Every finding on record at Waterview Hills Rehabilitation And Nursing Center

Based on observation, record review, and interviews, the facility failed to ensure that residents are free from significant medication errors for one of four residents (Resident #94) reviewed for hospitalization. Specifically, on 05/04/2025 at 9:00 AM and 9:00 PM, the facility failed to administer Levetiracetam (Keppra: medication used to help control seizures) 750 milligrams two tablets (1500 milligrams) every 12 hours to Resident #94 as per physician order. Subsequently, Resident #94 had a seizure on 05/05/2025 at approximately 12:20 AM and was transferred to the hospital. This resulted in actual harm to Resident #94 that was not Immediate Jeopardy. The findings include:The facility's policy Medication Administration revised 03/05/2024, documented medications should be administered in a safe and timely manner, as prescribed. Medications must be administered in accordance with the orders, including any required time frame, and within one hour of their prescribed time unless otherwise specified (before and after meals). The facility's policy Reordering/Refill revised 03/12/2024 documented medications should be ordered, reordered, and received from the dispensing pharmacy on a timely basis.Resident #94 had diagnoses including epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), and hepatic encephalopathy (decline in brain function that is caused by severe liver disease). The quarterly Minimum Data Set (a resident assessment tool) dated 03/10/2025 documented Resident #94 was cognitively intact and received anticonvulsant medications for seizures.The Care Plan for seizure disorders, revised 03/15/2025 documented Resident #94 was to be maintained on anti-seizure medication with the goal to maintain therapeutic levels of medication to prevent seizure activity.The Physician Order dated 04/16/2025 documented Keppra 750 milligram tablets, two tablets (1500 milligrams) by oral route every 12 hours for seizures, at 9:00 AM and 9:00 PM.The Physician Order dated 04/16/2025 documented seizure precautions in place every day from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM.The May 2025 Medication Administration Record documented on 05/04/2025 Keppra 750 milligram tablet, two tablets (1500 milligrams), were to be administered at 9:00 AM and 9:00 PM. Both doses were documented as given at 11:07 PM.The Investigation Summary dated 05/05/2025 documented on 05/05/2025 at approximately 12:20 AM, Resident #94 was observed with generalized seizures for one minute and was placed on their side. Afterwards, Resident #94 was unresponsive for a couple of minutes, with oxygen saturation at 97%. Temperature was 98.4 and increased to 99.2. Resident #94 regained consciousness was alert and verbal, but extremely restless in bed. The physician was notified and ordered a transfer to the emergency room. Resident #94's representative was made aware. Resident #94 was sent to the emergency room at 12:45 AM via emergency medical services and was admitted with a diagnosis of seizures. During a chart review by Registered Nurse Supervisor #10 on 05/05/2025, it was observed that Resident #94's Keppra was signed as being administered at 11:07 PM. Registered Nurse Supervisor #10 informed Registered Nurse Manager #12, who stated they would investigate. On 05/06/2025, Registered Nurse Manager #12 spoke with Licensed Practical Nurse #8 regarding the Keppra doses that were signed late. Registered Nurse Manager #10 re-educated Licensed Practical Nurse #8 about signing for Keppra at the time of administration. During a morning report on 05/09/2025, there was a discussion about Resident #94 returning to the facility and a review of hospital documentation from the resident's family, who stated that in the past, when the resident missed or was given their seizure medication late, Resident #94 would have a seizure. The Director of Nursing interviewed Licensed Practical Nurse #8 on 05/09/2025, who initially stated they forgot and signed the Keppra doses late, then informed the Director of Nursing that the Keppra was not available on the medication cart for the AM/PM doses. Licensed Practical Nurse #8 stated they signed for both doses of Keppra that were not available and did not notify the nurse supervisor, the physician, or the pharmacy. Licensed Practical Nurse #8 was suspended on 05/09/2025 pending investigation and was terminated on 05/12/2025.There was no documented evidence in the electronic medical record on 05/04/2025 to indicate that the medical provider was made aware that Keppra was not available and/or administered to Resident #94.The progress note dated 05/05/2025 at 4:43 AM entered by Registered Nurse Supervisor #9 documented that Resident #94 was admitted to the hospital with a diagnosis of seizures.The progress note dated 05/11/2025 at 10:20 PM entered by Registered Nurse Supervisor #9 documented that Resident #94 was re-admitted at 3:30 PM with a diagnosis of seizures. During a telephone interview on 06/04/2026 at 12:39 PM, Licensed Practical Nurse #8 stated that Resident #94's Keppra was not available on 05/04/2025. When they checked the record, they observed it had been reordered, though they could not recall the date it had been reordered. They stated they did not notify the supervisor that they did not have Resident #94's Keppra. Licensed Practical Nurse #8 stated they should have notified the nursing supervisor that the Keppra was not available and that it did not arrive on the evening of 05/04/2025. They stated they worked 16 hours that day and although Keppra was not available, they documented that the AM and PM doses of Keppra were given. They stated they were waiting for the pharmacy to deliver Keppra; once it arrived, they would give the PM dose to Resident #94. They stated that they did not inform Resident #94 that their Keppra was unavailable. They stated they gave all other medications to Resident #94 and that Resident #94 showed no signs or symptoms of distress and did not have a seizure during their shift.During an interview on 06/04/2026 at 1:23 PM, the Director of Human Resources stated that Licensed Practical Nurse #8 was hired on 09/07/2021 and terminated on 05/12/2025. They stated that Licensed Practical Nurse #8 was suspended pending an investigation conducted on 05/09/2025. They stated because Licensed Practical Nurse #8 documented that Keppra was administered when it was not available, they were reported to the Board of Professional Licensing.During a telephone interview on 06/05/2026 at 12:57 PM, Registered Nurse Supervisor #9 stated that on 05/04/2025, they heard a noise from Resident #94's room and found Resident #94 in bed, shaking and drooling. They stated Resident #94 was turned to the side and had a seizure lasting one minute, after which they remained unconscious, but responded after the seizure. They stated Resident # 94 was sent to the emergency department and admitted for a seizure. They stated they were unaware of the missed Keppra as it was signed off as given. They stated that when Resident #94's family was notified, they asked about the Keppra, prompting the supervisor to check the medication record and cart. They stated a blister pack of Keppra was not found in the medication cart. They stated typically, medication was reordered when five days remained in the blister pack. During a telephone interview on 06/08/2026 at 7:48 AM, Resident #94's Representative stated they were notified by the facility that Resident #94 had a seizure. They stated they asked the supervisor if Resident #94 received the Keppra, because they had spoken with Resident #94 at 8:00 PM that day, and Resident #94 told them they had not received the Keppra. They stated Registered Nurse Supervisor #10 told them the administration of Keppra was signed for after 11:00 PM. They stated in the past after each episode of seizures it took Resident #94 two to three months to return to baseline.During a telephone interview on 06/08/2026 at 10:20 AM, Pharmacist #2 stated that the facility ordered medication refills by phone, fax, or through electronic medical record. They stated that on 03/24/2025, a month's supply of Keppra (120 tablets) was sent to the facility. Pharmacist #2 stated they could not find a May 2025 request for Resident #94's Keppra, therefore, there were no deliveries of Keppra for Resident #94 until 05/11/2025. Pharmacist #2 stated they delivered to the facility two times each day, including weekends. They stated on 05/15/2025, 10 tablets of Keppra 250 milligrams were supplied in the Cubex machine (system for emergency use medication cabinet).During an interview on 06/08/2026 at 10:44 AM, Physician #1 stated they had been informed that Resident #94 experienced a seizure, and they ordered transfer of Resident #94 to the hospital for evaluation. They stated they were told that Resident #94 did not receive both doses of Keppra that day. They stated they did not receive a call from the nurse related to the Keppra not being available. They stated they would have expected the nurse to call and say the Keppra was not available. They stated that when Resident #94 did not receive their Keppra, it caused harm resulting in Resident #94 having a seizure. They stated the harm was not permanent. They stated the facility took appropriate action, sent Resident #94 out to the emergency room, and after hospitalization, followed up with neurology. They stated Resident #94 was currently doing well.During an interview on 06/08/2026 at 3:51 PM, Licensed Practical Nurse #11 stated they used the last two Keppra tablets and reordered the Keppra on 05/02/2026 using the electronic system. They stated the Keppra was expected to arrive that evening. Licensed Practical Nurse #11 stated they were off the next day and did not follow up on the delivery of Keppra.During a follow-up telephone interview on 06/09/2026 at 8:49 AM, Physician #1 stated they wanted to clarify that because Resident #94 did not receive their seizure medication, the effect was they had a seizure.During an interview on 06/09/2026 at 9:52 AM, the Director of Nursing stated they followed up with Licensed Practical Nurse #11, who reported using the last two Keppra tablets and reordering the medication through the electronic system on 05/02/2026. They stated they could not locate in the electronic medical records to indicate that Keppra was reordered on 05/02/2025. They stated Licensed Practical Nurse # 8 signed off on the Keppra administration on 05/04/2025. They stated when speaking to License Practical Nurse #8, they told them that they believed they gave the Keppra to Resident #94 on 05/03/2025. The Director of Nursing stated after the incident with Resident #94, Keppra was added to the Cubex system, and all nurses were re-educated on timely medication sign-off and procedures for missing medications, including calling the pharmacy or supervisor.During the onsite survey, past noncompliance was cited (F760) after the facility was able to demonstrate the following actions were implemented to correct the noncompliance as of 05/15/2025: QAPI meeting was held on 05/09/2025The policy and procedures for medication administration, unavailable medication process, and medication reordering documented 100% reviewed by all nurses.Staff education medication administration, unavailable medication process, medication reordering and refill process, medication error prevention, seizure management, falsification of documentation, and correct channels of communication documented completed by 100% of all nurses. Audits daily unavailable medications, staff knowledge for medication management, medication administration and staff knowledge of medication administration.Ongoing QAPI for six months/year as outlined (medication administration competency, staff knowledge of medication error prevention, refill process, and unavailable medication process). Daily check of the involved residents MAR and medication supply to ensure timeliness of medication administration and no unavailable medicationsThe facility was able to demonstrate monitoring of the corrective action and sustained compliance10 New York Code Rules Regulations 415.12(m)(2).

Based on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure that a resident's right was supported by the facility for 1 or 3 residents reviewed. Specifically, Resident #1 filed a grievance which was reported to the Director of Nursing in January 2025 that they prefer not to receive cares from Certified Nurse Aide #1 because they were too strong in their touch and at times manhandled them. On 3/18/2025, Certified Nurse Aide #1 provided care to Resident #1 and the resident reported to their family representative that Certified Nurse Aide #1 came to their room at approximately 4:45 am, woke them out of their sleep and provided cares to them after they refused the care. Resident #1 also alleged that they were manhandled by Certified Nurse Aide #1. There was no documented evidence that Resident #1's care plan was updated with their preference. The facility did not provide evidence that the Nurses and Certified Nurse Aides were made aware of Resident #1's preference. The findings are: The 7/1/2019 facility policy title Activities of a Daily Living (ADL) Supporting last revised on 11/7/23 documented that appropriate care and services will be provided for residents who are unable to carry out Activities of a Daily Living(ADL's) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with elimination (toileting) Resident #1 was admitted with diagnoses including but not limited to atrial fibrillation, deep vein thrombosis, and rhabdomyolysis. The 12/18/24 5 day Minimum Data Set documented that Resident #1 had intact cognition and required total assistance with bathing, bed mobility and toileting. The 1/22/2025 Grievance/Complaint Form documented that Resident #1 reported that some Certified Nurse Aides manhandle and cup their legs which hurts them because their legs are sensitive. During an interview on 5/28/25 at 12:24 pm, the Complainant stated Resident #1 was awaken out of their sleep at 4:45 PM by two Certified Nurse Aides to be changed and that Resident #1 refused because they did not get a reasonable amount of sleep, and Certified Nurse Aide #1 told Resident #1 that they must do it now because they're not coming back. The Complainant stated that they have complained about Certified Nurse Aide #1 aide in the past and they were supposed to been banned from giving cares to Resident #1. Upon review of the Certified Nurse Aide Documentation, there was no evidence to show that Resident #1's preference to not have Certified Nurse Aide #1 provide cares to them, in their plan of care. During an interview on 5/28/2025 at 1:54 PM, the Director Social Services stated that Resident #1 had complained in the past to the team that staff were insensitive to their feet, and that they filed a grievance on 1/22/2025 due to staff manhandling their legs. During an interview on 5/28/25 at 3:00 PM, Certified Nurse Aide #1 stated that Resident #1 had complained about them in the past that that they were too strong, and they were afraid that they would roll them out of their bed. During an interview on 5/28/25 at 2:45 PM, The Administrator stated prior to the incident on 3/18/25, they were informed by the Director of Nursing that Resident #1 complained about Certified Nurse Aide #1 being too strong with them while giving cares and that they prefer them not to give cares to them. During an interview on 5/28/25 at 3:16 PM, the Director of Nursing stated that one day they visited Resident #1, and they complained that Certified Nurse Aide #1 does not know their strength and that they requested to have other aides instead of Certified Nurse Aide #1 and that prior to the incident on 3/18/25, they told Certified Nurse Aide not to provide cares to Resident #1 and for while they were from their assignment and don't know how they ended providing care that night. The Director of Nursing stated that they did not write the instructions down for the nurse to give to the Certified Nurse Aide, they verbally informed them and that it was not put in the Kardex Care Guide. The Director of Nursing stated that they only put Resident's preferences of not wanting a male Certified Nurse Aide in the Care Plan, not for a particular person. 10NYCRR415.12

Based on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure for 1 (Residents #1) of 3 residents reviewed for abuse, had the right to be free from abuse, neglect, or mistreatment. Specifically, Resident #1 was awaken at 4:45am by Certified Nurse Aide #1 to provide personal hygiene care. Resident #1 refused cares but Certified Nurse Aide #1 continued to provide cares despite Resident #1's refusal. Resident #1 reported Certified Nurse Aide #1 mishandled them. Resident #1 was very upset because thier sleep was interrupted by Certified Nurse Aide #1 and reported to their family representative. The findings are: The 1/28/21 Facility policy titled Abuse Prevention/Prohibition documented that all Residents will be free from abuse, mistreatment, neglect, exploitation, misappropriation of property, corporal punishment, and involuntary seclusion. The 1/23/28 Facility policy titled Residents Rights documented that all residents have a right to a dignified existence and self-determination, has a right to make choices about aspects of his or her life in the facility that are significant to the resident. Resident #1 was admitted with diagnoses including but not limited to atrial fibrillation, deep vein thrombosis, and rhabdomyolysis. The 12/18/24 5 day Minimum Data Set documented that Resident #1 had intact cognition and required total assistance with bathing, bed mobility and toileting. The 12/12/24 Mood Care Plan documented that Resident #1 had altered mood state or feelings as manifested by resident showing signs of an unpleasant mood in the morning. The 3/18/25 Investigation Summary documented that on 3/18/25 at approximately 8:45 am, the Complainant reported to the Administrator that their mother left them a message early in the morning on 3/18/25, upset and stated that they were cleaned by two Certified Nurse Aides after asking them not to change them at that time. Resident #1 stated that at approximately 5:15 am, they told two Certified Nurse Aides that they did not want to be cleaned and changed but they cleaned and changed them due to having a bowel movement. The involved staff members were interviewed, and both stated that they changed Resident #1 out of concern of skin breakdown because they were soiled. Education was provided to all Certified Nurse Aides that if a resident refuses care to alert the nurse and/or supervisor for further guidance and document accordingly. Both Certified Nurse Aides were removed the Resident's care. The 3/18/25 Employee Statement by Certified Nurse Aide #1 documented that they were training Certified Nurse Aide #2 and being that Resident #1 is two assist with cares, they both went in to provide incontinence cares to Resident #1. Certified Nurse Aide #1 stated that they were afraid that their skin would breakdown and that was why they changed them. The 3/18/25 Employee Statement by Certified Nurse Aide #2 documented that on the morning of 3/18/25 they went in the room with a coworker to change resident due to the be soiled. Resident #1 told them hat they do not need to be changed and that they are fine, and although Resident #1 was getting upset, they changed them anyway. The Administrator Statement documented that on 3/18/25, they were notified by the Complainant that Resident #1 left a message and was upset telling them two Certified Nurse Aides cleaned them after asking not to be changed at the time. The Administrator explained to the Complainant the consequences of the resident lying in their incontinence for long periods of time. The Administrator interview both Certified Nurse Aides and they both confirmed that Resident #1 did not want to be changed but they insisted on changing them, and one aide stated that Resident #1 seemed unhappy that they were changing them at that time. Resident #1 told the Administrator that they felt they were being manhandled. The Grievance/Complaint Form dated 3/18/25 documented that on 3/18/25 at approximated 5:15 am, Resident #1 told two Certified Nurse Aides that they did not want to be cleaned and changed, and the Certified Nurse Aides changed them due to their concerns of large incontinence. Education provided to all Certified Nurse Aides that if a Resident refuses cares to alert the nurse and/or supervisor for further guidance and document accordingly. The 3/19/25 In-service and Continuing education titled Health Care Plan(HCP) for Resident #1 documented that Certified Nurse Aides were educated to document refusals of care and to report to nurse/supervisor. Both Certified Nurse Aides who provided cares were removed from taking care of Resident #1. The 3/18/25 Corrective Action Notice Form documented that Certified Nurse Aide #1 received a verbal counseling for failure to follow instruction for Residents, and education was provided. The 3/18/25 Corrective Action Notice Form documented that Certified Nurse Aide #2 received a verbal counseling for failure to follow instruction for Residents, and education was provided. During an interview on 5/28/25 at 11:45am, the Administrator stated the Complainant reported to them that Resident #1 told them that they were rough handled by two Certified Nurse aides while being provided with cares after they refused, and that they did an investigation, and the Attorney General called for information related to the incident. During an interview on 5/28/25 at 12:24 pm, the family representative stated Resident #1 was awaken out of their sleep at 4:45am by two Certified Nurse Aides to be changed and the Resident #1 refused because they wanted to get some more sleep, and Certified Nurse Aide #1 told Resident #1 that they must do it now because they're not coming back. The family representative stated that they had complained about Certified Nurse Aide #1 aide in the past to the facility administration and they were supposed to have banned them from giving cares to Resident #1. During an interview on 5/28/25 at 1:54pm , the Director of Social Services stated that Resident #1 has complained in the past to the team that staff were insensitive to their feet, and that they filed a grievance on 1/22/25 due to staff manhandling their legs. During an interview on 5/28/25 at 3:00pm, Certified Nurse Aide #1 stated that they changed Resident #1 anyway after they refused to be changed because they were soiled, and they didn't want to leave them like that for the next shift. Certified Nurse Aide #1 stated that they went into Resident #1's room while they were still sleeping and explained to them that the shift changes at 7am and they wanted to change them so that they can finish their shift. Certified Nurse Aide #1 stated that Resident #1 refused to be changed and was upset but they continued changing them because they were soiled, and they know were supposed to tell the nurse that they refused. Certified Nurse Aide #1 stated that Resident #1 has complained about them before the incident that they were too strong, and they were afraid that they would turn them out of their bed. During an interview on 5/28/25 at 3:16pm, the Director of Nursing stated that Residents have the right to refuse care, and that Certified Nurse Aides should not provide care if a resident says no and to report to a nurse and /or supervisor and to document. The Director of Nursing stated that one day they visited Resident #1, and they complained that Certified Nurse Aide #1 does not know their strength and they requested to have other aides instead of Certified Nurse Aide #1 and that prior to the incident on 3/18/25, they told Certified Nurse Aide not to provide cares to Resident #1 and for a while they were removed from their assignment and don't know how they ended providing care that night. 10 NYCRR 415.4(b)(3)

Based on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure for 1(Residents #1) of 3 residents reviewed for abuse, that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Survey Agency in accordance with State law through established procedures. Specifically, 1.) On 3/18/25, the facility initiated an investigation of alleged abuse due to a report from Resident #1's family on 3/18/25 that Resident #1 called them early in the morning on 3/18/25 upset that two certified nurse aides came into their room at approximately 4:45 am while they were asleep and insisted on changing them despite their refusal and while providing cares, they were manhandled by the Certified Nurse Aides. Resident #1 was very upset by the actions of the Certified Nurse Aide #1 & #2. The findings are: The 1/28/21 Facility policy titled Abuse Prevention/Prohibition documented the Federal and state regulations require the reporting of alleged violations of abuse, mistreatment, and neglect immediately to the facility administrator and in accordance with state law, to the Department of Health. Resident #1 was admitted with diagnoses including but not limited to atrial fibrillation, deep vein thrombosis, and rhabdomyolysis. The 3/18/25 Investigation Summary documented that on 3/18/25 at approximately 8:45 am, the Complainant reported to the Administrator that their mother left them a message early in the morning on 3/18/25, upset and stated that they were cleaned by two Certified Nurse Aides after asking them not to provide incontinence care. Resident #1 stated that at approximately 5:15 am, they told Certified Nurse Aides #1 & #2 that they did not want to be cleaned and changed but they cleaned and changed them. The involved staff members were interviewed, and both stated that they changed Resident #1 out of concern of skin breakdown because the resident was soiled. Education was provided to all Certified Nurse Aides that if a resident refuses care to alert the nurse and/or supervisor for further guidance and document accordingly. Both Certified Nurse Aides were removed from the Resident's care. The Administrator Statement documented that on 3/18/25, they were notified by the Complainant that Resident #1 left a message and was upset telling them two Certified Nurse Aides cleaned them after asking not to be changed at the time. The Administrator explained to the Complainant the consequences of the resident lying in their incontinence for long periods of time. The Administrator interview both Certified Nurse Aides and they both confirmed that Resident #1 did not want to be changed but they insisted on changing them, and one aide stated that Resident #1 seemed unhappy that they were changing them at that time. Resident #1 told the Administrator that they felt they were being manhandled. During an interview on 5/28/25 at 3:16 PM, the Director of Nursing stated that Residents have the right to refuse care, and that Certified Nurse Aides should not provide care if a resident says no and to report to a nurse and /or supervisor and to document. The Director of Nursing stated that they did not report the incident to the Department of Health because an investigation was initiated by the Administrator. During an interview on 5/28/25 at 2:45 PM, the Administrator stated that the family representative reported to them that Resident #1 complained about two Certified Nurses' Aides mishandling them and provided cares to them even though they refused causing them to be upset. The Administrator stated that they did not report the incident on 3/18/25 because they did their own investigation and Resident #1 always has made accusations and they were not sure if it they were really abused or not. The Administrator stated that they gave Certified Nurse Aide #1 and Certified Nurse Aide #2 verbal counseling because they provided cares to Resident #1 despite them refusing incontinence cares. 10 NYCRR 415.4(b)

Based on interviews and record review, conducted during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every 3 months. This was evident for 3 (Residents # 11,14, and 23) of 18 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments for Resident #11, Resident #14, Resident #23, were not completed within 14 days of the Assessment Reference Date. The findings are: The facility's policy titled Minimum Data Set Completion, initiated 9/1/18 last reviewed 6/14/24 documented assessments will be completed no later than 92 days after the previous Assessment Reference Date. 1) Resident #11's Quarterly Minimum Data Set (an assessment tool) with an Assessment Reference Date of 8/6/24 documented a completion date of 10/1/24, more than 14 days (8 weeks) after the Assessment Reference Date. 2) Resident #14's Quarterly Minimum Data Set (an assessment tool) with an Assessment Reference Date of 8/21/24 documented a completion date of 10/1/24, more than 14 days (6 weeks) after the Assessment Reference Date. 3) Resident #23's Quarterly Minimum Data Set (an assessment tool) with an Assessment Reference Date of 7/22/24 documented a completion date of 10/1/24, more than 14 days (10 weeks) after the Assessment Reference Date. During an interview with the Director of Minimum Data Set on 10/07/24 at 11:12 AM, they stated the Rehabilitation Director was out and they could not close the Minimum Data Set due to section GG being incomplete. They stated they notified the Administrator, and the Interdisciplinary Team was aware. During an interview on 10/07/24 at 11:28 AM, the Administrator stated they were aware of an issue with section GG. They stated the Minimum Data Set were being completed and they knew there was transmission issue but did not realize they were out of compliance. 415.11(a)(4)

Based on observation, record review and interview during the recertification survey, the facility did not ensure 1 of 3 residents (Resident #16) reviewed for positioning and range of motion, had the necessary treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, Resident #16 was observed poorly positioned and their plan of care did not include interventions to address body, head, and neck positioning. Findings include: Resident #16 was admitted to facility with diagnoses including Diabetes, Non-Alzheimer's Dementia, and osteoarthritis of the right shoulder. The 10/1/24 Quarterly Minimum Data Set (MDS) an assessment tool documented Resident #16 had moderately impaired cognition, received regularly scheduled pain medication, and was not receiving rehab services. The Minimum Data Set documented Resident #16 required set up or clean up assist for eating. The Activities of Daily Living Care Plan created 10/16/15 documented Resident #16 required set up and supervision for feeding. The 6/11/24 Occupational Therapy evaluation documented the resident was seen for a quarterly screen. The resident was functioning at their baseline, required set up for oral hygiene and feeding, and maximum assistance for activities of daily living and was dependent for transfers. Skilled occupational therapy was not recommended. There was no documented evidence in the resident electronic medical record that resident was referred or screened for occupational therapy after June 2024. During a lunch observation on 10/03/24 at 11:49 AM, Resident #16 was at the dining room table. Resident #16's left side was pushed in toward table while the right was further away from table. The resident attempted to reposition themselves in front of the table, but their feet did not touch floor and they could not move the chair on their own. Resident #16 was leaning to the left and their armpit was resting on the armrest of the wheelchair while they tried to eat. Food was observed on the floor and the resident appeared tired and closed their eyes while chewing food and leaning to the left. Their head was also leaning to left. There were no positioning devices in the resident's chair and no observations of staff offering to assist with repositioning resident at table and in wheelchair. During a lunch observation on 10/07/24 at 11:51 AM, Resident #16 was in wheelchair at dining room table. There was about a 10 inch a gap between the resident and table. Resident #16 was observed leaning to left side with armpit leaning on armrest. Resident #16 was eating only using the right hand and had to reach far across to tray to eat. Resident #16 appeared tired and resting eyes while chewing and head leaning to left side. Food was observed dropped on floor and tray. There were no observations of staff offering to assist with repositioning the resident at table and in wheelchair. When interviewed on 10/09/24 at 11:31 AM, Certified Nurse Aide #12 stated the resident was very difficult and the staff must do whatever the resident wanted. Certified Nurse Aide #12 stated the Rehab Department was aware the resident was leaning to the left side. Certified Nurse Aide #12 stated if they tried to readjust the resident, the resident would yell or scream. Certified Nurse Aide #12 stated the resident had a pain on right side and stated that was the reason the resident leaned to the left side. Certified Nurse Aide #12 stated they thought rehab worked with the resident about 2 months ago. Certified Nurse Aide #12 stated if they put a pillow to assist with sitting the resident up, the resident would remove it. When interviewed on 10/09/24 at 11:38 AM, Registered Nurse #2 stated the resident was not receiving Occupational Therapy services at the time and the last occupational therapy evaluation was 6/11/24. Registered Nurse #2 stated the resident had been observed leaning and when they attempted to reposition the resident, the resident got upset. Registered Nurse #2 stated even when resident sits in a more upright position, they noticed the resident leaned to the left side. Registered Nurse #2 stated they had not made a referral for occupational therapy. When interviewed on 10/09/24 at 12:00 PM, the Occupational Therapy Supervisor stated the resident had been able to eat okay. The Occupational Therapy Supervisor stated there had been no referrals from nursing describing the resident leaning to left side while eating. Occupational Therapy Supervisor stated the dietician observed meals often and was usually quick to refer residents to rehab. The Occupational Therapy Supervisor stated that rehab did rounds occasionally to observe residents, but they usually did quarterly evaluations or got referrals from the dietician. The Occupational Therapy Supervisor stated the occupational therapy evaluation was last done in June of 2024 and documented resident had weakness on right side. They stated the resident had osteoarthritis in the right shoulder and was seen then for that. The Occupational Therapy Supervisor stated Resident #16 was a set up with supervision for self-feeding and if they noticed a decline they would assess and see if they needed any more physical assistance. The Occupational Therapy Supervisor stated when positioning was not addressed it could cause negative outcomes in feeding, pain and could also result in a pressure sore. 10NYCRR 415.12(e)(1,2)

Based on observation, record review and interviews during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure that each resident received necessary respiratory care including oxygen therapy that was in accordance with professional standards of practice and as ordered by the practitioner for 1 of 2 residents (Resident #312) reviewed for respiratory care. Specifically, Resident #312 had an order for oxygen therapy but there was no documented evidence of monitoring to ensure it was being administered, and there was no evidence the nasal canula tubing was changed per policy. Findings include: The facility policy and procedure titled Oxygen Administration with effective date 3/30/10, last reviewed on 7/8/24, documented the following information should be recorded in the resident's medical record: the rate of oxygen flow, route, and rationale, the frequency and duration of the treatment, the date and time that the procedure was performed, the name and title of the individual who performed the procedure. The facility policy and procedure also documented to change oxygen tubing every Sunday 11:00 PM - 7:00 AM shift and to document the date and time and individual that performed the procedure. Resident #312 had diagnoses including chronic obstructive pulmonary disease, asthma, and heart failure. The Admission Minimum Data Set (resident assessment tool) dated 9/21/24 documented, Resident #312 was admitted to the facility on [DATE]. Resident #312 had intact cognition and was on continuous oxygen therapy on admission. The physician order dated 9/17/24 documented continues oxygen 2 Liter per minute via nasal canula. The comprehensive Care Plan titled Oxygen Dependent dated 9/15/24 documented maintain oxygen/nebulizer/puffer equipment per facility policy. During observations and interview on 10/03/24 at 11:34 AM, 10/04/24 at 9:31 AM, and 10/07/24 at 9:58 AM, Resident #312 was in their bed, wearing a nasal canula with a tube connected to the oxygen concentrator with 2-liter flow oxygen. The oxygen tubing was undated and without a signature. The resident stated they had been on oxygen continuously since they were admitted to the facility. Review of the October 2024 Treatment Administration Record on 10/07/24 at 9:31 AM revealed no documented evidence the oxygen therapy was being administered or monitored. During observation and interview of Resident #312 in their room on 10/07/24 at 10:01 AM, accompanied by the Licensed Practical Nurse #13, they stated the resident was on the oxygen continuously via oxygen concentrator or oxygen tank. Licensed Practical Nurse #13 said that they monitored and documented the oxygen therapy daily on the Treatment Administration Record. Licensed Practical Nurse #13 said that the oxygen order was not transcribed to the Treatment Administration Record, and it needed to be updated. They stated they maintained oxygen equipment on a weekly basis and as needed. The oxygen tubing was changed by a night shift nurse on Sunday and every tubing needed to be dated and signed. After observation of tubing, Licensed Practical Nurse #13 stated they did not see a date and nurse's signature and did not know if the tubing was changed last Sunday. During an interview on 10/07/24 at 10:18 AM, Registered Nurse Unit Manager #8 stated they had just updated the Treatment Administration Record placing the oxygen order for 2 Liters/min via nasal canula for continuous use. 10 NYCRR 415.12(k) (6)

Based on observations and interviews conducted during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, there was undated and without expiration dates food stored in the walk-in freezer and refrigerator. Finding include: The facility policy Food Inventory Receiving and Storage effective 09/09/2018 and reviewed 2/14/2024, documented each item must be dated and labeled. Any items opened/used and returned to storage shall be wrapped, labeled, and dated from initial date of use. During an initial tour of the kitchen on 10/03/24 at 9:08 AM, conducted with Food Service Director, the following were observed in the walk-in freezer: 1. A bag of frozen pork butt, without original box, with receiving date 9/26/24, no expiration date. 2. Open bags of hash brown patties, and French fries, both bags were undated. Observation of walk-in refrigerator on 10/03/24 at 9:21 AM revealed opened and undated packs of American cheese, liverwurst, Raskas Cream Cheese and a bag of opened shredded cheddar cheese with date of opening 9/17/24, an undated metal tray of ham salad and banana puree. Observation of the dry storage room on 10/03/24 at 9:36 AM revealed opened and undated bag of egg noodles, a bag of plain breadcrumbs and a bag of yellow cake mix. During an interview with Food Services Director on 09/26/24 at 9:49 AM, they stated that all opened and used food should be wrapped, labeled and dated from initial date of use. They said they educated the staff about it but could not explain why the staff did not put dates of opening on the food. The Food Services Director collected all undated items and stated that all of them would be discarded. 10NYCRR 415.14 (h)

Based on record review and interview conducted during a recertification survey 10/3/24- 10/10/24, the facility did not properly establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, the facility had not updated the Water Management Plan since 12/16/19. The findings are: During a review of the Legionella Assessment and Water Management Plan on 10/7/24 at 11:50 AM with the Director of Engineering, the facility's Water Management Plan was dated 12/16/19. The facility Administrator and Director of Nursing's names were handwritten on the form over white out from the former Administrator and Director of Nursing. During an interview on 10/7/24 at 11:50 AM, the Director of Engineering stated they were responsible for updating the plan annually but had not done it in the last year. The Director of Engineering stated it was important to have updated information and a current Management team. The plan was to have an outside company come in to do an assessment and formulate a Management Plan, which was scheduled for the upcoming week, but it should have been done sooner. During an interview on 10/08/24 at 10:03 AM, the Director of Nursing stated they were unsure of their role in the Water Management Plan for Legionella. They stated they did not go over the plan often enough to know what to do and was not sure of the steps to take if Legionella was identified in water samples. They stated they hoped to get guidance from the Department of Health if it happened. During an interview on 10/9/24 at 1:28 PM, the Administrator stated the Water Management Plan was important to ensure Legionella was controlled, and all parties involved needed to know their role. 10 NYCRR 415.19

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that foods were stored in accordance with professional standards for food safety practice. Specifically, for 2 of 4 nourishment refrigerators (Armonk and Canterbury units): (1) freezer thermometer readings did not reflect acceptable temperatures and no corrective action had been taken, and (2) foods stored in freezer compartments were not frozen solid. The facility's freezers must be in good working condition and must keep frozen foods frozen solid. The finding is: An Engineering policy and procedure for Temperature Logs dated (MONTH) (YEAR) revealed the Engineering Mechanic fills out logs for refrigerators and freezers on a daily basis; freezer temperatures should be between -10 and 0 degrees F and notifies Engineering Director of any temperatures that do not fall in the proper ranges. An inspection of all nourishment refrigerators in the facility conducted on 5/1/19 between 12:00 PM and 12:30 PM with the Food Service Director (FSD) present revealed: (1) Canterbury unit: freezer thermometer reading +10 degrees F and 15 ice cream cups/magic cups (a thickened frozen dessert) not frozen solid. Upon surveyor request for the unit temperature log, the FSD reported that Engineering is responsible for monitoring and recording thermometer readings. The Director of Engineering (DE) reviewed the (MONTH) 2019 temperature log with the surveyor and it revealed readings between +2 degrees and +8 degrees F for 29 of 30 days. The FSD responded by discarding the ice cream cups and magic cups. (2) Armonk unit: freezer thermometer reading +6 degrees F and 4 ice cream cups not frozen solid. (MONTH) 2019 temperature log for all days revealed readings between +2 degrees and +18 degrees F. The FSD responded by discarding the ice cream cups. The DE was interviewed on 5/1/19 at 12:10 PM and reported the Engineering Mechanic (EM) was responsible for monitoring freezer temperatures, temperatures should be maintained between -10- and 0-degrees F; the EM should report temperatures that are not in range, and further reported the EM had not reported temperatures out of range. The EM was interviewed on 5/01/19 at 12:45 PM and reported the freezer temperatures should be between 0- and +10-degrees F and he had reported the temperature of +18 degrees F to the DE. 415.14(h)

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan with measurable goals and interventions was developed to address the resident's diabetic needs. Specifically, 1 of 5 residents (Resident # 83) did not have a care plan in place to address his diabetic needs. The findings are: Resident # 83 had [DIAGNOSES REDACTED]. In an interview with the resident on 4/24/2019 at 1:54 PM he stated that his blood sugar levels had not been managed properly. He stated that the levels were usually in the 300's. According to the 3/22/2019 minimum data set (MDS- a resident assessment tool) the resident had a brief interview for mental status (BIMS) score of 14/15, which indicated intact cognition, dependent on insulin for Diabetes, and required extensive assistance with his activities of daily living (ADLs). The 4/8/19 physician orders [REDACTED]. Review of the blood sugar log from 3/15/19-4/29/19 revealed the resident's blood sugar levels fluctuated and were over 300 mg/dl on multiple occasions. There was no documented evidence that a person-centered care plan with measurable goals and interventions was developed to address the resident's diabetic needs. The Registered Nurse (RN#1) was interviewed on 4/29/19 at 1:19 PM and stated that the resident's blood sugar was elevated related to a medication injection that was given for back pain. RN #2 was interviewed on 4/29/19 at 1:42 PM and stated that the nurses were responsible for developing specific diabetic care plans. RN #2 further stated that the resident should have had one in place because of the fluctuating blood sugar levels. 415.11 (c) (1)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that residents received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 resident reviewed for vision and hearing. ( Resident #55). The finding is: Resident #55 was admitted with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS-a resident assessment tool) dated 03/01/2019 documented that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 indicating severe cognitive impairment. The MDS further documented that the resident had minimal hearing difficulty with no hearing aid. Review of the Annual MDS dated [DATE] documented that the resident had minimal hearing difficulty and used a hearing aid. Review of the Admission Nursing Evaluations dated 10/17/2018 and 02/25/2019 documented that the resident had adequate hearing to both ears and does not use a hearing aid. Review of the Hearing Impaired, Hearing Aid Care Plan initiated on 10/26/2018 and updated on 02/01/2019 documented the following interventions: maintain proper hygiene of hearing aid(s) ,proper storage of hearing aid (s) when not in use and promote resident's compliance with usage and storage. Review of the Physician order [REDACTED]. Review of the Progress Notes from 10/17/2019 to 05/01/2019 revealed no documentation that an ENT consultation took place. Review of the Resident Nursing Instructions from 10/17/2018 to 05/01/2019 documented that the resident hears adequately and had no hearing devices. During the initial pool interview on 04/24/19 at 10:07 AM the resident stated that she could not hear the surveyor's questions because she wasn't wearing her hearing aid. She further stated the hearing aid was lost and she told staff, but no one has been able to locate it. The resident added that she had not had an ENT consult. An interview was conducted with the License Practical Nurse on 05/01/19 at 9:44 AM. She stated that the resident was admitted without a hearing aid. An interview was conducted with the Registered Nurse Manager (RNM) on 05/01/19 at 1:35 PM. She stated that the resident was assessed upon admission on hearing function but had an adequate assessment and there was no hearing aid documented. The RNM added that they did not refer the resident to an ENT. The RNM also stated that the resident's hearing aid (s) are documented on the physician's orders [REDACTED]. 415.12(3)(b)

Based on record review and interview the facility did not ensure proper documentation of an antianxiety medication administered for 1 of 5 residents reviewed for unnecessary medications (#110). Specifically, the dosage of the antianxiety medication was not consistently and accurately recorded in accordance with the physician's orders [REDACTED].>The findings are: Resident #110 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (a resident assessment tool) dated 4/12/17 indicated the resident was receiving antidepressant and antianxiety medications on the last seven days of the assessment period. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Control Record of Narcotics and Sedatives Record for July and August 2017 indicated inconsistencies in the documentation regarding administration of the Klonopin. In some instances the documentation indicated that half a dose (of 0.25mg) was given and in other instances the documentation indicated that one full dose was given. The documentation identifying how many doses remained after each administration went down by one each time. The Licensed Practical Nurse (LPN) in charge was interviewed on 8/31/17 at 11:30 AM and stated that the pills were pre split so that only one dose is administered each time. The LPN reviewed the documentation and stated that the nurses are documenting incorrectly the dosage incorrectly. When asked about the number of doses remaining after each administration, the LPN stated that the count was correct and that since the blister pack contained pre-split pills and only one dose is given, the count should go down by one each time. The LPN stated she would bring the issue of inaccurate documentation to the attention of the Inservice Coordinator. 415.22(a)(1-4)

Based on observation, record review and interview, the facility did not provide on-going activity programs to meet residents' interests and needs to enhance the highest level of mental and psychosocial well-being. Specifically: (1) cognitively impaired residents were not encouraged to be active participants in activity programs; and (2) an alert and oriented resident was not offered activities of personal interest. This was evident for three of four residents reviewed for activities (Residents #67, #113 and #121). This resulted in no actual harm with a pattern of potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #67 was admitted to the facility on [DATE] for short term rehabilitation and has [DIAGNOSES REDACTED]. A Social Service Progress Note, dated 4/9/13, indicated that the resident was disappointed that she was unable to return home and her care plan had changed to long term care placement. In an interview with the resident, on 5/15/13 at 10:18 AM, the resident stated that she did not find the group activities offered by the facility to be stimulating. The resident stated that her hobbies, when living at home, were piano playing, painting and traveling. In addition, she stated that the facility did not have books that she would be interested in reading. A review of the resident's current Activity Care Plan revealed a goal for the resident to continue to attend three group programs weekly over the next 90 days. Interventions included quarterly evaluations of the resident's participation and preferences. A review of the resident's Events Attendance Forms for March, April and May, 2013 indicated that the only group activities attended by the resident were religious activities. There was no documented evidence of attempts to provide opportunities for the resident to participate in other activities that met her personal interests. The resident's Activity Leader was unavailable to be interviewed. In an interview with the Social Worker, on 5/17/13 at 1:15 PM, the Social Worker stated that the resident enjoyed going down stairs for lunch and dinner and family visits in the facility. The Social Worker further stated that the resident tended to stay in her room and that the only activities that the resident attended were religious services. 2. Resident #121 has [DIAGNOSES REDACTED]. According to the 3/15/13 MDS (Minimum Data Set) assessment for a significant change in status, 3/15/13, the resident was severely cognitively impaired and the staff had to determine activity preferences for the resident. The preferences identified included music, being outdoors and attending religious activities. The activity plan of care for the resident, dated 3/12/13, noted that the resident attended activities but did not participate due to impaired communication, cognition and physical ability. The goals developed to address the resident's need for leisure activities were 1) to continue to attend three programs weekly and 2) to attend large social events. The interventions to achieve these goals included for the activity staff to invite and escort the resident to activities as needed and to encourage and praise participation in activities. The activity assessment dated [DATE] revealed that the resident chose to pursue the following activities: peer socialization, television, music and family visits. A Turning and Positioning schedule indicated that the resident's time out of bed was limited since 4/27/13. The resident's attendance record for activities for the month of May 2013 was reviewed. This review showed no participation in room activities conducted by staff. On 5/16/13 the resident was observed in bed between 10:00 AM and 10:42 AM. No music or television was on in the room. At 1:00 PM on 5/16/13 the resident was again observed in bed sleeping. No music or television was on in the room. On 5/16/13 at 2:00 PM the Licensed Practical Nurse charge nurse (LPN) stated that currently the resident currently spent most of the time in bed to aid in the healing of a wound as per the Nurse Practitioner's recommendation. The LPN also stated that the resident got up at 11:00 AM and went back to bed after lunch, and was gotten out of bed again just before the evening shift for supper. The Head of Activities was interviewed at 1:10 PM on 5/17/13 and reported no knowledge or awareness of the resident being confined to bed to aid in wound healing. On 5/17/13 at 2:05 PM the resident was observed in bed sleeping. The CNA (Certified Nurse Aide) assigned to the resident was interviewed on 5/17/13 at 2:05 PM. The CNA stated that the resident did not watch TV and slept in bed the majority of the time. 3. Resident #113 has [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed that the resident had little interest in activities, and showed preferences for music, group activities, outdoor activities and was somewhat interested in animals and going to religious activities. The MDS also revealed that the resident had both expressive and receptive communication abilities, that she usually understands others and had difficulty communicating some words or finishing thoughts but was able if prompted or given time and misses some part/intent of messages but comprehends most of a conversation. Additionally the MDS showed that the resident had impaired vision and scored 4 out of 15 on the Brief Interview for Mental Status test to assess orientation and ability to recall new information. According to the care plan to address the resident's mood, dated 3/10/13, the resident showed little interest in doing things and had an anxious mood. To address these concerns, the resident was to be encouraged to participate in recreational programs. The 3/10/13 care plan showed that the resident was an active participant in activity programs. The interventions to address activity needs included to encourage and praise participation in activities and allow time to respond in interactive activities. On 5/16/14 the resident was observed in multiple activities conducted in a large room with over 20 residents present. These activities were as follows: - 10:30 AM. Word search in progress. The resident was not seated close to the activity leader. The resident did not participate and was not prompted to participate. - 1:26 PM. Discussion/word game activity. The resident was not seated close to the activity leader. The resident's head was bowed low and she did not take part in the activity. - 3:40 PM. Discussion/trivia activity. The resident was not sitting close to the activity leader and was not prompted to take part in the activity. The resident showed no interest in the activity. The Activity Director was interviewed following these observations and stated that the activity leaders were trained on how to engage residents in activities and was not aware of why the resident's needs were not addressed. 415.5(l)(1)

Based on observation, interviews and record review, the facility did not ensure that a potentially hazardous food was stored at the proper temperature. This had the potential of resulting in more than minimal harm to multiple residents in the facility that was not immediate jeopardy. The findings are: On 5/14/13 at about 9:00 AM two extra large pieces of roast beef (1 piece greater than 10 lbs and the other piece greater than 20 lbs were stored covered in insert stainless steel pans in the walk-in refrigerator. The temperature of the smaller piece was noted to be 50 degrees Fahrenheit and the larger piece was 60 degrees Fahrenheit. The internal temperature of potentially hazardous, refrigerated foods are to be stored at 41 degrees Fahrenheit or below. (The temperature of the refrigerator was in the acceptable range). A review of temperature log for cooling revealed that the beef was cooked on 5/13/13 at 8 AM, cooled to 70 degrees at 10 AM and by 12 noon was cooled to 39 degrees Fahrenheit. The roast beef was scheduled to be served for supper on the evening of 5/14/13. The Food Service Director stated that it would not be served. The cook who had cooled the beef on 5/13/13 was interviewed on 5/14/13 at 1:00 PM. She stated that both pieces of beef were placed in an ice bath for 2 hours and were cooled to 70 degrees Fahrenheit within 2 hours. The cook stated that the meats were then placed in the freezer and, by the end of four hours, they had cooled to 39 degrees Fahrenheit. The cook also stated that the thermometer was placed in the center of each piece. She stated however, that she believed that the thermometer was probably not placed far from the surface of each piece of the beef. . A review of the facility's policy revealed that large items are to be made smaller before cooling with items to be cooled to 70 degrees in 2 hours and then to 40 degrees within the next 4 hours. This policy was not implemented in that both pieces of beef were not cut into small pieces. 415.22(a)(1-4), 14-.40

Based on interview and record review, the facility did not ensure that a resident who displayed adjustment disorder after admission to the facility was provided comprehensive medically-related social services to attain and maintain the highest practicable psychosocial well-being. Specifically, the resident's refusals for psychological services, identified as being necessary to address depression and adjustment disorder, was not acknowledged and addressed by the social worker. This was evident for one of one residents reviewed for behavior (Resident #198) and had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #198, a [AGE] year old female, was admitted to the facility on [DATE] for rehabilitation services following hospitalization for a fracture sustained at home. The resident's admitting [DIAGNOSES REDACTED]. A review of the resident's clinical record showed multiple notes written by the social worker (SW) in reference to a decline in the resident' mood state, as follows: - 8/30/12 note showed that there was no change in the resident's status since the last assessment except for a decline in mood. "The resident reported difficulty in sleeping, energy level and appetite. Little pleasure in doing anything. Res (resident) thought that she would be better off dead; denies wanting to hurt self. Struggling with adjustment to placement. SW (social worker) to remain available to resident and family. Offer emotional support as needed." - 9/12/12 "Some decline in mood due to report of increased feeling of depression; decline in sleeping appetite and self esteem. Resident wishes she was no longer alive. Did report improved interest and pleasure in doing things. Treatment team aware of res's mood state. SW to remain available. Offer emotional support, monitor for changes." - 9/13/12 Treatment team met with resident's daughter. The family states that they are unable to care for the resident at home. - 11/7/12 Resident Change Adjustment Note. Mood score declined from 6 to 15 due to resident expressing feelings of depression, little energy, poor appetite, poor self esteem and often wishing she was no longer alive. The treatment team made aware and psychologist notified. - 12/8/12 Mood score declined due to resident reporting problems with sleep and continues to wish she was dead. Treatment team aware. Resident would like to be discharged to home but knows she cannot manage there. - 2/27/13 "Resident continues to feel very down, trouble sleeping, little energy, poor appetite, feeling like she is letting herself down and wishing she was no longer alive. No behaviors observed. Resident is diagnosed with [REDACTED]. SW to remain available to res family, offer emotional support and to monitor for changes in res' status and for (signs and symptoms) of distress over placement." The resident's record also showed that she was under the care of a psychiatrist for medication management. The psychiatrist's visits reflected the following: - 9/05/12. Noted to be depressed. Recommended 10 mg Prozac (an antidepressant). - 9/12/12 Remain depressed, not eating, does not feel life worth living. Increased Prozac to 20 mg - 4/12/13 History of episodes of anxiety; on Prozac and Xanax (an antianxiety medication). Behavior worse. Increase Prozac to 20 mg daily secondary to anxiety. - 4/23/13 Mood euthymic. Continue medication management. Follow-up in 8 weeks. The review of the resident's record revealed no visits/evaluations by a psychologist to address the referral made by the SW on 11/7/12 and physician orders [REDACTED]. The resident was observed and interviewed on 5/16/13 during lunch meal. The resident did not eat most of her meal. She expressed concern about living so long and that she would "like to go." The SW was interviewed at 4:10 PM on 5/16/13. The SW stated that the resident was referred to the team and psychologist as documented in the note written on 11/7/13 mentioned above. The SW then searched the resident's record for the psychologist's report. The SW reported that none could be found. The SW also stated that she was not aware if the resident was seen by the psychologist after the referral was made on 11/7/12. Following this interview, the SW called the psychologist assigned to the facility to inquire about the psychologist's evaluation related to the 11/7/12 referral. On 5/17/13 at 12:40 PM the SW presented the surveyor with three psychological evaluations/reports. The initial report (Report of Initial Diagnostic Interview) was dated 8/30/12 and noted that the resident had Adjustment Disorder and psychosocial & environmental problems related to health and loss of independence. The psychologist documented that the resident was not interested in receiving psychological services at that time and that he would revisit at the resident's interest in psychological services at her request or at the request of the staff. The second documented visit/report by the same psychologist occurred on 12/24/12 (31 days after the SW had made a referral) due to coping with loss of independence and depressed mood. The documented outcome of the session was that the resident indicated that she was not interested in psychological services at that time and would not meet with the psychologist. There was no documented evidence that the SW or any other member of the interdisciplinary treatment team was informed of the resident's refusal for psychotherapy or that the SW offered to provide 1:1 counsel as an alternative to the psychotherapy with the psychologist refused by the resident. An interview with the SW on 5/17/13 at 12:40 PM revealed that she was not aware that the resident had refused psychological therapy. The SW stated that she should have been aware. Following surveyor's inquiry, the resident was evaluated by another psychologist on 5/16/13. The report of this visit was one of the reports the SW presented to the surveyor on 5/17/13 at 12:40 PM. The outcome of this visit as documented by the psychologist was that the resident has agreed to see the psychologist for therapy. 415.5(g)(1)(i-xv)

Based on observation, record review and interview, the facility did not review and/or revise care plans for activities to reflect residents' interests and needs. This was evident for three of four residents whose care plans were reviewed for activities (Residents #67, #121 and #171). This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #67 was admitted to the facility on [DATE] for short term rehabilitation and has [DIAGNOSES REDACTED]. A review of a Social Service Progress note dated 4/9/13 indicated that the resident was disappointed that her status was changed from returning home to long term care.. A review of the resident's current Activity Care Plan revealed a goal for the resident to continue to attend three group programs weekly over the next 90 days. Interventions included quarterly evaluations of resident's participation and preferences. A review of the resident's Events Attendance Forms for March, April and May, 2013 indicated that the only group activities attended by the resident were religious group activities. In an interview with the resident on 5/15/13 at 10:18 AM, the resident stated that she had no interest in the group activities provided by the facility and that the facility did not have books that she would be interested in reading. The resident's Activity Leader was unavailable to be interviewed. In an interview with Social Worker on 5/17/13 at 1:15 PM, she stated that the resident enjoyed going down stairs for lunch and dinner and family visits in the facility. The Social Worker stated that the resident tended to stay in her room and that the only recreational group activities that the resident may attend are religious services. 2. Resident #121 has [DIAGNOSES REDACTED]. According to the 3/15/13 MDS (Minimum Data Set) assessment for a significant change in status, 3/15/13, the resident was severely cognitively impaired and the staff had to determine activity preferences for the resident. The preferences identified included music, being outdoors and attending religious activities. The activity plan of care for the resident, dated 3/12/13, noted that the resident attended activities but did not participate due to impaired communication, cognition and physical ability. The goals developed to address the resident's need for leisure activities were 1) to continue to attend three programs weekly and 2) to attend large social events. The interventions to achieve these goals included for the activity staff to invite and escort the resident to activities as needed and to encourage and praise participation in activities. The activity assessment dated [DATE] revealed that the resident chose to pursue the following activities: peer socialization, television, music and family visits. A Turning and Positioning schedule indicated that the resident's time out of bed was limited since 4/27/13. On 5/16/13 the resident was observed in bed between 10:00 AM and 10:42 AM. No music or television was on in the room. At 1:00 PM on 5/16/13 the resident was again observed in bed sleeping. No music or television was on in the room. On 5/16/13 at 2:00 PM the Licensed Practical Nurse charge nurse (LPN) stated that currently the resident currently spent most of the time in bed to aid in the healing of a wound as per the Nurse Practitioner's recommendation. The LPN also stated that the resident got up at 11:00 AM and went back to bed after lunch, and was gotten out of bed again just before the evening shift for supper. The resident's attendance record for activities for the month of May 2013 was reviewed. This review showed no participation in room activities conducted by staff. A review of the resident's activity care plan revealed that it was not revised to address lack of participation in activities when out of bed and to include activities conducted by the staff when in bed. The Head of Activities was interviewed at 1:10 PM on 5/17/13 and reported no knowledge or awareness of the resident being confined to bed to aid in wound healing. On 5/17/13 at 2:05 PM the resident was observed in bed sleeping. The CNA (Certified Nurse Aide) assigned to the resident was interviewed on 5/17/13 at 2:05 PM. The CNA stated that the resident did not watch TV and slept in bed the majority of the time. 3. Resident #113 has [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed that the resident had little interest in activities, and showed preferences for music, group activities, outdoor activities and was somewhat interested in animals and going to religious activities. The MDS also revealed that the resident had both expressive and receptive communication abilities, that she usually understands others and had difficulty communicating some words or finishing thoughts but was able if prompted or given time and misses some part/intent of messages but comprehends most of a conversation. Additionally the MDS showed that the resident had impaired vision and scored 4 out of 15 on the Brief Interview for Mental Status test to assess orientation and ability to recall new information. According to the care plan to address the resident's mood, dated 3/10/13, the resident showed little interest in doing things and had an anxious mood. To address these concerns, the resident was to be encouraged to participate in recreational programs. The 3/10/13 care plan showed that the resident was an active participant in activity programs. The interventions to address activity needs included to encourage and praise participation in activities and allow time to respond in interactive activities. On 5/16/14 the resident was observed in multiple activities conducted in a large room with over 20 residents present. These activities were as follows: - 10:30 AM. Word search in progress. The resident was not seated close to the activity leader. The resident did not participate and was not prompted to participate. - 1:26 PM. Discussion/word game activity. The resident was not seated close to the activity leader. The resident's head was bowed low and she did not take part in the activity. - 3:40 PM. Discussion/trivia activity. The resident was not sitting close to the activity leader and was not prompted to take part in the activity. The resident showed no interest in the activity. The Activity Director was interviewed following these observations and stated that the activity leaders were trained on how to engage residents in activities and was not aware of why the resident's needs were not addressed. 3. Resident #171 is an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS Annual assessment, dated 1/1/13, revealed that it was important for the resident to listen to music, to do things with groups of people and to participate in religious services. A review of the Comprehensive Care Plan for Activities, dated 1/8/13, revealed that activity goals for the resident included: "Resident to continue to attend 5 programs weekly," and "Resident will attend large Social Events over the next 90 days." Care Plan Interventions included: - Activity Staff will encourage and praise participation in activities. - Encourage resident to reminisce about past. - Allow resident time to respond in interactive activity programs. The resident was observed in the parlor room on 5/14/13 between 10:00 AM and 10:45 AM, when she was seated in a wheelchair along with three other residents. There was a small group around the television watching a travel program and there was an Activities staff person with the group. The resdient was not engaged in the activity. No interaction was observed with this resident or the other three residents who were seated along side her. The resident was observed again on 5/17/13 between 9:30 AM and 11:00 AM seated in a wheelchair along with several residents in a small group with a movie playing on the television screen, followed by silent scenes on the television. In the other end of the room there was a religious Mass being held from 10:00 AM until 11:00 AM. According to the resident's assessment, dated 1/8/13, it was very important for her to participate in religious services. During the service the resident was at the other end of the room with her back to the religious service. There was a member of the Activity staff in this area who was involved with one resident. There was no interaction observed with the resident. The Director of Activities was interviewed on 5/17/13 at 1:15 PM and at that time she stated that she had folded a lot of towels with the resident earlier in the day. She further stated that it is important to "get to" the resident early in the day when she is "at her best" and that the resident likes to do things with her hands. She also stated that she had done other things when the resident was able to use her hands on the day of the first observation. There was no evidence that the care plan for Activities was reviewed and revised to reflect the current status of the resident to reflect that she liked to do activities with her hands during the early part of the day. . 414.11(c)(2)(i-iii)

Based on observation, interview and record review, the facility did not ensure that a resident who displayed psychosocial difficulty was provided appropriate treatment and services to correct the problem. Specifically: 1) the resident's refusal of psychological services to address problems in adapting to loss in independence and long term placement in the facility was not addressed with appropriate alternative services/treatment by another qualified staff member; and 2) causal factors for increased anxiety demonstrated by the resident in the evenings were not assessed and addressed with non-pharmacological interventions as appropriate . This was evident for one of one residents reviewed for behavior (Resident # 198). This had the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #198, a [AGE] year old female, was admitted to the facility on [DATE] for rehabilitation services following hospitalization for a fracture sustained at home. The resident's admitting [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, an assessment instrument) dated 2/26/13 revealed that the resident exhibited the following symptoms indicative of problems with her mood: depression, trouble falling asleep, little energy, poor appetite, feeling bad about self and thoughts of being better off being dead. The resident had a score of 13 out of 15 on the Brief Interview for Mental Status test to measure orientation and ability to recall new information, reflected in the MDS. A) One of the psychosocial goals developed for the resident on 8/24/12 was to have a positive adjustment to placement as evidenced by verbalizations of same and no symptoms of emotional distress. A review of the resident's clinical record showed multiple notes written by the social worker (SW) in reference to a decline in the resident' mood state. These notes are as follows: - 8/30/12 note showed that there was no change in the resident's status since the last assessment except for a decline in mood. "The resident reported difficulty in sleeping, energy level and appetite. Little pleasure in doing anything. Res (resident) thought that she would be better off dead; denies wanting to hurt self. Struggling with adjustment to placement. SW (social worker) to remain available to resident and family. Offer emotional support as needed." - 9/12/12 "Some decline in mood due to report of increased feeling of depression; decline in sleeping appetite and self esteem. Resident wishes she was no longer alive. Did report improved interest and pleasure in doing things. Treatment team aware of res's mood state. SW to remain available. Offer emotional support, monitor for changes." 9/13/12 Treatment team met with resident's daughter. The family states that they are unable to care for the resident at home. - 11/7/12 Resident Change Adjustment Note. Mood score declined from 6 to 15 due to resident expressing feelings of depression, little energy, poor appetite, poor self esteem and often wishing she was no longer alive. The treatment team made aware and psychologist notified. - 12/8/12 Mood score declined due to resident reporting problems with sleep and continues to wish she was dead. Treatment team aware. Resident would like to be discharged to home but knows she cannot manage there. - 2/27/13 "Resident continues to feel very down, trouble sleeping, little energy, poor appetite, feeling like she is letting herself down and wishing she was no longer alive. No behaviors observed. Resident is diagnosed with [REDACTED]. SW to remain available to res family, offer emotional support and to monitor for changes in res' status and for (signs and symptoms) of distress over placement." The resident's record also showed that she was under the care of a psychiatrist for medication management. The psychiatrist's visits reflected the following: - 9/05/12. Noted to be depressed. Recommended 10 mg [MEDICATION NAME] (an antidepressant). - 9/12/12 Remain depressed, not eating, does not feel life worth living. Increased [MEDICATION NAME] to 20 mg - 4/12/13 History of episodes of anxiety; on [MEDICATION NAME] and [MEDICATION NAME] (an antianxiety medication). Behavior worse. Increase [MEDICATION NAME] to 20 mg daily secondary to anxiety. - 4/23/13 Mood euthymic. Continue medication management. Follow-up in 8 weeks. The review of the resident's record revealed no visits/evaluations by a psychologist to address the referral made by the SW on 11/7/12 and physician order [REDACTED]. The resident was observed and interviewed on 5/16/13 during lunch meal. The resident did not eat most of her meal. She expressed concern about living so long and that she would "like to go." The SW was interviewed at 4:10 PM on 5/16/13 and stated that the resident was referred to team and psychologist as documented in the note written on 11/7/13 mentioned above. The SW then searched the resident's record for the psychologist's report. The SW reported that none could be found. The SW also stated that she was not aware if the resident was seen by the psychologist after the referral was made on 11/7/12. Following this interview, the SW called the psychologist assigned to the facility to inquire about the psychologist's evaluation related to the 11/7/12 referral. On 5/17/13 at 12:40 PM the SW presented the surveyor with three psychological evaluations/reports. The initial report (Report of Initial Diagnostic Interview), dated 8/30/12, noted that the resident had Adjustment Disorder and psychosocial & environmental problems related to health and loss of independence. The psychologist documented that the resident was not interested in receiving psychological services at that time and that he would revisit at the resident's interest in psychological services at her request or at the request of the staff. The second documented visit by the same psychologist occurred on 12/24/12 (31 days after the SW had made a referral on 11/7/12) due to coping with loss of independence and depressed mood. The outcome of the session was that the resident indicated that she was not interested in psychological services at that time and would not meet with the psychologist. There was no documented evidence that the SW or any other member of the interdisciplinary treatment team was informed of the resident's refusal for psychotherapy or that the SW offered to provide 1:1 counsel as an alternative to the psychotherapy by the psychologist refused by the resident. An interview with the SW on 5/17/13 at 12:40 PM revealed that she was not aware that the resident had refused psychological services. The SW stated that she should have been aware. Following surveyor's inquiry, the resident was evaluated by another psychologist on 5/16/13. The report of this visit was one of the reports the SW presented to the surveyor on 5/17/13 at 12:40 PM. The outcome of this visit as documented by the psychologist was that the resident agreed to see the psychologist for therapy. B) A review of the Medication Administration Records for the months of April through May 2014 revealed that an antianxiety medication ([MEDICATION NAME] or [MEDICATION NAME] ) prescribed to be given as needed was administered to the resident almost daily in the evenings. The resident's clinical record did not include any evidence that the nursing staff (or any other member of the treatment team) attempted to determine the causative factors for the resident's anxiety or provide non-pharmacological interventions in addition to or in lieu of medication, as deemed appropriate, to aid in relieving the resident's anxiety and reduce dependency on medication. The medication evening nurse was not available to be interviewed. An interview with Licensed Practical Nurse charge nurse (LPN) on 5/17/13 at 9:00 AM revealed that the resident was provided the antianxiety medication in the evenings because she displayed symptoms of anxiety i.e shortness of breath although the resident's oxygen saturation level revealed that she was receiving sufficient oxygen. The LPN stated that calming techniques and reasons for administering medication should have been noted. 415.12(f)(1)

Based on observation, record review and interviews the facility did not ensure that medications were administered with error rates of less than 5%. This was evident for two residents on the Armonk Unit (Residents #39 and #268) during observation of administration of thirty-one medications and resulted in a medication error rate of 6%. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. During observation of the medication administration pass on the Armonk unit on 5/16/13 at 3:45 PM the Licensed Practical Nurse (LPN) was observed to administer medications to Resident #268 including [MEDICATION NAME] 25 Mg. A review of the resident's current physician's orders [REDACTED]. The Blister Pack (a package designated for the resident with name and instructions for time of administration) was reviewed. According to the blister pack, the time for administration of the [MEDICATION NAME] was 8:30 AM and 8:30 PM. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Under the column where times of administration are designated, the hours of administration were identified as 8:30 AM and 4:30 PM. The Licensed Practical Nurse was interviewed at the time of administration and, at that time, she stated that the designated times were 8:30 AM and 4:30 PM. The Registered Nurse/Unit Manager (RN) was interviewed immediately following the above interview and, at that time, the RN stated that she would clarify with the physician. The RN stated that the orders are to be checked for accuracy and signed by three nurses. The Medical Director was interviewed on the unit at 4:15 PM on 5/17/13 and, at that time, he stated that the medication should be given at 8:30 AM and 4:30 PM and he wrote an order at that time.. The Director of Nursing (DON) was interviewed at 1:00 PM on 5/17/13 at 1:15 PM and at that time the DON stated that medications which are ordered to be administered twice daily are entered on the computer, and the administration times for twice daily medications at the facility are 8:30 AM and 4:30 PM. The DON further stated that the order should have been clarified with the physician. 2. During observation of medication administration on the Armonk Unit on 5/17/13 at 8:20 AM the LPN was observed to administer medications to Resident #39. The medications included Vitamin C 250 Mg. A review of the resident's current physician's orders [REDACTED]. 415.12(m)(1)

Based on interview and record review, the facility did not ensure that a record of psychological assessments/evaluations was maintained in the clinical record of a resident who displayed signs and symptoms of adjustment disorder. These assessments/evaluations contained information necessary for the interdisciplinary team to develop approaches in addressing the resident's psychosocial problems. This was evident for 1 of 25 sampled residents (Resident #198) and had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #198, a [AGE] year old female, was admitted to the facility on [DATE] for rehabilitation services following hospitalization for a fracture sustained at home. The resident's admitting [DIAGNOSES REDACTED]. A review of the resident's clinical record showed multiple notes written by the social worker (SW) in reference to a decline in the resident's mood state. These notes were written on 8/30/12, 9/12/12, 11/7/12, 12/8/12 and 2/27/13. Specific examples are as follows: - 8/30/12 note showed that there was no change in the resident's status since the last assessment except for a decline in mood. "The resident reported difficulty in sleeping, energy level and appetite. Little pleasure in doing anything. Res (resident) thought that she would be better off dead; denies wanting to hurt self. Struggling with adjustment to placement. SW (social worker) to remain available to resident and family. Offer emotional support as needed." - 11/7/12 Resident Change Adjustment Note. Mood score declined from 6 to 15 due to resident expressing feelings of depression, little energy, poor appetite, poor self esteem and often wishing she was no longer alive. The treatment team made aware and psychologist notified. - 2/27/13 "Resident continues to feel very down, trouble sleeping, little energy, poor appetite, feeling like she is letting herself down and wishing she was no longer alive. No behaviors observed. Resident is diagnosed with [REDACTED]. SW to remain available to res family, offer emotional support and to monitor for changes in res' status and for (signs and symptoms) of distress over placement." The review of the resident's record revealed no evidence of visits/evaluations by a psychologist to address the referral made by the SW on 11/7/12 and physician orders [REDACTED]. The resident was observed and interviewed on 5/16/13 during lunch meal. The resident did not eat most of her meal. She expressed concern about living so long and that she would "like to go." The SW was interviewed at 4:10 PM on 5/16/13. The SW stated that the resident was referred to team and psychologist as documented in the note written on 11/7/13 mentioned above. The SW then searched the resident's record for evidence of a psychologist's report. The SW reported that none could be found. The SW also stated that she was not aware if the resident was seen by the psychologist after the referral was made on 11/7/12. Following this interview, the SW called the psychologist assigned to the facility to inquire about the psychologist's evaluation related to the 11/7/12 referral. On 5/17/13 at 12:40 PM the SW handed the surveyor two psychological evaluations/reports that were not available at the facility. An initial report (Report of Initial Diagnostic Interview) was dated 8/30/12 and noted that the resident had Adjustment Disorder and psychosocial & environmental problems related to health and loss of independence. The psychologist documented that the resident was not interested in receiving psychological services at that time. He would revisit the resident's interest in psychological services at her request or at the request of the staff. The second visit by the same psychologist occurred on 12/24/12 (31 days after the SW had made a referral) due to coping with loss of independence and depressed mood. The documented outcome of the session was that the resident indicated that she was not interested in psychological services at that time and would not meet with the psychologist. There was no documented evidence that the SW or any other member of the interdisciplinary treatment team was informed of the resident's refusal for psychotherapy or that the SW offered to counsel as an alternative to therapy by the psychologist. An interview with SW on 5/17/13 at 12:40 PM revealed that she was not aware that the resident had refused psychological therapy. She stated that she should have been aware. 415.22(a)(1-4)