPN#5 stated that she had not been oriented to monitoring the O2 tanks in use on residents and that she was not aware of any standard for frequency of checking the tanks or monitoring the tanks other than signing the MAR at the beginning of the shift that the resident was on O2. During an interview on 3/15/12 at 10:58 am, the DON stated that there was no policy which addressed monitoring O2 tanks in use by residents. The DON reviewed the P&P for Oxygen Administration and stated that maintenance was responsible for ensuring that there was enough oxygen cylinders in the facility for the residents but was not responsible for checking the volume remaining in a tank when in use by a resident. She also stated that this resident should never have an empty O2 tank because waiting even 20 minutes as alleged in the complaint could have been a high risk for injury for him because he was very delicate with his lung disease. 10NYCRR415.12(h)(1)

Based on observation, record review, and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection for 2 ( #'s- 30 and 95 ) of 32 residents, and finding #1, reviewed during the extended recertification survey and a complaint investigation (Case #NY 946). Specifically, interviews with facility staff confirmed that one electric razor had been used to shave multiple residents without properly disinfecting the razor between residents, and that blood had been observed on the razor on at least one occasion. Furthermore, on numerous occasions, dietary staff have reported that food trays had been returned to the kitchen with blood-contaminated gauzes and used lancets (sharp, needle-edged devices used to draw blood from residents) which were not appropriately disposed of in accordance with acceptable infection control standards. Additionally, the facility did not ensure that staff washed their hands between resident care. These practices had the potential to effect all 122 residents in the facility. This resulted in no actual harm with potential for serious harm which is Immediate Jeopardy to the health and safety of the residents. This is evidenced by: Resident #30: The facility failed to ensure that blood-contaminated gauzes and used lancets were appropriately disposed of in accordance with acceptable infection control standards. The P&P for Needle/Syringe Disposal with a revision date of 2/2012, documented that after use, all needles were to be immediately discarded in designated sharps containers located on each medication cart and in the medication room. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] , assessed the resident to have intact cognition. A printed e-mail provided by the Dietary Services Supervisor (DSS) that had been sent to multiple facility staff members, and dated 12/13/11 at 1:50 pm, documented that meal trays had been returned to the kitchen with bloody gauze on the trays. Staff were to ensure that only dietary items were on the trays when being returned to the kitchen. This had been brought to the attention of the department heads and senior nursing staff and was a serious concern that needed to be stopped immediately. An Employee Statement dated 3/4/12 at 9:10 am, documented that an uncapped needle and bloody gauze was found on a breakfast tray. The tray was taken to the Unit #2 Registered Nurse Manager (RNM) #2. The Statement also documented that more than one written statement had been completed concerning this issue and a memorandum had been circulated also. The statement was signed by Dietary Technician (DT) #1, an Assistant Cook who was the immediate supervisor working at the time of the incident, and by RNM#2. An Employee Statement dated 3/18/12 at 9:30 am, documented that another bloody gauze came to the kitchen on a meal tray. A nurse came to the kitchen and stated that a resident had put it on the tray and that nobody had been watching her. The nurse used a glove to pick up the bloody gauze and placed the gauze in the kitchen garbage can. The Statement was signed by DT#1. During an interview on 3/14/12 at 9:06 am, the DSS stated that he had found a bloody gauze on a meal tray on one occasion and spoke to the ICRN about this issue. He stated that it had been happening for months and kitchen staff had found needles, lancets and/or bloody gauzes on meal trays at least five or six times in the past six weeks. In his discussion with the ICRN, it was decided that if kitchen staff found such items, they were to go to the nurse on the unit and the nurse was to go to the kitchen to remove the item. During an interview on 3/14/12 at 11:54 am, the ICRN stated that when she learned of the issue of needles, lancets and/or bloody gauzes found on meal trays that had been returned to the kitchen, she asked that kitchen staff notify her or the DON. She stated that she believed that residents were getting fingerstick blood sugars done on them and would hold the gauze on their finger until it stopped bleeding and would then put the gauze on the tray. She stated that staff should have been removing the gauze before returning the tray to the kitchen and that nurses should have been putting needles and/or lancets in the sharps container to dispose of them properly. During an interview on 3/19/12 at 12:51 pm, the DON stated that a couple months ago at an Interdisciplinary Team (IDT) meeting, a DT had reported that a bloody gauze on a tray had gone to the kitchen. She told RNM#3 to address the issue with the staff on Unit#2, and not to let it happen again. The DON stated that there had been no other education or follow-up and that she was not aware of any further occurrences. She stated that she had never heard that needles or lancets had been found on trays in the kitchen and that the first time she heard of this was during this recertification survey. She was not aware of any conversation between kitchen staff and the ICRN. During an interview on 3/19/12 at 1:03 pm, DT#1 stated that needles, lancets and bloody gauzes found on meal trays that had been returned to the kitchen had been going on for months and that any time she has found these items it had been reported to the DSS. She stated that she had completed at least six reports concerning this issue and gave copies to the DSS and the ICRN. DT#1 also stated that she has specifically found a bloody gauze on this resident's tray after returning to the kitchen from the dining room. During an interview on 3/19/12 at 1:16 pm, DT#2 stated that she had found bloody gauzes and pills on meal trays when they had been returned to the kitchen. She stated that she always reported this to the DSS. During an interview on 3/19/12 at 2:23 pm, the Administrator stated that this issue had come up before but was not aware of this involving more than one nurse or one resident. During interview on 3/19/12 at 3:05pm, CNA#10 stated that this resident eats in the dining room at a table assigned to two other residents. She also stated that she has seen residents receiving fingerstick blood sugar tests being performed by nurses in the dining room with other residents around. During an interview on 3/19/12 at 3:51 pm, the ICRN stated that this issue involving needles, lancets and/or bloody gauzes being found on meal trays returned to the kitchen had been going on at least since 9/2011. During an IDT meeting in 2/2012, the DSS reported that the issue was continuing. She told the DSS that if kitchen staff could identify whose tray the item had been found on, they should report this to her and she would address it with the nurse responsible. The ICRN stated that this was a potentially serious infection control problem, especially if a needle, lancet or bloody gauze had come from a resident infected with a communicable disease. The ICRN stated that if staff were leaving lancets or other needles on trays after using them on residents, this had the potential to effect other residents. She gave as an example Resident #91 who often picked up items belonging to other residents and put them on her own meal tray. The ICRN stated that nurses were supposed to dispose of needles and lancets in the sharps container, and bloody gauzes were supposed to be handled with gloves and put in a red biohazard bag in the soiled utility room. Resident #95: The facility failed to ensure that electric razors were not used to shave multiple residents without properly disinfecting the razor between residents. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severe cognitive impairment. The Policy and Procedure (P&P) for Shaving Resident - Electric Razor dated 6/2010, documented that a resident was to have their own razor and that another resident's razor could not be used. If a resident did not have an electric razor, a safety razor (a manual razor with a blade) was to be used. The Activities of Daily Living (ADL) / Nurse Aide Card Card (used by staff to know what care each resident required) dated 10/24/11, documented that the resident required the extensive assistance of a staff member for personal hygiene. During an observation on 3/19/12 at 3:09 pm, Certified Nursing Assistant (CNA) #8 was observed coming out of this resident's room carrying an electric razor. There was no resident name on the electric razor. During an interview on 3/19/12 at 3:09 pm, CNA#8 stated that the resident was shaved and the razor was being returned to the utility room. The electric razor did not belong to any one particular resident and was the razor that was used to shave female residents .CNA#8 stated that the razor was not new and that it had been in use for several months. The razor was cleaned in between uses with a rubbing alcohol wipe. The CNA stated that he did not see this as an infection control problem because the razor was cleaned between uses. CNA#8 stated there was direction not to use a razor on more than one resident, and that other CNAs had used the same razor on multiple residents and that it just needed to be cleaned with an alcohol swab between uses. During an interview on 3/19/12 at 3:41 pm, CNA#9 stated that a backup electric razor was kept in the dirty utility room to be used on residents whose electric razor may be broken or if the battery was dead. CNA#9 stated that other staff stated it was okay to use the razor on more than one resident as long as it was wiped off with an alcohol swab between uses. CNA#9 stated that the razor was not used frequently and that it had not been checked for blood in or on the razor because it was an electric razor and the blade did not come in direct contact with the resident's skin. During an interview on 3/19/12 at 3:44 pm, CNA#10 stated that each unit kept backup electric razors in the dirty utility rooms for use by whichever resident needed it. CNA#10 stated that, it was okay to share an electric razor between residents as long as it was cleaned with an alcohol swab between uses. The CNA stated that there was blood on the electric razor on one occasion because the razor must have nicked a small blemish or pimple. CNA#10 stated that the razor was wiped with an alcohol swab to remove the blood. During an interview on 3/19/12 at 3:51 pm, the Infection Control Registered Nurse (ICRN) stated that staff were not supposed to share electric razors between residents. She stated that it did not surprise her that staff were sharing electric razors because the level of education in the facility was not up to par. She stated that she had never specifically told staff that electric razors could not be shared between residents, but that she had only been in her current role at the facility for about two months. The ICRN also stated that a 70% alcohol swab was not the appropriate solution to disinfect an electric razor between uses, especially if blood had been present on a razor. During an interview on 3/19/12 at 3:59 pm, the Director of Nursing (DON) stated that she was not aware that staff were sharing an electric razor between residents and that there was no system in place to properly disinfect razors between use because that was not to be done. She stated that the P&P clearly documented that razors were for use by only one person and were not to be shared. During an interview on 3/19/12 at 4:05 pm, the Administrator stated that he was not aware that staff were sharing an electric razor between residents and that this should not have been happening. Finding:# 1: The P&P for Hand Hygiene: Hand Washing and Hand Rubs with a revision date of 2/2012, documented that hand hygiene was to be performed upon and after contact with residents with intact skin and after contact with inanimate objects soiled or in the immediate vicinity of a resident. Hand hygiene was also supposed to be performed before leaving a resident's room where environmental tasks had been performed such as bed making, straightening dresser drawers or closets or handling resident belongings that may have been contaminated in any way. Hand hygiene was also to be performed before and after entering isolation precaution settings. During an observation on 3/12/12 at 11:50 am, Unit Assistant (UA) #1 walked into a resident room that had a contact precaution sign on the door. The UA did not wear gloves, handled several items in the room, and straightened the blankets on the bed that a resident was resting in. The UA left the room and went into another resident's room and rearranged items in the room. UA#1 did not wash her hands between rooms. During an interview on 3/12/12 at 11:56 am, UA#1 stated that she did not make contact with the resident so she did not think she needed to wash her hands. During an interview on 3/14/12 at 11:54 am, the ICRN stated that staff were supposed to wash their hands before and after resident contact and when going in and out of resident rooms, and especially should have washed hands after being in a room with a contact precaution in place. 10 NYCRR 415 .19 (a) (b)

Based on observation, record review and staff interview, the Administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident, during a extended recertification survey and complaint investigations (NY 984, NY 139, NY 156, NY 946, NY 392). The Administrator failed to have systems in place to ensure thorough investigations were performed, Accidents and Incidents were recorded and investigated and Infection Control Policies were followed. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to residents health and safety. This is evidenced by: Refer to F 225 Investigations, scope/severity = L: This a Repeat Deficiency from recertification surveys on [DATE] and [DATE] Specifically, the Administration failed to thoroughly investigate and report as needed accidents and incidents and protect the residents and staff from potential harm. During an interview on [DATE] at 4:30 pm, the Administrator stated that the Director of Nursing (DON) was responsible for ensuring that all investigations were thoroughly completed and reported as necessary. He stated that there was an Interdisciplinary Team (IDT) meeting every morning Monday through Friday, and the 24 Hour Reports were reviewed at that time. He stated that the 24 Hour Reports should clue management staff in to issues that may have come up and what may require an investigation. The Administrator stated that he attended the meetings but did not read the 24 Hour Reports himself. He stated that he was not particularly involved in investigations other than the DON summarizing the results of various investigations during the IDT meetings. He also said that the staff at the facility knew that they were supposed to immediately report allegations of abuse and neglect and that there was not much that management or administration could do if the staff did not do the right thing and did not notify them of allegations. When asked about the role of the Social Work Assistants (SWA) in investigating resident complaints, the Administrator stated that the SWAs notified him after a case was resolved. He stated that there was a Social Work consultant under contract with the facility and that the consultant should have reviewed investigations conducted by the SWAs. When asked who was the supervisor for the Social Services Department, the Administrator stated that he was. The Administrator also stated that he had never spoken to or met the consultant Social Worker, did not know how often she came to the facility and did not know when the last time she had been in the facility. He also stated that he did not know that the consultant Social Worker's contract with the facility had expired. Refer to F520, Quality Assurance, scope /severity L Specifically, the Administrator failed to ensure the Quality Assurance Program identified issues that have the potential to cause serious harm to residents. During an interview on [DATE] at 4:30pm, the DON and the Administrator stated that the QA committee met once but the QA program was not effective and had failed. They stated that an effective QA program had not been established to effectively identify the root cause of incidents so that corrective actions could be taken to protect residents from potential harm. They stated that communication was lacking between staff and management. The DON stated that the QA committee did not review investigations that they were reviewed in IDT and signed off by her and the Administrator. The DON also stated, in the presence of the Administrator, that Incident and Accident (I&A) forms were not reviewed by the QA committee either and that they were reviewed in IDT meetings. Refer to F323, Accidents and Supervision, scope/severity L Specifically, the Administrator failed to provide adequate supervision and a safe environment to ensure the residents were not at risk for injury. During an interview on [DATE] at 4:30pm the DON and the Administrator stated that the lack of communication between staff and management is causing a major problem and affecting all the residents in the facility. The Administrator stated that he was not aware that there was no Policy and Procedure related to monitoring oxygen tanks. He also stated that monitoring oxygen was a basic nursing function and that he could not understand why professionals would not do the basics without constant supervision. Refer to F441, infection control, scope/everity L During an interview on [DATE] at 12:51 pm, the DON stated that a couple months ago at an Interdisciplinary Team (IDT) meeting, a DT had reported that a bloody gauze on a tray had gone to the kitchen. She told RNM#3 to address the issue with the staff on Unit#2, and not to let it happen again. The DON stated that there had been no other education or follow-up and that she was not aware of any further occurrences. She stated that she had never heard that needles or lancets had been found on trays in the kitchen and that the first time she heard of this was during this recertification survey. During an interview on [DATE] at 3:59 pm, the Director of Nursing (DON) stated that she was not aware that staff were sharing an electric razor between residents. The DON stated that there was no system in place to properly disinfect razors between use because that was not to be done. She stated that the policy and procedure clearly documented that razors were for use by only one person and were not to be shared. During an interview on [DATE] at 4:05 pm, the Administrator stated that he was not aware that staff were sharing an electric razor between residents and that this should not have been happening. 10 NYCRR 415.26

Based on record review and staff interview, the facility failed to have a Quality Assurance (QA) program that readily identified issues that have the potential to cause serious harm to residents. The QA program failed to effectively identify issues that established and maintained an infection control program designed to provide a safe ,sanitary and comfortable enviroment. Specifically, interviews with facility staff confirmed that one electric razor had been used to shave multiple residents without properly disinfecting the razor between residents, and that blood had been observed on the razor on at least one occasion. Furthermore, on numerous occasions, dietary staff have reported that food trays had been returned to the kitchen with blood-contaminated gauzes and used lancets (sharp, needle-edged devices used to draw blood from residents) which were not appropriately disposed of in accordance with acceptable infection control standards. Additionally, the QA program failed to identify issues that the facility was free from accident hazards and that the residents received supervision to prevent accidents. Specifically, the facility did not remove items (brooches/ pins/ knives) which had the potential to injure residents, the QA program did not have a procedure in place to monitor residents oxygen tank levels. Additionally, the facility did not provide adequate supervision of a resident with known suicidal ideation with attempts. The QA program failed to ensure that each resident was provided a safe environment that was free from abuse and neglect, and that allegations of abuse and neglect, and medication errors were thoroughly investigated, and reported as needed to the state agency and the Administrator of the facility during an extended recertification survey. Specifically, QA program failed to ensure the facility investigated events of resident self mutilation, medication errors, allegations of verbal abuse and neglect. Also, the QA program failed to ensure the facility investigated why a six inch serrated knife remained in the possession of a resident with cognitive impairment and who resided on a locked dementia unit. The facility failed to ensure that effective Quality Assurance systems were in place to monitor the effectiveness of facility policies and practices related to thorough investigations into allegations of suspected abuse and injuries. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to the health and safety of the residents. This had the potential to effect all 122 residents in the facility. The findings were as follows: During an interview on 3/20/12 at 4:30pm, the DON and the Administrator stated that the QA committee met once but the QA program was not effective and had failed. They stated that an effective QA program had not been established to effectively identify the root cause of incidents so that corrective actions could be taken to protect residents from potential harm. They stated that communication was lacking between staff and management. The DON stated that the QA committee did not review investigations that they were reviewed in IDT and signed off by her and the Administrator. The DON also stated, in the presence of the Administrator, that Incident and Accident (I&A) forms were not reviewed by the QA committee either and that they were reviewed in IDT meetings. 10NYCRR 415.27(a-c)

Based on medical record review and staff interview the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for three (Resident #1, 3 and 4) of six residents reviewed during a partial extended survey ( Case # NY 0299). Specifically, the facility failed to obtain laboratory test results in a timely manner and failed to report an abnormally high sodium, blood urea nitrogen and blood sugar levels promptly to the physician. The laboratory test was obtained on [DATE]. On [DATE] the resident had a decline in condition and was transferred to the hospital and admitted with the [DIAGNOSES REDACTED]. The resident later expired at the hospital. On [DATE], the test results from [DATE] were found in the physician's (MD) communication book. It was unknown as to when the results were received by the facility and placed in the book. Additionally, the facility failed to notify the physician of a sub-therapeutic [MEDICATION NAME] level and an elevated blood glucose level and potassium level. This resulted in actual harm for Resident #1 and potential for serious harm for all residents that is Immediate Jeopardy to the health and safety of residents and Substandard Quality of Care. This is evidenced by the following: Resident #1 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident to have had severe cognitive loss. The MD's sixty day renewal orders dated [DATE], documented orders for [MEDICATION NAME] ( a diuretic medication to reduce fluid retention ) 20 milligrams (mg) once a week on Mondays, Sodium [MEDICATION NAME] ( [MEDICATION NAME], used to lower potassium levels in the blood) 30 Grams (gm) by mouth everyday. The same orders included an order for [REDACTED]. The Nurse's Notes (NN) dated [DATE], documented the resident was seen by the MD for a routine sixty day visit. There was no documentation that the resident showed symptoms of an acute illness. The MD's Progress note dated [DATE], documented that the resident was seen for a routine visit. The note documented that the residents intake by mouth remained somewhat problematic. The note further documented that the resident had some upper respiratory infection symptoms which "seemed to be settling down" and the resident appeared to be well hydrated. The laboratory report dated [DATE] documented a sodium level of 153 (,[DATE]), glucose 185 (,[DATE]), Blood Urea Nitrogen (BUN) of 28 (,[DATE]),creatinine (measures kidney function) of 2.4 (0XXX,[DATE].3), and carbon [MEDICATION NAME] 40 ( ,[DATE]). There was no evidence found that the MD had been notified of the laboratory results. The NN dated [DATE], ( no specified time was documented), documented that the Licensed Practical Nurse ( LPN) was summoned to the residents' room by the Certified Nursing Assistant (CNA). The resident was noted to be in respiratory distress, purse lip breathing ( is a symptom of respiratory distress when the oxygen exchange is impaired), and very pale. The vital signs were; blood pressure of ,[DATE], pulse rate 80, and respiratory rate 22. The oxygen saturation ( O2 Sat- used to measure the level of oxygen in the blood ) was 64 %( normal range in a well person runs above 95% ) on room air. O2 was applied and the Registered Nurse and MD were notified. An order was received to give a nebulizer treatment( used to open the air tubes in the lungs) and to transfer the resident to the emergency room . The next NN dated on [DATE], (again no time was specified when the note was written), documented that the resident was admitted to the hospital with [REDACTED].) The hospital History and Physical (H&P), dated [DATE] at 8:46 pm, documented the Laboratory Data in the emergency room was as follows; Glucose 260, BUN of 41, creatinine of 2.9, sodium of 156, potassium of 2.7 ( 3XXX,[DATE].1). The [DIAGNOSES REDACTED]. The documented plan was for the resident to be admitted to the intensive care unit. On [DATE] a family member requested a meeting with the nursing staff at the nursing facility to review the resident's medical record. During this meeting it was discovered that the results of the laboratory test obtained on [DATE] was not available in the medical record. The laboratory results were located on the nursing unit in the MD's communication book. A undated handwritten notation " patient in hospital" was documented on the report. During an interview on [DATE] at 10:00 am, the Assistant Director of Nursing (ADON) stated that on [DATE] the resident's family member came to the facility to speak with the Registered Nurse Manager (RNM). The ADON stated that she was on the unit and overheard the family member inquiring about laboratory results that were obtained on [DATE] and wanted to know why the resident was receiving [MEDICATION NAME] on a routine basis. The ADON stated that she began to look into it and found the laboratory report in the MD's communication book. She stated that during her investigation and interview of staff, she was not able to determine when, or who placed the report in the MD's book. She stated that it was obvious that the MD had not been made aware of the results. During an interview on [DATE] at 11:00 am, the MD stated that he was not notified of the laboratory results obtained on [DATE]. He stated he became aware of the results after finding the report in the resident's chart on [DATE]. He stated that if had he been notified he would have discontinued the diuretic treatment and hydrated the resident by means of intravenous therapy. He stated that even though the resident suffered from co-morbidities, the laboratory results should had been addressed and the resident should have been treated. During an interview on [DATE] at 3:30 pm, the LPN stated that she had not finished receiving report from the off going shift when the CNA's summoned her to the residents' room. She stated that she had not been on duty for several days, and after the resident was sent to the hospital she asked the CNA's if the resident had been ill. She stated that she was told by one of the CNA's that the resident " had not been his usual self for the past few days prior to this acute episode and she (the CNA) reported it to the RN". During an interview on [DATE] at 3:45 pm, the Registered Nurse Manager (RNM) stated that she was not aware that a laboratory test was obtained on the resident on [DATE]. She stated the facility has no procedure for reconciling laboratory test, but she could look results up in the computer. The RNM stated she does not recall seeing the results from [DATE] and that typically the results for a BMP would come back the same day. She stated she did not see the results from [DATE] until [DATE], when she went to the computer to check on the resident's hospital status. The RNM stated that the abnormal results should had been received by the evening shift on [DATE] and a nurse should have notified the MD, but she did not know why the results were delayed in being received or reported to the MD. The RNM further stated that the resident was having loose bowel movements on [DATE], but she was not that concerned because other residents on the unit were ill with a [MEDICAL CONDITION] illness. During an interview on [DATE] at 10:25 am, the Director of Nursing (DON) stated that the nurse's were not always marking off when the laboratory results were received, therefore there was no way to determine if the results were received and reported to the MD. She stated that when the laboratory test is obtained it should be recorded on the 24 hour report sheet. When the test results are received by fax the nurse is to mark off on the report sheet that the results were received and reviewed. During an interview on [DATE] at 11:10 am, the Administrator stated that he was not aware of any major problems with laboratory services and that the procedure being followed by the nursing staff was an unwritten policy (not in print), but was well known by many of the nursing staff. When asked if he was aware of any delays in reporting laboratory test results to the physician's, or problems with laboratory test not being performed as ordered, he stated he was aware of some problems,but was not aware of the depth of the problem. Resident # 3 The facility did not promptly report a sub- therapeutic (low level) [MEDICATION NAME] (a heart medication used to strengthen the beat and lower the heart rate) level to the physician. The resident was admitted to the facility on [DATE] with a readmission date of [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to have severe cognitive loss. The Readmission History and Physical, dated [DATE], documented that the resident was admitted to the hospital on [DATE]- [DATE]. During this hospitalization the resident was started on [MEDICATION NAME] for the treatment of [REDACTED]. The physician's orders [REDACTED]. The laboratory report dated [DATE], documented a [MEDICATION NAME] level of 0.8 (0XXX,[DATE].0). During an interview on [DATE] at 3:40 pm, the physician stated that he would not have been to concerned with the low level, but would have expected to be made aware. He stated if he was made aware of the result he most likely would have had the level rechecked in month ' s time. Resident # 4 The physician was not promptly notified of an elevated blood glucose and potassium levels. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have severe cognitive loss. The laboratory report dated [DATE] documented a potassium level of 5.7 (3XXX,[DATE].1). and a blood sugar level of 178 (,[DATE]). The physician's progress notes and nurse's notes were reviewed and there was no evidence found that the physician was made aware of these results. The report did not include documentation as to when the report was received or if the physician was made aware. During an interview on [DATE] at 3:40 pm, the physician stated he would have expected to be notified of the results. He stated that he or the other physician would have at the least initialed the report if either one reviewed it. During an interview on [DATE] at 4:40 pm with the ADON and the Quality Assurance (QA) Nurse, the ADON stated that she would expect all laboratory results to be reviewed by a nurse and the physician to be notified of abnormal findings. The QA nurse stated that laboratory reports are received everyday and the nurse should be reviewing the results. If blood results are abnormal and out of the range for the resident then the physician should be notified, otherwise the report would be signed off by the nurse and placed in the physician ' s communication book for physician review and sign off. 10NYCRR415.12

Based on observation, record review and staff interview, the administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for each resident, during a partial extended survey ( Case #NY 299). Specifically, the administrator failed to ensure that a written policy and procedure was in place for Laboratory Services that included a system to ensure the monitoring and tracking of laboratory testing, and the prompt reporting of laboratory results to the physician. The Administrators' failure to have an effective procedure in place to ensure that laboratory test were obtained as ordered, laboratory results were received in a timely manner, and the results were promptly reported to the physician placed all of the residents at risk. This resulted in actual harm for Resident #1 and a potential for serious harm to all residents that t is Immediate Jeopardy to residents' health and safety. This is evidenced by: Refer to Quality of Care-F 309 Scope/Severity L During an Interview on 4/21/11 at 10:00 am, the Assistant Director of Nurse's (ADON) stated that Resident #1 had a laboratory test obtained on 4/6/11. On 4/9/11 the resident experienced a change in condition and was sent to the hospital. The resident was admitted with severe dehydration and acute [MEDICAL CONDITION]. She stated that she was not aware of the laboratory results prior to the resident's change in condition. She stated that on 4/12/11 the resident's family member came to the facility and requested to speak with nursing administration regarding the resident's hospitalization . She stated the family member wanted to know why the resident was not treated for [REDACTED]. The ADON stated this was the first time she had been made aware that the resident had abnormal laboratory results. She stated she immediately started an investigation and found the report dated 4/6/11 in the physician's communication book. The report was not stamped or dated by the person whom received it. The report also did not include a date or signatures of a nurse. She further stated that only nurse's are to place these reports in the physician's book and through interview she was not able to determine who placed the report in the book or when the report was actually received. The report was not checked off on the daily laboratory schedule sheet as being reconciled or received. She further stated there was no documentation on the 24 hour nursing report related to the laboratory results. Refer to Laboratory Services- Prompt notification to the attending physician - F 505 Scope/Severity L During an interview on 4/22/11 at 10:25 am, the Director of Nursing (DON) stated that the nurse's were not always marking off when the laboratory results were received, therefore there was no way to determine if the results were received and reported to the physician. She stated that when the laboratory test is obtained it should be recorded on the 24 hour report sheet. When the test results are received by fax the nurse is to mark off on the report sheet that the results were received and reviewed. During an interview on 4/22/11 at 11:10 am, the Administrator stated that he was not aware of any major problems with laboratory services. He stated that the procedure being followed by the nursing staff was an unwritten policy ( not in print), but was well known by many of the nursing staff. When asked if he was aware of any delays in reporting laboratory test results to the physician's, or problems with laboratory test not being performed as ordered, he stated he was aware of some problems, but was not aware of the depth of the problem. During an interview on 4/21/11 at 11:00, the Medical Director stated that he felt the facility had a good procedure in place with the handling of laboratory testing. He stated there may be an occasion or two when a test or results may be missed, but over all he felt that the reporting of laboratory results were being done effectively. He stated he did not know if the procedure being used was in print. He stated there should be a formal type of tracking and monitoring procedure in place to avoid a delay in reporting laboratory test results. Refer to Quality Assessment and Assurance - F520 Scope/Severity L During an interview on 4/21/11 at 4:40 pm, the Quality Assurance (QA) Nurse stated that the facility has no formal system or procedure for reconciling laboratory reports, but it is just something that the Registered Nurse Manager's (RNM) do. She stated that though the RNM checks on a daily basis the receipt of laboratory reports, no one person is responsible to check that the reports have been received. She stated that the ADON makes out daily laboratory schedules. She stated what should happen is when a laboratory report is received by fax the secretary would place a stamp with the date on the report. She would then notify a nurse to make them aware of the arrival of reports. The nurse would then retrieve the reports, review them, and notify the physician if need be. The nurse should then go to the laboratory schedule sheet and place a line or check mark next to the test performed to acknowledge it was received, reviewed and addressed. After completing all the steps, the laboratory report would then be placed in the physician's book for a final review and sign off by the physician. She stated there was no auditing of this procedure being done. During an interview on 4/22/11 at 11:10 am, the Administrator stated that he was not aware that auditing of laboratory services was not taking place. He further stated he would have expected some kind of auditing to take place. 10NYCRR 415.26

Based on medical record review and staff interview the facility failed to promptly notify the attending physician with laboratory test results during a partial extended survey ( Case # NY 0299). Specifically, for four ( #1,2,3,4) of six residents reviewed the facility did not notify the physician of abnormally high laboratory results for Resident #1. Three days after the laboratory test was obtained the resident experienced a decline in condition and was admitted to the hospital with severe dehydration and acute [MEDICAL CONDITION]. Additionally, the physician was not notified of Resident #2's refusal to have blood drawn. For Resident #3 the physician was not notified of a sub-therapeutic (low level) [MEDICATION NAME] level and for Resident #4 the physician was not notified of an elevated blood glucase level and an elvated potassium. The facility's failure to notify the attending physician of abnormal laboratory results placed all residents in the facility at risk. This resulted in actual harm for Resident #1 and potential for serious harm to all residents that is Immediate Jeopardy to residents health and safety. This is evidenced by: Resident #1 The facility did not report abnormal elevated laboratory results promptly to the physician. Three days later the resident suffered a decline in condition and was admitted to the hospital with [REDACTED]. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident to have had severe cognitive loss. The Physician' s Orders dated 4/5/11, documented an order for [REDACTED]. The laboratory report dated 4/6/11 documented a sodium level of 153 (136-145), blood urea nitrogen 28 (7-24), creatinine 2.4 (0.6-1.3) and a blood sugar of 185 (74-106). The laboratory report included an undated hand written notation "patient in hospital" . The resident was sent to the hospital on [DATE]. It is unknown on what date and time the laboratory results were received by the facility. During an interview on 4/21/11 at 10:00 am, the Assistant Director of Nursing (ADON) stated that the laboratory report was located in the physician's communication book on 4/12/11. The ADON stated that it was not known to the facility until 4/12/11 that the laboratory results were not reported to the physician. During an interview on 4/21/11 at 11:00 am, the physician stated that he was not made aware of the laboratory results from 4/6/11. He stated that if he had he been made aware of the elevated sodium and blood urea nitrogen (BUN), he would have at the least discontinued the diuretic and sent the resident out to the hospital for hydration. The physician stated he first became aware of the laboratory results on 4/19/11. During an interview on 4/21/11 at 1:25 pm, the Laboratory Administration Director from the hospital laboratory stated that paper laboratory report would have been delivered to the facility sometime in the morning on 4/8/11. He stated that in the interim, the facility had access to the computer to view laboratory results. He stated that the results were available for review on 4/6/11 at 11:23 am. Resident # 2 The facility did not notify the physician of the resident's refusal to have blood work obtained and the resident blood work was not obtained. The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have impaired long and short term memory and severely impaired daily decision making skills. The resident was assessed to sometimes understand and be understood. The Nurse's Notes dated 3/22/11 documented that the resident was seen by the physician due to increased cough and congestion. The physician's orders [REDACTED]. The facility form titled laboratory orders, documented that the resident refused the blood draw. There were no nurse's notes found documenting the resident refused the blood draw and or that the physician was made aware of the residents refusal . There was no evidence found that a second attempt to draw the blood specimen was made. During an interview on 4/22/11 at 3:40 pm, the physician stated that if the laboratory test was an order for [REDACTED]. Resident # 3 The facility did not promptly report a sub- therapeutic (low level) [MEDICATION NAME] (a heart medication used to strengthen the beat and lower the heart rate) level to the physician. The resident was admitted to the facility on [DATE] with a readmission date of [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to have severe cognitive loss. The Readmission History and Physical, dated 4/1/11, documented that the resident was admitted to the hospital on [DATE]- 3/30/11. During this hospitalization the resident was started on [MEDICATION NAME] for the treatment of [REDACTED]. The physician's orders [REDACTED]. The laboratory report dated 4/6/11, documented a [MEDICATION NAME] level of 0.8 (0.9-2.0).There was no documented evidence the physician was notified of the sub-therapeutic [MEDICATION NAME] level. During an interview on 4/22/11 at 3:40 pm, the physician stated that he would not have been to concerned with the low level, but would have expected to be made aware. He stated if he was made aware of the result he most likely would have had the level rechecked in month ' s time. Resident # 4 The physician was not promptly notified of an elevated blood glucose and potassium levels. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have severe cognitive loss. The laboratory report dated 2/19/11 documented a potassium level of 5.7 (3.5-5.1). and a blood sugar level of 178 (74-106). The physician's progress notes and nurse's notes were reviewed and there was no evidence found that the physician was made aware of these results. The report did not include documentation as to when the report was received or if the physician was made aware. During an interview on 4/22/11 at 3:40 pm, the physician stated he would have expected to be notified of the results. He stated that he or the other physician would have at the least initialed the report if either one reviewed it. During an interview on 4/21/11 at 4:40 pm with the ADON and the Quality Assurance (QA) Nurse, the ADON stated that she would expect all laboratory results to be reviewed by a nurse and the physician to be notified of abnormal findings. The QA nurse stated that laboratory reports are received everyday and the nurse should be reviewing the results. If blood results are abnormal and out of the range for the resident then the physician should be notified, otherwise the report would be signed off by the nurse and placed in the physician ' s communication book for physician review and sign off. 10NYCRR 415.20

Based on record review and staff interview, the facility failed to have a Quality Assurance(QA) program that readily identified issues that have the potential to cause serious harm to residents reviewed during a partial extended survey (Case #NY 299). Specifically, for 4 (#1,2,3,4 ) of 6 residents reviewed, the QA committee failed to ensure that effective systems were in place to ensure that all laboratory test were obtained as ordered, the test results were received in a timely manner, and that the test results were promptly reported to the physcian. This resulted in actual harm for Resident #1 and a potential for serious harm to all residents that is Immediate Jeopardy to the health and safety of residents. The findings were as follows: Refer to Laboratory Services/Prompt reporting to the attending physician - F 505 Scope and Severity L Refer to Quality of Care-F 309 Scope and Severity L During an interview on 4/21/11 at 4:40 pm, the Quality Assurance (QA) Nurse stated that the facility has no formal system or procedure for ensuring laboratory tests are performed , results are received and physicians are notified when necessary. The QA nurse stated it is just something that the Registered Nurse Manager's (RNM) do. She stated that though the RNM checks on a daily basis the receipt of laboratory reports, no one person is responsible to check that the reports have been received. She stated that the ADON makes out daily laboratory schedules. She stated what should happen is when a laboratory report is received by fax the secretary would place a stamp with the date on the report. She would then notify a nurse to make them aware of the arrival of reports. The nurse would then retrieve the reports, review them, and notify the physician if needed. The nurse should then go to the laboratory schedule sheet and place a line or check mark next to the test performed to acknowledge it was received, reviewed and addressed. After completing all the steps, the laboratory report would then be placed in the physician's book for a final review and sign off by the physician. She stated there was no auditing of this procedure being done. The QA nurse stated that after the discovery of an abnormally high laboratory result that was not received and reported to the physcian in a timely manner, she and the Education Nurse have been reviewing and revising facility policies related to laboratory services as well as educating staff. She stated that she has not conducted any audits as of 4/21/11. During an interview on 4/22/11 at 11:10 am, the Administrator stated that he was not aware that auditing of laboratory services was not taking place. He further stated he would have expected some kind of auditing to take place. 10NYCRR 415.27(a-c)

Based on medical record review and staff interview the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health during a partial extended survey (#NY 961). Specifically, for 1 (Resident #6) of 6 residents reviewed, the facility did not monitor the resident's fluid intake, did not assess for dehydration timely, or notify the physician timely of the resident's decrease in fluid intake. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Resident # 6 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident had impaired short and long term memory, sometimes understands and is sometimes understood, and had severely impaired cognitive skills for daily decision making. This same MDS also assessed the resident required extensive assistance of one staff for eating and drinking. The "Nursing Assessment Form" dated 3/8/11 documented the resident needed to be totally fed by staff. The Resident Care Plan (RCP) dated 3/8/11 documented the resident was at risk for skin breakdown. Approaches documented on the RCP included monitor fluid intake, and dietary consult with follow through for assurance of adequate nutritional intake every month. There was no documented evidence that the resident was offered extra fluids. The routine chemistry results dated 3/9/11 documented the resident's blood urea nitrogen (BUN-indicates level of hydration and kidney function) was 17 (normal values 7-24), creatinine (Cr-indicates level of hydration and kidney function) was 1.0 (normal values 0.6-1.3) and sodium (Na) was 140 (normal value 136-145). The RCP dated 3/10/11 documented the residents skin was reddened on admission. Approaches documented on the RCP included " Dietary referral as indicated to assess nutrition and fluid intake, institute interventions as needed. There was no documented evidence the resident was offered extra fluids. The Nurse Aide Care Card (documented care to be given by the CNAs) dated 3/10/11 and 3/28/11 documented the resident was dependent on staff for eating (full staff performance of this activity). The " Nutrition Risk Assessment " (a screening form for new admissions) dated 3/11/11 documented that according to the nurses notes the resident had a poor appetite. This same form documented that the resident was assessed as a high nutritional risk, was noted to have poor po (by mouth intake), and an intake study was to be completed. The " Initial/Annual Assessment " form signed and dated by the Registered Dietician (RD) on 3/11/11 documented the resident required 1963 cc of fluid intake every day, and was noted to have a poor po intake per the nursing notes. This same form documented on 3/19/11 the results of the resident's intake study that the resident only consumed 1030 cc of fluid, however the estimated needs of the resident was 1835 cc of fluid/day. The RD documented the resident was only consuming 56% of her estimated fluid needs, and asked nursing to please push fluids between meals. The "Intake and Output " (I&O) form initiated on 3:00 pm-11:00 pm shift on 3/8/11 documented intake for 3/8/11, 3/9/11, 3/10/11 and 3/11/11 with 24 hr totals of 0 cc, 840 cc, 240 cc, and 360 cc. There was no documented fluid intake after 3/11/11. The "Dietary Recommendations" form signed and dated 3/19/11 by the RD documented the resident was consuming only 56% of fluid needs and the dietician recommended pushing fluids at medication pass to aid with healing and resolution of a UTI (urinary tract infection). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Comprehensive Plan of Care dated 3/24/11 and entitled " At risk for altered nutrition " documented the resident's appetite and fluid intake should be observed while on program, and fluids should be pushed between meals. Both of these approaches were dated 3/24/11, 5 days after the RD' s recommendations. The Nurse's Notes (NN) dated 3/8/11 at 3:00 pm-11:00 pm, documented the resident had a poor appetite. The NN dated 3/11/11 at 10:00 am documented the physician (MD) was notified regarding the resident' s poor po intake and labs were ordered for 3/14/11. The NN dated 3/11/11 at 3:00 pm-11:00 pm documented the resident consumed 75% of her drinks, and the MD wanted staff to notify him on 3/14/11 with an update on the residents condition. There was no documented evidence in the NN that the MD was notified with an update on 3/14/11 regarding the resident's condition. The routine chemistry results dated 3/14/11 documented the resident ' s BUN was 26, Cr 1.2, and Na 147. All of the values were increased from the initial laboratory tests on 3/9/11. The NN were reviewed for the period of 3/18/11 (late entry for 3/17/11) through 3/26/11 and there was no documentation regarding the amount of fluids the resident was drinking. There was no documented evidence in any of the NN that the resident was being offered additional fluids as recommended by the RD on 3/19/11. The NN dated 3/29/11 at 1:00pm documented the Registered Nurse (RN) was called to the resident's room by the certified nurse's aid (CNA) due to shaking and tremors in the resident's arm. The RN documented the resident was lethargic (drowsy), not speaking, and could not follow commands. The resident ' s blood sugar (BS) was 283. The RN also documented the resident was very unresponsive at lunch time, and ate less than 25% of her lunch and drank only 80 cc of fluids. There was no documentation the physician or the resident's family was notified. There was no documentation regarding the amount of fluids the resident was drinking for the next 3 shifts. The NN dated 3/30/11 at 4:30pm documented the resident was noted to be unresponsive and flaccid (weak and loose). The note documented the resident' s BS, oxygen saturation (amount of oxygen in the blood) and vital signs were checked. The MD on call was notified and the resident was transported to the hospital. The Emergency Department Report dated 3/30/11 at 8:38 pm documented the resident's BUN was 62, Cr 2.5 and Na 176. The note also documented the resident's first chemistry showed an extremely high Na level and the lab was asked to draw a second sample. The second sample documented the resident was truly profoundly hypernatremic (high Na) and dehydrated. There was no result of the second Na level documented in this report. The report also documented the resident was admitted with [DIAGNOSES REDACTED]. During interview on 4/22/11 at 1:30pm the Registered Nurse Unit Manager (RNUM) stated the resident required staff to physically hand food and drink items to her and then bring those items to the resident's mouth. The RNUM also stated there was no additional documentation of the resident's I&O (other than 3/8/11-3/11/11). The RNUM stated on 3/29/11 when the resident had the shaking and tremors, with only 80 cc fluid intake and 25% of food intake, she would expect the MD to have been notified. The RNUM stated she did not believe she was aware of this incident, and if she was, she would have notified the MD. During interview on 4/22/11 at 4:15 pm the Assistant Director of Nursing (ADON) stated she would have expected the resident's I&O to be monitored and documented. When shown the lab values upon the resident's admission to the emergency room , the ADON stated the resident must have had obvious symptoms, and this did not occur all of the sudden. During interview on 4/22/11 at 3:15pm the Medical Director stated he would expect the MD to be notified whenever a resident has a change in condition. When shown the lab values upon the resident's admission to the emergency room , the medical director stated the resident was obviously very ill and must have had obvious symptoms prior to being transferred to the hospital. 10 NYCRR 415.12(j)