Every finding on record at Wayne Center For Nursing & Rehabilitation

Based on record review and interviews, the facility failed to ensure that the resident and their representative were provided with a copy of the resident health care records upon written request and two working days' advance notice to the facility. This was evident for one of two residents (Resident #15) reviewed for Choices and one of two residents (Resident #117) reviewed for Notification of Change out of 38 sampled residents. Specifically, 1) Resident #15 requested medical records on 05/25/2026, which were not received until 06/09/2026, and 2) Resident #117's representative requested medical records on 05/29/2026, which were not received until 06/15/2026. The findings include: The facility policy and procedure titled Medical Records last revised in January 2025, documented that it is the facility's policy to release clinical information to those requesting it in a timely manner, within two business days. 1. Resident #15 was admitted to the facility with diagnoses that include diabetes mellitus, (a chronic condition where high blood sugar occurs because the body cannot make enough insulin or use it proper) and coronary artery disease (a condition where the major blood vessels supplying the heart get narrow or blocked). The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #15 is cognitively intact and participated in assessment and goal setting. During an interview on 07/14/2026 at 11:54 AM, Resident #15 stated that it has been two months since they requested their medical records and that the social worker had not gotten back to them. Resident #15 presented a copy of the completed form to the state surveyor, indicating a request for medical records and stated that they requested the medical records themselves. A care plan note dated 05/06/2026 by Social Worker #2, documented that Resident #15 requested medical records copy, however documents were given to Resident #15 to sign for the HIPPA (Health Insurance Portability and Accountability Act) consent and social worker has been constantly asking for it, to proceed with their request. There was no documented evidence Resident #15 was provided with a copy of their medical record within two working days of their request. On 07/20/2026 at 10:09 AM, Social Worker #2 was interviewed and stated that they are the assigned social worker for Resident #15. Social Worker #2 also stated that when Resident #15 was transferred to the 4th floor, they had been requesting documents, so the social worker gave Resident #15 the form to complete and stated that Resident #15 never returned the form that they gave them to complete. On 07/20/2026 at 12:41 PM, Social Worker #3 was interviewed and stated that Resident #15 had requested their medical records and that they received it via a disc, but Resident #15 requested paper copies. Social Worker #3 also stated that they informed Resident #15 that there would be a charge if they got a large amount of paper, and that if they wanted something specific, then they would request the specific pages from the Administrator. Social Worker #3 further stated that they were just assisting Resident #15 and was not aware of how long it took for Resident #15 to receive the documents. On 07/20/2026 at 3:29 PM, the Medical Records Director was interviewed and stated that Resident #15 requested the medical records on 05/25/2026 and they were given to them on 06/09/2026. The Medical Records Director also stated that Resident #15 made the request themselves on 05/25/2026, and when a request is made, the process should take about 48 hours to get the requested information. On 07/21/2026 at 2:12 PM, the Administrator was interviewed and stated that they spoke with Resident #15 about the medical records which were 8000 pages and would fill about two boxes. The Administrator also stated that Resident #15 did not ask for anything else and that the time frame for receiving the medical records depends on corporate compliance as if there is any discrepancy that would be reviewed first. 2. Resident #117 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it difficult to breathe) and dementia (a pattern of mental decline). The Minimum Data Set (an assessment tool) dated 05/19/2026 documented Resident #117 had moderately impaired cognition, and their representative participated in the assessment. During an interview on 07/14/2026 at 11:36 AM, Resident #117's representative stated that Resident #117 fell on [DATE], and they requested a copy of their medical records on 05/29/2026 and received them about a month ago. A review of the Authorization for Release of Health Information form revealed that Resident #117's representative submitted the request to the facility on [DATE]. During an interview on 07/20/2026 at 3:08 PM, the Medical Records Director stated that if a resident or family requests medical records, they must submit a request form, which is sent to their corporate compliance department. The Medical Records Director also stated that once corporate compliance approves the request, they compile the information, they present it to the administrator and provide it to the family representative after the administrator approves it. The Medical Records Director further stated it takes 72 hours for someone to receive their medical records after they request them. The Medical Records Director stated they needed the health care proxy authorization from Resident #117's representative before they could release the records. During an interview on 07/20/2026 at 3:15 PM, the Administrator stated that the medical record request takes 24–48 hours, and it also depends on when they receive the request. The Administrator also stated they received the request from Resident #117's representative on 05/29/2026. Their corporate compliance office requested a copy of the health care proxy authorization before they could approve the request, and Resident #117's representative was made aware. The Administrator further stated that on 06/11/2026, the Medical Records Director reached out to Resident #117's representative, and they stated that they did not have the health care proxy authorization, so they decided that since the representative is active in Resident #117's care, they approved the request, and the records were picked up on 06/15/2026. 10 New York Codes, Rules and Regulations 415.3(d)(1)(iv)

Number of residents sampled: 2Number of residents cited:1Based on record reviews and interviews, the facility failed to make prompt efforts to resolve grievances. This was evident for one resident (Resident #131) of two residents reviewed for Personal Property. Specifically, facility failed to investigate and provide a written grievance decision to Resident #131's representative regarding missing personal items. The findings include:The facility policy titled Grievance Reporting and Response, dated 01/01/2017 and last revised 10/30/2019, documented that the facility is responsible for investigating and responding to all resident grievances in a timely manner. The policy identified the Social Services Department as responsible for overseeing the grievance process, including receiving, tracking, investigating, and following grievances through to resolution. The policy further required that an investigation be initiated within 48 hours of receipt of the grievance and that both the resident and the complainant be notified in writing of the investigation's outcome. In addition, the facility was required to document the receipt, review, investigation, and disposition of each grievance, including the name of the complainant and resident, a summary of the grievance, and the staff member designated to conduct the review and investigation.Resident #131 had diagnoses that included congestive heart failure (a chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), coronary artery disease (a condition when the blood vessels that supply your heart get clogged, making it harder for your heart to get the blood and oxygen it needs). cerebrovascular accident (also called a stroke or brain attack-happens when blood flow to part of the brain is suddenly blocked or stopped)The Quarterly Minimum Data Set (a resident assessment tool) dated 01/30/2026, documented Resident #131's memory was severely impaired, they required supervision during transfers between the chair and bed, and their family representative participated in the assessment and goal setting process.On 07/15/2026 at 10:14 AM, Resident #131 was observed alert and awake and seated in a wheelchair in the hallway. Resident #131 appeared confused and was able to respond to name and engage in minimal conversation.During an interview conducted on 07/21/2026 at 12:45 PM, Resident #131's representative stated that several personal belongings had gone missing from the resident's closet. Resident #131's representative also stated that all items were labeled when brought to the facility and that the nursing staff maintained a record of the items provided for the resident. Resident #131's representative further stated shoes, clothing, and even food stored in the dining room refrigerator had disappeared, and they had met with the social worker on several occasions regarding the missing items but felt that their concerns were not believed. A review of an email sent to the facility social worker dated 04/21/2026 documented a concern reported by Resident #131's family representative who stated that they had purchased three pairs of shoes for Resident #131, however, all three pairs were reportedly missing. The family representative requested assistance from the facility in replacing the missing items.A review of the family representative's undated, handwritten and signed note which was attached to the email dated 04/21/2026, documented that this was the third time Resident #131 had been missing shoes and a request was made for the facility to get shoes for the resident as they were not going to be purchasing items again.There was no documented evidence that a Resident #131's representative had voiced a grievance or that the grievance had been followed up on and resolved by the facility. During an interview on 07/20/2026 at 10:34 AM, Registered Nurse #8 stated that the resident's family representative approached them on 04/21/2026 in the evening hours and reported concerns regarding missing shoes belonging to the resident. Registered Nurse #8 also stated that the social worker was not available at that time. Registered Nurse #8 further stated that the family representative reported they had previously informed Social Worker #1 about the missing items; however, no action had been taken. Registered Nurse #8 stated that they sent an email to Social Worker #1 regarding the concern and attached a handwritten note from the family representative. Registered Nurse #8 further stated that they informed Social Worker #1 about the missing shoes, either that same day or the next day.During an interview on 07/20/2026 at 10:51 AM, Social Worker #1 stated that when family members bring personal items for residents, the items should be documented and labeled to assist with tracking and accountability if items become missing. Social Worker #1 also stated that the family representative had previously reported missing sneakers and that they had begun addressing the concern. Social Worker #1 further stated that the family representative later informed them that they had purchased another pair of shoes for the resident. Social Worker #1 stated that there was no documentation in the resident's medical record regarding the outcome or resolution of the missing items concern. 10 New York Code Rules and Regulation 415.3(d)(1)(i)

Number of residents sampled: 4Number of residents cited: 1 Based on observation, record review, and interview, the facility failed to ensure that the resident received adequate supervision to prevent accidents. This was evident for one resident (Resident #131) of four residents reviewed for accidents. Specifically, Certified Nursing Assistant #10 did not provide the necessary supervision to a severely confused resident who was also identified as restless, agitated, and at high risk for falls during an attempted transfer to bed. Certified Nursing Assistant #10 left Resident #131 alone in the room, and Resident #131 attempted to transfer independently and fell while trying to get into bed without assistance. Upon re-entering the room, Certified Nursing Assistant #10 placed Resident #131 back into bed without first notifying the nurse or obtaining an assessment by the nurse. Resident #131 sustained a left subtrochanteric hip fracture (a break in the upper portion of the left thigh bone).The findings include:The facility's policy and procedure titled Accident Prevention Reporting and Investigation dated 06/06/2021, documented that, the facility will provide an environment that is free from accident hazards for the safety of residents, and identify the cause of accidents and obtain appropriate care for the injured residents. The facility policy also documented that the facility would implement individualized fall prevention interventions by closely monitoring residents for cognitive impairment, communication deficits, and visual limitations that may affect safety awareness. Staff will observe behaviors that increase fall risk, including wandering, restlessness, impulsiveness, and poor safety judgment, and provide supervision and redirection as needed.Resident #131 had diagnoses that included congestive heart failure (a chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), coronary artery disease (a condition when the blood vessels that supply your heart get clogged, making it harder for your heart to get the blood and oxygen it needs) and cerebrovascular accident (also called a stroke or brain attack-happens when blood flow to part of the brain is suddenly blocked or stopped).Review of the Minimum Data Set assessment (a resident assessment tool) dated 01/30/2026 revealed that Resident #131's memory was severely impaired, and they required supervision when transferring from a chair to the bed. On 07/15/2026 at 10:14 AM, Resident #131 was observed alert and awake and seated in a wheelchair in the hallway. Resident #131 appeared confused and was able to respond to name and engage in minimal conversation.Review of a registered nurse note dated 02/14/2026 11:0PM, documented that at 05:35 PM, Certified Nurse Assistant #2 reported that Resident #131 complained of pain to the left thigh following transfer from wheelchair to bed. The note also documented that Resident #131 was assessed immediately and noticed with swelling to the left thigh. Area was tender to palpation with increased pain upon movement. Resident rated pain at 7/10 on numeric pain scale. Resident denied any fall, and no fall was witnessed or reported by staff. Nursing supervisor was notified of change in condition, medical provider informed and order received for stat X-ray of left thigh and hip. Tylenol 625 mg administered as per order for pain management. Resident repositioned for comfort and movement minimized pending diagnostic evaluation.Review of a registered nurse note dated 02/15/2026 2:49PM, documented Resident #131 was observed in bed, noted with swelling to left knee, thigh and hip. Complained of pain to left lower extremity, rated pain as 6/10, pain management, Tylenol 650mg given every 8 hours as ordered with some effect. X-Ray results of left hip demonstrate a subtrochanteric fracture. Resident was sent to the hospital around 3:35PM on 02/15/2026.The review of x-ray reports dated 02/15/2026 revealed two views of the pelvis and left hip demonstrate a subtrochanteric fracture of the left hip.The facility investigation dated 02/14/2026 documented that, on 02/14/2026 at 05:35 PM, Certified Nurse Assistant #10 stated that they wheeled Resident #131 to the room and then stepped out to get additional supplies needed for care. Upon entering the room, they observed the resident transferring self into bed. Certified Nurse Assistant #10 observed that resident legs were bent, so the Certified Nurse Assistant #10 moved quickly to assist Resident #131 to prevent them from falling. Certified Nurse Assistant #10 also stated they lifted Resident #131 and swung them to the bed, and a few minutes later, resident started complaining of pain to left hip. X-Ray was ordered and result demonstrated a subtrochanteric fracture of the left hip. The facility investigation concluded that, based on investigation conducted through staff interviews, statements, the clinical documentation, there was no evidence of abuse, neglect or mistreatment that occurred relevant to the left acute subtrochanteric fracture. The investigation further stated the left hip must have been accidentally twisted when the Certified Nursing assistant #10 lifted and swung resident towards the bed causing the angulated fracture of the left femoral shaft.Review of hospital discharge records dated 03/02/2026 revealed that Resident #131 presented to the hospital on [DATE] with left subtrochanteric hip fracture and underwent left femur intramedullary nail (a surgical procedure where a metal rod is inserted into the femur to stabilize a fracture and allow early mobilization) surgery on 02/17/2026 and can bear weight on the left lower extremity as tolerated.The nursing readmission note dated 03/02/2026 documented that Resident #131 returned from hospital, was recently sent out due to left hip fracture. Resident was observed with post operative surgical sites, including eleven staples to left upper hip, twenty-two staples to left mid hip and seven staples to the left lower hip.The Care Plan Activity Report for focus Behavioral Symptoms effective 07/18/2024, and last revised on 11/10/2025 documented that Resident #131 manifested behavioral problems by constantly trying to get out of bed by rolling self-off bed and sliding off self from wheelchair. The care plan also documented that the resident is restless, tried to get out of bed, and fall precautions maintained. Bed on the lowest position, with floor mat on the right side of the bed, fall safety maintained.During a telephone interview conducted on 07/17/2026 at 9:37 AM, Certified Nursing Assistant #10 stated that they wheeled Resident #131 to their room and then stepped out briefly to obtain needed supplies because there were not enough supplies available in the room. Certified Nursing Assistant #10 also stated that the wheelchair had been locked before leaving the resident. Upon returning, Certified Nursing Assistant #10 stated that, as they approached the room, they heard Resident #131 screaming and observed resident attempting to self-transfer from the wheelchair to the bed and was halfway to the floor. Certified Nursing Assistant #10 stated they quickly grabbed Resident #131 and placed them onto the bed. Certified Nursing Assistant #10 stated Resident #131's leg appeared to twist during the transfer and they immediately began complaining of pain.During a further interview conducted 07/17/2026 at 10:30 AM, Certified Nursing Assistant #10 stated that Resident #131 had a history of behaviors in which they would sometimes propel themselves in and out of the wheelchair or attempt to move independently. Certified Nursing Assistant #10 also stated that since this was Resident #131's typical behavior the resident should have been more closely monitored. The Certified Nursing Assistant #10 stated they were gone for a short time and did not expect this to happen in such a short period of time.During an interview conducted on 07/17/2026 at 10:29 AM, the Director of Nursing stated that staff should not attempt to lift a resident after a fall and instead should immediately notify the registered nurse as the resident should not be lifted unless a Registered Nurse is present. The Director of Nursing also stated that the facility investigated the incident and determined that Resident #131 was in the process of falling. The Director of Nursing further stated Resident #131 required a one-person assist because they were able to pivot during transfers. The Director of Nursing stated Certified Nursing Assistant #10 attempted to prevent Resident #131 from falling but should have assisted the resident to the floor in a controlled manner rather than lifting them back onto the bed. The Director of Nursing also stated the appropriate practice would have been for staff to gather all necessary supplies before beginning resident care. The Director of Nursing concluded that abuse was ruled out and it was an accident as the fracture may have occurred during transfer. During an interview conducted on 07/20/2026 at 12:18 PM, Medical Doctor #1 stated that they were aware a Certified Nursing Assistant #10 was assisting Resident #131 in the room, and they complained of pain during the night and was subsequently sent to the emergency room for evaluation. Medical Doctor #1 also stated Resident #131 underwent a surgical procedure to repair the left hip fracture during hospitalization and was doing better a few days after returning to the facility. Medical Doctor #1 further stated that the surgical procedure was routine for an injury such Resident #131 sustained and did not cause any significant change in resident's status or ability to ambulate following the injury. 10 New York Code, Rules and Regulation 415.12(h)(1)(2)

Number of residents sampled: 4Number of residents cited: 1 Based on observation, record review, and interviews, the facility failed to ensure medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident were provided. This was evident in one resident (Resident #131) of four residents reviewed for Discharge out of 38 sampled residents. Specifically, there was no documented evidence in the resident's medical record that appropriate information was communicated to the receiving facility when Resident #131's representative request a transfer to another facility. The findings include:The facility policy and procedure titled Discharge/Transfer, dated 01/25/2025, documented that the facility social worker is responsible for coordinating the discharge and transfer process and ensuring an effective transition. The social worker is to meet with the resident and/or the resident's representative to determine the reason for the requested transfer and identify any concerns related to care, safety, resident preferences, dissatisfaction with services, family concerns, financial issues, or changes in the resident's medical needs. The policy also documented that when a discharge or transfer is necessary, the social worker is responsible for providing information regarding available facilities that may meet the resident's needs, assisting the resident or family with contacting potential receiving facilities, as appropriate, and documenting all discharge or transfer activities in the resident's medical record.Resident #131 had diagnoses that included congestive heart failure (a chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), coronary artery disease (a condition when the blood vessels that supply your heart get clogged, making it harder for your heart to get the blood and oxygen it needs). cerebrovascular accident (also called a stroke or brain attack-happens when blood flow to part of the brain is suddenly blocked or stopped)The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 01/30/2026 documented Resident #131's memory was severely impaired, hey required supervision when transferring from chair to bed. The assessment also documented that the resident's family representative participated in the assessment and goal setting.On 07/15/2026 at 10:14 AM, Resident #131 was observed alert and awake and seated in a wheelchair in the hallway. Resident #131 appeared confused and was able to respond to name and engage in minimal conversation.Review of the social services note dated 03/10/2026 revealed that Resident #131's representative expressed a desire for the resident to be transferred to another facility. The social worker explained the process for transferring a resident from one nursing home to another. Resident #131's representative verbalized understanding and stated that they would provide the social worker with the names of several facilities they wished to explore for possible placement.The social services note dated 03/24/2026 documented that, as per family member's request, the Patient Review Instrument and additional required documentation were faxed to a nursing facility for review and consideration of possible admission.The nursing progress note dated 05/21/2026 documented that Resident #131 was evaluated by orthopedics on 05/18/2026 for a follow-up appointment related to a left hip fracture. The orthopedic consultation documentation included a note indicating that the resident's family member reported that Resident #131 does not feel safe in the facility and requested that the resident be transferred to another facility. The note instructed that Social Services be contacted for follow-up.Review of the medical record revealed no further documentation regarding follow-up on transfer to any other facilities, the status of the transfer request, or how updates related to the transfer process were communicated to the resident's family member.During an interview on 07/21/2026 at 10:31 AM, Registered Nurse #9 stated that the resident's family representative had expressed concerns on multiple occasions and was upset, requesting that the resident be transferred to another facility. Registered Nurse #9 also stated that they asked the family representative if there were concerns regarding the care being provided or if the facility was not meeting the resident's needs; however, the resident's sister continued to insist that the resident be transferred. Registered Nurse #9 further stated that the family's concerns were communicated to the facility social worker for follow-up.During an interview on 07/21/2026 at 11:00 AM, Social Worker #1 stated that part of their roles is to assist with facilitating, coordinating, and supporting a safe and appropriate transfer transition when a resident or representative requests a transfer. Social Worker #1 also stated that Resident #131 had severe confusion and that the resident's family members were responsible for participating in the resident's care planning process. Social Worker #1 further stated that they met with the resident representative to discuss the reason for requesting a transfer and they advised the family representative to identify a facility of choice before the transfer process could proceed. Social Worker #1 stated that the family representative later provided a facility name, and they contacted the facility and faxed the Patient Review Instrument and other required documentation. Social Worker #1 stated that they did not receive a response from the receiving facility and that there was no additional documentation regarding further follow-up after the records were sent. During an interview conducted on 07/21/2026 at 12:44 PM, the Administrator stated that Resident #131 was receiving good care at the facility and that they were not aware of another facility willing to accept the resident at that time. The Administrator also stated that the resident's records had been sent to multiple nursing facilities, but no facility had accepted the resident. 10 New York Code Rules and Regulation 415.5 (g)(1)(i-xv)

Based on record review and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include: The undated facility policy titled Staffing of Nursing Service Personnel documented; each nursing home reports daily staffing hours to Medicare. Medicare calculates a ratio of staffing hours per resident day, the percent of nurse staff that stop working at the facility, and the number of administrators who have left the facility within a given year. These types of staff are included in the nursing home staffing information: Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 - 09/30/2024) documented that excessively low weekend staffing was triggered. The undated Facility Assessment Survey documented facility capacity of 243 residents with a weekend staffing plan by shift distributed as follows: Day shift (7 AM to 3 PM) by units: 2nd Floor (ventilator unit): 3 Registered Nurses, 1 Licensed Practical Nurse, 6 Certified Nurse Aides 3rd Floor: 2 Registered Nurses, 1 Licensed Nurse, 5 Certified Nurse Aides 4th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides 5th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides 6th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides 7th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides Evening shift (3 PM to 11 PM) by units: 2nd Floor (ventilator unit): 3 Registered Nurses, 1 Licensed Practical Nurse, 5 Certified Nurse Aides 3rd Floor: 2 Registered Nurses, 1 Licensed Practical Nurse, 4 Certified Nurse Aides 4th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides 5th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides 6th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides 7th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides Night shift (11 PM to 7 AM) by units: 2nd Floor (ventilator unit): 3 Registered Nurses, 1 Licensed Practical Nurse, 4 Certified Nurse Aides 3rd Floor: 1 Registered Nurse, 1 Licensed Practical Nurse, 3 Certified Nurse Aides 4th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides 5th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides 6th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides 7th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides Review of the actual weekend facility staffing schedule from 07/06/2024 to 09/29/2024 documented the following: On 07/06/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/13/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/13/2024 on the 7 AM to 3 PM shift, there was a shortage of 1 Certified Nurse Aide on the 2nd Floor (ventilator unit). On 07/14/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/20/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/21/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/27/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 07/28/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 08/04/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/10/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 08/11/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 08/17/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/18/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/24/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/25/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/31/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/01/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse and 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/072024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/07/2024 on the 3 PM to 11 PM shift, there was a shortage of 1 Certified Nurse Aide. On 09/08/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/142024 on the 3 PM to 11 PM shift, there was a shortage of 1 Certified Nurse Aide on the 2nd Floor (ventilator unit). On 09/15/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/21/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 09/21/2024 on the 7 AM to 3 PM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/22/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 09/28/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/29/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). Review of the actual weekend facility staffing schedule from 07/06/2024 to 09/29/2024 revealed that the facility had an ongoing pattern of shortage of nursing staff. Resident #98 was admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease and Renal Insufficiency. The Comprehensive Minimum Data Set assessment dated [DATE] documented that Resident #98 was cognitively intact. On 01/17/2025 at 12:48 PM, Resident #98 was interviewed and stated that they believed the facility was sometimes understaffed at night. They stated that there had been an incident where it took three hours for a Certified Nurse Aide to provide them with a new gown after they notified the Certified Nurse Aide that they had spilled something on the one they were wearing. They stated that on a separate occasion, it took multiple hours for a staff member to assist them to the bathroom on the night shift. Resident #203 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus and Hypertension. The Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #203 had moderate cognitive impairment. On 01/17/2025 at 02:33 PM, Resident #203 was interviewed and stated that the facility is very understaffed. They stated that they notice this on all shifts but that it is worse during the night shift and on weekends. They stated that this affects timeliness of receiving food, being cleaned, and being provided incontinence care. Resident #176 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the Left Lung and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #176 was cognitively intact. On 01/17/2025 at 02:44 PM, Resident #176 was interviewed and stated that the facility is understaffed on the weekends. They stated that when they use the call bell to request water or to notify staff that they are feeling unwell, it sometimes takes 30 to 40 minutes for someone to answer the call bell to see what the resident needs assistance with, which the resident finds to be unsettling. Resident #132 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction and Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #132 was cognitively intact. On 01/17/2025 at 02:50 PM, Resident #132 was interviewed and stated that the facility did not have enough staff members. They stated that the staffing issue was worse on the night shift and impacts the timeliness of being provided incontinence care after having a bowel movement. Resident #157 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Malignant Pleural Effusion, and Dependence on Ventilator. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #157 had severe cognitive impairments. On 01/21/2025 at 12:04 PM, Resident #157's relative was interviewed and stated that they believed the facility could improve their staffing practices. They stated that on multiple occasions when they have come to visit Resident #157, they will find the resident in need of incontinence care. They stated that staff are also not consistently able to transfer Resident #157 out of bed in a timely manner. On 01/21/2025 at 09:50 AM, Certified Nursing Assistant #5 was interviewed and stated that they work on the night shift and are typically assigned twenty residents. They stated that they are typically able to complete most tasks but sometimes struggle to ensure that all residents are clean and dry by the end of the shift and that they cannot always get to every resident. On 01/21/2025 at 10:12 AM, Certified Nursing Assistant #4 was interviewed and stated that the night shift was understaffed. They stated that they worked on the day shift and consistently start their shift to find that residents are soaked in urine because the staff on the night shift were unable to provide care to every resident due to the size of their assignments. On 01/21/2025 at 09:22 AM, the Administrator was interviewed and stated that the facility's Staffing Coordinator was out on medical leave and their Medical Records Employee was now managing the scheduling. However, the Medical Records Employee was on vacation, so the Administrator was assisting with scheduling. The Administrator stated that they did not know why the facility was triggered for low weekend staffing by the Payroll Based Journal. They stated that it is difficult to find nursing staff due to competition with other facilities and hospitals, union restrictions on using agencies, and the increasing cost of staffing. They stated that the facility receives around 30 Certified Nursing Assistant callouts per week. They stated that the facility offers bonuses and financial incentives, uses agencies, and works with Certified Nursing Assistant schools to improve staffing levels but struggles due to competition with other facilities who are facing similar staffing issues. On 01/21/2025 at 10:45 AM, the Director of Nursing was interviewed and stated that they believed that the low weekend staffing was triggered in the Payroll Based Journal report because the facility only schedules one Registered Nurse Supervisor for the building on the weekends, instead of one Registered Nurse Supervisor for each floor, like they do during the week. They stated that the facility is calmer on the weekends, so they do not need a Registered Nurse Supervisor for every floor. They stated that they believe that the facility is staffed safely and that they inflated the necessary staffing ratios in their facility assessment to receive additional money for their staffing budget. The Director of Nursing denied being aware of staff or resident concerns related to care being provided in a timely manner. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification Survey from ,d+[DATE] /2025 to [DATE], the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and pantry observations. Specifically, 1.) The dairy walk-in refrigerator contained opened and expired loaves of bread and bags of rolls. 2.) 2 of 6 pantry unit refrigerators contained expired milk as well as spilled, spoiled, undated and unlabeled food items. The findings are: The facility policy and procedure titled Dry Storage with revision date of [DATE] documented; that all dry goods must be stored in a safe and secure environment. New stock must be stored behind old stock so oldest items will be used first. Products should be dated to ensure First In-First Out. The Food Items Expiration Date Audit Tool documented that all areas must be inspected at least weekly to ensure that there are no expired food items. Any items that are expired must be immediately discarded. The facility's policy and procedure titled Food Receiving and Storage, undated, documented; Food shall be received and stored in a manner that complies with safe food handling practices. Food services or designated staff will maintain clean food storage areas at all times. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. All foods stored in the refrigerator or freezer will be covered, labeled and dated with the use by date. Other opened containers must be dated and sealed or covered during storage. Partially eaten food may not be kept in the refrigerator. Food items and snacks kept on the nursing units must be maintained as indicated: Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Beverages must be dated when opened and discarded after (72) hours. Other open containers must be dated and sealed or covered. The facility's policy and procedure titled Personal Food Safety/Food entering the Facility, undated, documented that it is the policy of the facility to limit entry of food into the facility. Food storage in the units will be monitored by the nursing staff. Quantities should be limited to a reasonable size to prevent spoilage of leftovers. All prepared food stored in the refrigerator will be discarded after 72 hours. Perishable foods must be stored in resealable containers in the refrigerator. Containers will be labelled with the resident's name, room number, and the date. The nursing staff is responsible for discarding perishable food on or before the sell by date, or any food that shows signs of food borne danger, for example mold growth or foul odor. The nursing department will monitor and document the internal temperature of the refrigeration units daily. Units must maintain safe internal temperatures in accordance with the State and Federal guidelines (41 degrees Fahrenheit or below). The refrigerators will be cleaned and defrosted by the Nursing and housekeeping staff will assist as needed. 1) On [DATE] at 9:23AM, an initial kitchen observation was conducted with the Dietary Supervisor. The walk-in dairy refrigerator was found to contain One box of (8) 24 packages of hot dog rolls labeled with the manufacturer's use by date of [DATE], One open/unsealed and undated package of 10 hamburger rolls, originally listed to contain 12 rolls. Two plastic bags torn open/unsealed and undated containing partial loaves of bread. On [DATE] at 9:30AM, the Dietary Supervisor was interviewed and stated, that they inspect all refrigerator and food storage areas weekly for expired food items and would have discarded the expired bread but did not see the items as they were contained in an undated, unlabeled box on the top shelf. On [DATE] at 9:40AM, the Director of Food Service was interviewed and stated that once a week a Dietary Supervisor checks the entire kitchen for the expiration dates of food items, discards expired foods and documents the dates of inspection on an audit tool that they review. The Director of Food Service further stated that the expired bread observed in the walk-in refrigerator was simply missed as the Dietary Supervisor did not notice the box with the expired open items because it was on the top shelf. 2) On [DATE] at 9:19 AM, the 7th floor pantry refrigerator was observed with Registered Nurse #4 the unit manager. A malodourous beige tinged liquid was observed on the bottom of the refrigerator unit. The refrigerator unit was also observed to be overpacked, containing 11 seperate bags of food containers labeled with room numbers only. No bags or containers were observed to be labelled with names or dates. One large bag of contents included a glass bowl of degraded soup and or vegetables. The additional bags were observed to contain multiple cooked food items. On [DATE] at 9:25 AM, Registered Nurse #4, the unit manager was interviewed and stated, that the certified nursing assistants are responsible to have food dated and labeled when placed in the pantry refrigerator, but essentially it is everyone's responsibility. The unit manager also stated that the refrigerator unit temperatures are checked and logged at night by nursing staff, the housekeeping porter is responsible to clean the refrigerator unit daily and the certified nursing assistant is to throw the food out daily that is not labeled, dated and or has been in the refrigerator unit longer than 2 days. Registered Nurse #4 further stated that overall the pantry unit refrigerator is the responsibility of the unit manager and It was an oversight that they did not look at the refrigerator during daily rounds to ensure compliance. 3) On [DATE] at 9:56 AM, the 5th floor pantry unit refrigerator was observed with the Registered Nurse #1, the unit manager. The contents included one half pint of expired milk with manufacturer's expiration date of [DATE]. (1) 24 oz jar of opened mayonnaise undated and unlabeled with manufacturers expiration date of ,d+[DATE], (1) 8oz plastic cup of cream cheese unopened with manufacturer's expiration date of [DATE], 4 undated unlabeled bags containing various cooked food items including 1 quart of brown rice, multiple fried shrimp, scoops of collard greens, 2 turkey wings and scoops of yams. The refrigerator shelf was observed with a spilled clear liquid. On [DATE] at 9:45 AM, Registered Nurse #1, the unit manager was interviewed and stated that all contents of the unit refrigerators should be dated and labeled with the resident's name or room number and the items should be discarded within ,d+[DATE] days by a certified nursing assistant who is assigned to check the unit daily and the housekeeping staff should clean the refrigerator daily. The unit manager further stated that it is their responsibility during daily rounds to ensure that the unit is checked but they became tied up with other issues. On [DATE] at 08:29 AM, The Director of Nursing was interviewed and stated that the pantry refrigerator process includes temperature checking and inside cleaning by the night nurses and the certified nursing assistants. While staff is checking the unit temperatures, the Director of Nursing stated that they should also discard all food items that are not labeled and any that are dated outside of ,d+[DATE] hours. The Director of Nursing also stated that any staff member who receives food from the outside should label the items with the resident's name, room number and the date prior to placing the items in the pantry unit refrigerator and that external cleaning of the refrigerator unit is the responsibility of the housekeeping porter. The Director of Nursing further stated that the morning shift nurse manager should round daily and make sure the refrigerator unit is clean, that food is discarded and that the temperatures are checked. On [DATE] at 10:20 AM The facility Administrator was interviewed and stated that they would follow up with the food service director for clarification on the findings. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that the garbage storage areas were maintained in sanitary condition. This was evident during the Kitchen Observation. Specifically, kitchen waste was not disposed of properly and the outside garbage compacter lid was left open and uncovered. The findings are: The facility policy and procedure titled Solid Waste and Pick-up, dated 07/11/2024, documented that the assigned dietary staff removes solid waste from all dietary areas. Solid waste is transported in covered receptacles and disposed of in the compactor. The outdoor compactor side lid must be kept always closed except when emptying trash bins or washing of dumpsters. On 01/15/2025 at 11:26AM During the kitchen observation of lunch preparation with Dietary Supervisor #1, Dietary Aide #1 was observed transporting an uncovered garbage can from the outside trash compactor past the food preparation area while lunch was being prepared. On 01/15/2025 at 11:30AM, an interview was performed with Dietary Aide #1 who stated that anytime they take the garbage out and bring the can back into the kitchen, they are supposed to place the garbage bag inside the can and cover the can with the garbage can lid before they bring the can back into the kitchen from the outside trash compactor. Dietary Aide #1 further stated that they did not put the lid on the garbage can prior to transporting it back into the kitchen from the outside trash compactor because they were in a rush. On 01/15/2025 at 11:49AM, an Interview was performed with Dietary Supervisor #1 who was present during the observation. They stated, that after emptying the trash in the outside trash compactor, the dietary aide is supposed to enter the kitchen from the outside with the garbage can lid covering the garbage can because the garbage can is unsanitary and is passing by the food. Dietary Supervisor #1 further stated that typically, when the dietary staff takes out the trash from the kitchen, they monitor them to ensure a lid is on top of the garbage can before and after disposal. There was no documented evidence of monitoring of trash containment or disposal. 01/21/25 at 9:50 AM, the Food Service Director was interviewed, and stated, I have no comments regarding the garbage disposal and compactor observations findings as it just shouldn't have happened. On 01/15/2025 at 11:55AM, An observation of the outside garbage compactor was conducted with Dietary Supervisor #1 and Dietary Aide #1, The compactor lid was observed to be open and uncovered. Dietary Supervisor #1 stated that the compactor lid is supposed to be kept closed when not in use. On 08/14/24 at 11:15AM, An interview was performed with the facility Administrator who stated that they will clarify and discuss the findings with the Food Service Director. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during a Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that a comprehensive care plan was developed and implemented to meet each resident's needs. This was evident in 1 (Resident #46) out of 38 sampled residents. Specifically, Resident #46 who had diagnosis of Osteoporosis had no care plan developed and implemented. The findings are: The facility policy and procedure titled Care Plans Comprehensive Person - Centered with the last revised date January 2023, documented that a comprehensive person-centered care plan that include measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. The facility's policy and procedure entitled Baseline Care Plan, approved 03/2018, states that the care plan will include conditions and risks affecting the resident's health and safety. Resident #46 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychosis, Alzheimer's Disease, Hypertension, Bipolar Disorder, Seizure Disorder, Chronic Obstructive Pulmonary Disease and Osteoporosis. The resident had physician orders in place for each medical condition, including an order dated 12/25/2024 for Alendronate 70 mg once a week for Osteoporosis. The resident had care plans in place for Cognitive Loss, Hypertension, Psychotropic Drug Use, Alteration in Neurological Status and Alteration in Respiratory Status. However, there was no care plan reflecting the resident's diagnosis of Osteoporosis. On 01/16/2025 at 10:58 AM, Registered Nurse Manager #1 was interviewed and stated that the Registered Nurses are responsible for initiating all care plans. The Nurse Manager stated that the Osteoporosis Care Plan had been put in place for Resident #46 in 2020, but the resident had been hospitalized in 2023 and upon their return in November of that year, the Osteoporosis care plan was not reactivated. The Nurse Manager had no explanation for why it had not been done. On 01/21/2025 at 9:52 AM, the Director of Nursing was interviewed and stated that when a resident is admitted to the hospital, they are discharged from the facility and their care plans are discontinued; when they return, all their care plans are reinstated. The Director stated that there was no specific regulation that every physician order had to have a separate care plan and looked on their screen, noting that the resident's osteoporosis diagnosis was mentioned on their Pain and Discomfort care plan. The surveyor's copy of the plan of care did not mention the diagnosis on the Pain/Discomfort care plan, and the Director stated that it must have been put in when the Nurse Manager was made aware that the Osteoporosis care plan had not been reactivated into the current plan of care. 10NYCRR415.11(c)(1)

Based on record reviews and interviews conducted during the Recertification Survey between 01/13/2025 and 01/21/2025, the facility did not ensure that resident's Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment, including quarterly review assessments. 1) Resident #74 Self care Comprehensive Care Plan was last reviewed 8/1/2024, and not updated quarterly, 2) Resident #187 who was maintained on Oxygen Therapy the Alteration in Cardiopulmonary Care Plan was not updated. This was evident for 1 of 5 residents of reviewed for Activities of daily Living (Resident #74), and 1 out of 3 resident review for oxygen (Resident #187) out of an investigative sample of 37 residents. The findings are: The facility policy and procedure titled Care Plans Comprehensive Person-Centered dated reviewed 7/16/2024 documented the Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Resident #74 was admitted to the facility with diagnoses that included Persistent vegetative state, Nontraumatic intracerebral hemorrhage, Diabetes and Seizure Disorder. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #74 had Short-term Memory and Long-Term Memory Problem, with no memory recall, and is severely impaired-never/rarely made decisions. The Comprehensive care Plan titled Self-Care Deficit dated effective 3/13/2018 and last evaluation note 8/1/2024 with interventions including Dependent of two plus staff, for bed mobility, dressing, locomotion, personal hygiene, toilet use and , transfer with Hoyer lift. The Quarterly Minimum Data Set Assessments were completed on 10/29/2024. There was no documented evidence that the care plans were reviewed and revised after each assessment for Resident #74 On 01/21/25 at 01:54 PM, during the Quality Improvement Performance Improvement (QAPI) interview, the Director of Nursing stated, care plans are reviewed quarterly, annually for significant change as needed. The Director of Nursing did not explain why care plans was not completed as least quarterly. On 01/21/25 at 09:43 AM, The Director of Rehab was interviewed and stated the resident who is total care with Activities of Daily Living. Director of Rehab stated the resident is screened quarterly and as needed, Director of Rehab stated the resident is also on passive range of motion which is done during activities of daily living care. Director of Rehab stated this resident had no functional abilities on own and needs staff assistance for everything, and resident cannot follow commands secondary to medical conditions. Director of Rehab stated Rehab goes to each care planning meeting and is part of the care planning process. Director of Rehab stated if a resident is on therapy the Rehab will create own care plan for physical and occupational therapy with goals and interventions. Director of Rehab stated once the goal has been reached Rehab will discharge the care plan. Director of Rehab stated Rehab is not responsible for creating and or updating the Self Care Deficit care plan and stated Rehab creates their own care plans only if the resident is on therapy, and discharged when goals are reached. On 01/17/25 at 10:08 AM, Registered Nurse #7 and was interviewed and stated the resident is total care with all activities of daily living, takes nothing by mouth and gets feeding via GT. Registered Nurse #7 stated the resident is nonverbal and unable to make all needs known, and staff anticipates all needs. Registered Nurse #7 stated all care plan including self-care deficit care plans are updated quarterly, annually, significant changes and as needed. Registered Nurse #7 looked at the Self Care deficit Care plan and stated the last evaluation note was in 8/1/2024. Registered Nurse #7 stated Rehab and Nursing are responsible for updating the Self Care deficit care plans. Registered Nurse #7 stated nursing is responsible for overseeing that all the care plans are updated to reflect the status of the resident and if the care plans are not updated Nursing will update the care plans. Registered Nurse #7 stated the care plans are reviewed in care planning meetings and not sure why this care plan was not updated. Registered Nurse #7 stated they will update the care plan now. 48876 2) Resident #187 was admitted with diagnoses that include Hypertension and Peripheral Vascular Disease The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 had severely impaired cognition skills for daily decision making. The most recent Annual Minimum Data Set Assessment was completed on 07/05/2024. The most recent Quarterly Minimum Data Set Assessment was completed on 10/04/2024. The Care Plan Activity Report titled Alteration in Cardio/Pulmonary Status dated active and effective 06/30/2024, documented the last quarterly review done 08/26/2024. Goals that documented that Resident #187 will be free of signs and symptoms of cardiac distress and interventions that documented for nursing to observe for signs/symptoms of cardiac distress were active and effective 06/30/2023 with no review or revision dates entered. There was no documented evidence that the care plans including goals and interventions were reviewed and revised after each assessment for Resident #187. On 01/21/25 at 1:54 PM, during QAPI interview the Director of Nursing stated care plans are reviewed quarterly, annually for significant change as needed. The Director of Nursing did not explain why care plans was not completed as least quarterly. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observations, record review and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/20245, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #187) of 35 total sampled residents. Specifically, Resident #187 did not receive monitoring and maintenance of the peripheral intravenous site for the infusion of fluids and antibiotics. The finding is: The facility's policy and procedure titled Administration, Monitoring and Maintenance of Intravenous Therapy, undated, documented that the facility shall have a system in place for the administration, monitoring and maintenance of Intravenous therapy. Intravenous tubings shall be labeled with the date and time change. The Intravenous site and dressing shall be labeled with the date and time the needle/catheter was inserted, the gauge of the needle/catheter, and the date and time the dressing was changed. The nurse or physician who changes a dressing after the initial insertion must relabeled the dressing with the date of the initial insertion and needle gauge, and the date the dressing was changed. All must be documented on the medical record. The nurse must notify the physician to change the peripheral intravenous needle/catheter or heparin lock after 3 days (72 hours). Transparent dressings shall be changed and relabeled every 72 hours as per procedure. At the time of the dressing change the insertion site is to be observed for signs of phlebitis, infection, or infiltration and the insertion site cleansed per procedure. Resident #187 was admitted with diagnoses that include Hypertension and Peripheral Vascular Disease The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 had severely impaired cognition skills for daily decision making. On 01/15/25 at 11:16 AM, Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter. On 01/15/25 at 02:52 PM, Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter. On 01/16/25 at 12:18 PM, Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter. On 01/16/25 at 1:10PM Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter in the presence of Registered Nurse #4, the unit manager. The Physician Order dated 01/11/2025 at 5:29PM, documented for the administration of Dextrose 5% and 0.45% Sodium Chloride intravenous solution to be infused at 60 cubic centimeters per hour for 72 hours. The Physician Order dated 01/11/2025 at 5:31PM, documented for the administration of Zosyn 3.375 grams/50mililiters in Dextrose intravenous piggyback every 8 hours for 5 days. The Physician Order dated 01/16/2025 at 2:21PM, documented for the treatment of the Peripheral Intravenous Line: Dressing Change Now for 1 treatment then every 3 days and as needed. The Resident Medication Administration Record dated January 2025 documented that Resident #187 received administrations of Zosyn 3.375 grams/50ml in Dextrose intravenous 01/11/2025 thru 01/16/2025. The Resident Medication Administration Record dated January 2025 documented that Resident #187 peripheral intravenous line dressing change treatment was initially performed on 01/16/2025. The Care Plan Activity report dated 01/11/2025, documented that the first dose of Zosyn was administered intravenously 01/11/2025. The Care Plan Activity report dated 01/16/2025, documented that the peripheral intravenous line was removed 01/16/2025. Prior to 01/16/2025, There is no documented evidence that the peripheral intravenous line dressings were changed nor is there documented evidence that the peripheral intravenous insertion site was assessed. On 01/16/25 at 1:20PM Registered Nurse #4, the unit manager, was Interviewed and stated that the intravenous infusion through the left peripheral line was started on 01/11/2024 for resident #187, but until today the dressing at the insertion site had not been changed. Registered Nurse #4 also stated that the nurse who inserted the peripheral intravenous line was responsible to date the dressing and that the dressing is to be changed and dated every 72 hours per the policy and procedure. Registered Nurse #4 also stated that the intravenous medication was infused three times a day and no one observed that the dressing was not dated and had not been changed. The dressing change should have been documented in the progress notes and the order for the dressing changes should have been entered at the initiation of the IV medication, but neither are in the computer system. Registered Nurse #4 further stated that it is their responsibility to round daily and assess that the Intravenous dressings are changed, dated and that the documentation and orders are entered into the electronic medical record. On 01/17/25 at 10:09 AM, The Director of Nursing was interviewed and stated that regarding peripheral intravenous lines, the insertion site is rotated every 3 days and that collaborates with the dressing change so essentially the dressing should be changed every 3 days. The Director of Nursing also stated that the ideal practice is to date the dressing when it is changed and enter that date in the Treatment Activity Record with documentation of the insertion site assessment. The physician should be made aware if there is difficulty with the insertion and the physician order be for dressing changes then should be changed to every 5 days. The Director of Nursing further stated that outside of the nurse who changes the dressing, the nurse manager should be looking for evidence of this during their daily rounds and when they run the Treatment Activity Report at the end of each day. 10NYCRR 415.12

Based on observation, record review interviews, and record review conducted during the recertification and complaints (NY00342658) survey from 01/13/2025 to 01/21/2025, the facility did not ensure a resident remained free of accident hazards. This was evident for 1 (Resident #290) of 3 residents reviewed for accidents out of 38 sampled residents. Specifically, Resident #290 fell out of bed and sustained a 2.5 cm skin tear to the forehead during care when one staff provided care without a second staff member. The Findings are: The facility policy and procedure titled Accident Prevention Reporting and Investigation, last revised June 6, 2021, documented that the purpose is to provide an environment free from accident hazards for the safety of the residents and staff. Identify the cause of an accident and obtain appropriate care for the injury. Resident #290 was admitted to the facility with diagnoses that include Hemiplegia or Hemiparesis, Respiratory Failure, and Dependence on respirator [ventilator] status. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #290's cognition as severely impaired and never/rarely made decisions. The resident was dependent and requires one person assistance with personal care and two persons for bed mobility. The Comprehensive Care Plan for Falls/Injury, initiated on 12/31/2020 and last revised on 05/19/2024, documented that while certified nursing assistant #3 was providing care, the unit nurse was alerted that the resident had fallen out of bed. The Resident Nursing Instruction for Certified Nurse Aid dated 09/25/2023 documented that Resident #290 is dependent and requires two-person assistance for bed mobility and one-person assistance for personal hygiene. The Certified Nursing Assistant (CNA) Documentation History Detail dated 05/01/2024 to 05/31/2024 documented personal hygiene support provided one-person physical assistance. The Nursing Note dated 05/20/2024 at 3:37 PM documented that on 05/19/2024 at 9:40 AM, certified nursing assistant # 3 called the writer's attention to Resident #290's room. The writer immediately went to the room and found out the resident was on the floor. Upon assessment, Resident #290 was conscious and alert; a skin tear was noted on the left side of the forehead with slight swelling measuring 2.5cm x 1.0cm. The area was cleansed with normal saline, and Steri strips were applied. The nursing supervisor was made aware, and the physician and the family were notified. The facility Resident Incident/Accident Report dated 05/19/2024 at 9:40 AM documented that Certified Nursing Assistant # 3 stated that while giving care to Resident #290, the resident was turned to the left side, and the resident got agitated and fell out of bed. The resident was unable to state what had happened. Resident # 290 sustained a 2.5 cm x 1 cm abrasion and skin tear to the forehead. The facility Summary of Occurrence concluded that Certified Nursing Assistant #3 did not intentionally harm Resident #290. However, given the circumstances and information gathered, the incident met the criteria of Department of Health incident reporting for not following the plan of care. On 01/17/2025 at 3:14 PM, Certified Nursing Assistant #3 was interviewed and stated that I was providing care for Resident #290, who was on a ventilator. I turned the resident, and the resident started shaking and then fell . It was only me taking care of the resident. I do not know if they changed it now, but when I looked at the computer, it was one person's assistant for care. I did not get the time to call someone to assist me when the resident became agitated and was shaking. I went to inform the nurse immediately. The nurse and the manager came to see the resident before we put the resident back to bed. On 01/16/2025 at 2:54 PM, Registered Nurse #3 was interviewed and stated that certified nursing assistant #3 called that Resident #290 was on the floor. I assessed the resident; the resident had a small abrasion on the forehead. I called the supervisor and reported to the doctor. We transferred the resident back to bed after the assessment. On 01/21/2025 at 11:40 AM, the Director of Nursing was interviewed and stated that Resident #290 fell during care. They investigated the fall and concluded that there was no intentional harm, but the incident met the criteria for Department of Health reporting for not following the plan of care. Certified Nursing Assistant # 3 was sent home immediately and was suspended for three days. Certified Nursing Assistant # 3 was educated upon return. Resident #290 requires two-person assistance for bed mobility and one person for personal hygiene. Certified Nursing Assistant # 3 was providing care and tried to turn the resident, but the resident became agitated and fell . They will increase the staff for personal hygiene to coincide with the care for bed mobility. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interviews conducted during the recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 2 (Resident # 19 and #187) out of 6 residents reviewed for respiratory care out of 38 sampled residents. Specifically, 1) Resident # 19 was observed using oxygen via the Nasal Cannula (NC) at 2 liters with no Medical Doctor's Order (MDO), and 2) Resident # 187 was observed using oxygen via undated nasal cannula tubing. The findings are: The facility's undated policy and procedure, Supplemental Oxygen, documented that oxygen therapy is administered to residents with medical conditions in which an enriched oxygen atmosphere will benefit them. Depending on the residents' inspiratory flow demands, oxygen can be administered using low-flow or high-flow oxygen delivery devices. The procedure is to check the resident chart for a physician's order. The facility's undated policy and procedure, Supplemental Oxygen, documented that a nasal cannula will deliver low concentration of oxygen at flow rates of 1-6 liters per minute. Infection Control: disposable equipment should be changed according to the equipment change schedule. The facility's undated policy and procedure titled Supply Change Standards, documented that respiratory supplies must be routinely changed to maintain proper infection control procedure and hygienic standards. Respiratory supplies will be changed according to the schedule listed below to reduce the risk of infection. Nasal Cannula change frequency - Weekly and as needed. 1. Resident #19 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia and Seizure Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident # 19 cognition as moderately impaired with a Brief Interview for Mental Status score of 12. On 01/13/2025 at 11:40 AM, Resident #19 was observed out of bed in a wheelchair in their room, using oxygen at 2 liters via nasal cannula. On 01/14/2025 at 9:43 AM, Resident #19 was observed out of bed in a wheelchair in their room, using oxygen at 2 liters via nasal cannula. The Medical Doctor's Orders dated 12/09/2024 to 01/13/2025 have no documented evidence that Resident #19 was receiving oxygen. The Medical Doctor's Order dated 01/14/2025 documented oxygen inhalation via Nasal Cannula at 2-3 liter/minute for oxygen saturation below 95%. The Nursing Note dated 12/16/2024 at 10:41 PM documented that at around 9:00 PM, Resident #19 complained of chest pain and described pain as heavy and in the middle of their chest. The registered nurse supervisor was notified and assessed the resident. I informed the doctor with an order to give a 0.4 mg of nitroglycerin sublingual tablet in one dose and administer oxygen. The order was carried out and endorsed. Nitroglycerin was given with relief of the chest pain and oxygen via nasal cannula at 2 liters/minute in progress and well tolerated. The Nursing Note dated 12/19/2024 at 6:21 AM documented that oxygen via nasal cannula was in progress, with oxygen saturation at 98%. The Nursing Note dated 12/23/2024 at 10:20 AM documented Resident#19 on the bed, not in distress, on oxygen inhalation via nasal cannula at 2 liters. On 01/17/2025 at 11:53 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #19 was on oxygen at 2 liters as needed. The resident went to the hospital and returned about three weeks ago with 2 liters of oxygen as needed. The resident did not have oxygen before but has been using it since returning from the hospital. Resident # 19 has an order for 2 liters of oxygen. It was ordered on 01/14/2025. On 01/21/2025 at 12:39 PM, Licensed Practical Nurse #4 was interviewed, and stated that that Resident #19 complained of chest pains on 12/16/2024 after 8:00 PM. I took the vitals and reported them to the doctor. The doctor ordered Nitroglycerine and oxygen. I put the resident on oxygen at 2 liters. I forgot to write the order for the oxygen; it skipped my mind. I did not follow up the next day to see if the order was in place. I should have written the order for the oxygen. On 01/17/2025 at 12:51 PM, Registered Nurse #5, the unit manager, was interviewed and stated that Resident # 19 had been on oxygen since the resident was readmitted on [DATE]. Oxygen 2 liters via nasal cannula was ordered on 01/14/2025. There was no order for the oxygen, so I put an order in on 01/14/2025. The oxygen was started on 12/16/2024 by the evening nurse. I did not check to see if an order was in place for the oxygen. I missed it because it did not occur on my shift. On 01/21/2025 at 12:03 PM, the Director of Nursing was interviewed and stated that an order for oxygen administration must be obtained. Before a resident is placed on oxygen, an assessment should be done and report to the doctor, and an order must be obtained. The oxygen is ordered based on the resident's clinical condition. There is a note that the doctor was notified and gave an order. It should have been ordered. They will reinforce documentation. 48876 2. Resident #187 was admitted with diagnoses that include Hypertension and Peripheral Vascular Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 had severely impaired cognition skills for daily decision making. On 01/15/25 at 11:16 AM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute. On 01/15/25 at 02:52 PM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute. On 01/16/25 at 12:18 PM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute. On 01/16/25 at 1:10PM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute, in the presence of Registered Nurse #4, the unit manager. The Physician Order dated 09/24/2024 at 3:58PM, and renewed 12/04/2024 at 11:42 AM, documented for the administration of Oxygen at 2-3 liters per minute as needed per nasal cannula every shift. The Resident Treatment Administration Record dated January 2025, had no nursing documentation entries that Resident #187 was administered Oxygen in the month of January or that oxygen tubing was dated or changed. On 01/16/25 at 1:25PM, Registered Nurse #4, the unit manager, was Interviewed and stated that the oxygen tubing connected to the nasal cannula should be dated and changed every 7 days but that they observed that there was no date on the tubing today. On 01/21/25 at 10:30 AM, The Director of Nursing was interviewed and stated that the oxygen/nasal cannula tubing has to be dated and changed every 7 days by the night shift staff and documented on an oxygen therapy list. The Director of Nursing further stated that is the day shift nurse manager who is responsible to observe for compliance during rounds and update the oxygen therapy list weekly. There was no documented evidence that the nasal cannula or oxygen tubing used for administration of Oxygen to resident #187 was dated or changed weekly or as needed. 415.12(k)(6)

Based on interviews and record review conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that the Medical Director participated in the Quality Assurance and Performance Improvement quarterly meetings. This was evident during review of the attendance sheets for the last four quarterly meetings, and the facility provided list of members of the Quality Assurance and Performance Improvement Committee, and through interview with the Medical Director and other members of the Quality Assurance Committee. Specifically, the Medical Director stated that they do not attend the Quality Assurance quarterly meetings, and the Administrator stated that the Medical Director was too busy to attend the Quarterly Assurance quarterly meetings. The findings are: The undated policy titled Quality Assurance and Performance Improvement Program documented; that the Quality Assurance and Performance Improvement Program is designed to provide an ongoing, coordinated systematic and objective approach to monitor, evaluate, and improve [NAME]'s performance. The Quality Assurance and Performance Improvement Committee meets at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance and Performance program. [NAME] maintains a QAPI Committee consisting at minimum of the: Director of Nursing, Assistant Director of Nursing, Medical Director/Designee, Infection Preventionist, Administrator, Assistant Administrator, Director of Social Work, and at least two other members of the facility's staff. The undated document titled QAPI Committee documented; that the Quality Assurance and Performance Improvement Committee consisted of the: Administrator, Director of Nursing, Assistant Director of Nursing, Director of Admissions, Director of Social Work, Minimum Data Set Coordinator, Director of Recreation, Director of Rehabilitation, and Dietician. The QAPI Committee document did not include the Medical Director as a member of the Quality Assurance and Performance Improvement Committee. Review of the Quality Assurance and Performance Improvement Committee Meeting Sign-In Sheets documented that the Medical Director did not attend the Quality Assurance and Performance Improvement meetings on 02/06/2024, 05/03/2024, 07/25/2024, and 11/01/2024. On 01/17/2025 at 02:20 PM, the Director of Nursing was interviewed and stated that the Medical Director does not attend the quarterly Quality Assurance and Performance Improvement meetings. On 01/21/2025 at 09:33 AM, the Administrator was interviewed and stated that the Medical Director has not attended the last four Quality Assurance and Performance Improvement meetings because the Medical Director is too busy to attend them. The Administrator stated that they send the Medical Director copies of the meeting notes from each Quality Assurance and Performance Improvement meeting after each meeting to inform the Medical Director of what was discussed during each meeting. The Administrator stated that ideally, the Medical Director would attend the quarterly Quality Assurance meetings, but the Medical Director is so busy that it is difficult to schedule a time where they can attend. On 01/21/2025 at 11:58 AM, the Medical Director was interviewed and stated that they do not attend the quarterly Quality Assurance and Performance Improvement meetings. They stated that instead of attending the meetings with the committee, they meet with the Director of Nursing and are briefed on what was discussed in the meetings afterwards. 10 NYCRR 415.15(a)

Based on observations, interviews and record review conducted during an abbreviated survey (NY00269802), the facility failed to ensure that a resident had the right to refuse treatment. This was evident in 1 out of 3 residents sampled for resident rights (Resident #1). Specifically, Resident #1 refused to have the Medical Director (MD) check their wounds and refused to have Haldol (an antipsychotic drug) on 01/08/2021. The MD insisted on checking Resident #1's wounds and Resident #1 bit the MD's right thumb. Additionally, the MD stated that someone (does not remember the name of the person) held Resident #1's arm while they injected Resident #1 with Haldol 1mg intramuscular on 01/08/2021. The findings are: The facility's policy and procedure titled Medical Care and Resident Rights, last reviewed 08/2010, states that the resident has the right to refuse any treatment; the refusal must be documented in the resident's medical record and be countered by discussions with the resident of the health, safety and consequences of the refusal and the availability of any therapeutic alternative that may exist. It may be appropriate to insist on care in a situation where the decision of the resident to refuse care might harm self or others, e.g., the resident refuses treatment for an infection that might cause sepsis. The Facility's RESIDENT'S BILL OF RIGHTS states the right to refuse treatment. Resident #1 was admitted to the facility with diagnoses including Paraplegia due to Gunshot Wound, Multiple Stage IV Pressure Ulcers and Psychotic Disorder. The Minimum Data Set, dated dated dated [DATE] documented that Resident #1's cognitive status was intact. Resident #1's Treatment Administration Record (TAR) for 01/05/2021 through 01/31/2021 revealed that Resident #1 refused wound treatments 23 times. The Nursing Progress Notes for 01/2021, revealed that Resident #1 had been refusing wound care and was noncompliant with care. Resident #1 was educated on the importance of wound care and hygiene. The doctor and Social Worker (SW) #1 were notified. A Medical Progress Note, by the Medical Director, dated 01/08/2021 at 01:04 PM documented that Resident #1 had been refusing hygiene and decubitus care since admission and had not allowed staff to see their ulcers. The room and hallway noted odorous originating from Resident #1's body. Resident #1 became very aggressive when approached for assessment and reinforcing wound care. Resident #1 bit the Medical Director's right thumb. Haldol 1mg injected intramuscularly to address aggressive behavior. Resident #1 called 911 to be transferred out of nursing home (but later refused to go). The Medical Director spoke with Resident #1's next of kin and informed them of Resident #1's behavior and action taken, i.e., Haldol injection. A Grievance Form dated 01/08/2021 documented that Resident #1 complained to SW #1 that a doctor (Medical Director) entered their room and demanded to see their wounds and Resident #1's refusal was ignored. Also documented, Resident #1 was held down by the doctor and another male staff member and were given an injection against their will. A Facility's Incident/Accident Report initiated 01/08/2021 at 11:20 AM revealed a written statement by Registered Nurse (RN) #3 who documented that Resident #1 had been given a dose of Methadone for pain as requested by Resident #1 at 11:15 AM. RN #3 stated that they were then called to Resident #1's room by the MD to assist with wound dressing. Resident #1 was noted to start being aggressive and was educated on the need for wound assessment and wound dressing. Resident #1 started spitting and bit the MD's right thumb. The MD ordered to give Haldol 1mg intramuscularly. Resident #1 refused the injection, and the MD administered the Haldol themself. 911 was called and responded. At 12:30 PM, Resident #1 allowed wound dressings to be done. Resident #1 denied pain. The Police Officers came to speak with Resident #1, but Resident #1 refused to be transferred to the hospital by 911. Since Resident #1 was alert and able to decide for themself, 911 declined to take Resident #1 to the hospital. The incident was reported to the New_York State Department of Health (NYSDOH) at 11:30 AM on 01/08/2021. The Facility's Internal Investigation conclusion was that Resident #1 had been noncompliant with care since admission despite continual education regarding the importance of receiving wound care and that the Medical Director acted within their professional judgment in approaching the resident. The facility stated to be unable to determine if any intentional mistreatment or violation of care plan had occurred. On 11/15/2022 at 1:28 PM, the MD was interviewed and stated that Resident #1 had been refusing wound care and the entire unit smelled of feces and infection. The MD stated that medical and nursing staff had provided daily counseling to Resident #1 on accepting care and treatment. The MD stated that on 01/08/2021, they went to see Resident #1 because the unit smelled terrible, and the other unit residents were complaining. The MD stated that they told Resident #1 that they had to see the wound and clean it. The MD also stated that they told Resident #1 You cannot refuse treatment if your backside is one big hole full of feces and smelling, someone must clean you up. That is not a right, to make everybody else miserable. The MD stated that Resident #1 became more and more agitated, refusing to be touched, and was banging their head and their arms, screaming, and trying to roll off the bed. The MD stated that they asked the nurse (RN #1) and a male staff member to hold the resident so they could put some towels on the bed to support the resident on their side. The MD stated that they were not trying to do anything against the Resident's will. The MD stated that Resident #1's entire sacral area was open and infected, with days of feces in the wound. In a follow up interview on 11/23/2022 at 10:10 AM, the MD stated that they were never alone with Resident #1 and never physically held Resident #1. The MD stated that they could not recall who was in the room with them, and stated, somebody did hold the resident's arm so the resident could be injected. The MD stated that they do not remember who, but somebody had to hold the resident's arm. The MD stated that Resident #1 hit them repeatedly in the face and arms but that they could not leave the room when the resident became aggressive because they were trying to help. On 11/15/2022 at 2:11 PM, RN #1 was interviewed and stated to have been with the MD when they went to see Resident #1. RN #1 stated that the MD had heard about Resident #1's refusal of treatment and hygiene and came to the unit to encourage the resident to comply. RN #1 stated that the MD asked RN #1 to prepare a dose of Haldol in case Resident #1 became agitated. RN #1 stated that they prepared the dose as well as the supplies to change Resident #1's wound dressings. RN #1 stated that Resident #1 became argumentative and agitated and refused the injection of Haldol. RN #1 stated that they told the MD that they could not give the injection because Resident #1 refused. RN #1 stated that the MD gave Resident #1 the injection themself. RN #1 stated, I believe that residents have a right to refuse treatment. We had been trying to explain to the resident and encouraged the resident to comply, but the resident would always refuse everything despite whatever we did. But that was their right. In a follow up interview with RN #1 on 11/17/2022 at 1:52 PM, RN #1 stated that on 01/08/2021, the MD explained to Resident #1 that they would give Resident #1 a shot to calm Resident #1 down and Resident #1 said no. RN #1 stated that they saw the MD give Resident #1 the injection and Resident #1 bite the MD. RN #1 stated that the MD's finger was bleeding. RN #1 stated that they do not recall anyone else being in the room or holding Resident #1 down. On 11/17/2022 at 2:17 PM, [NAME] #1 was interviewed and stated to have been delivering some items to Resident #1's unit on 01/08/2021 when the MD called for help from Resident #1's room. The [NAME] stated that they entered the room and saw the MD's hand in Resident #1's mouth and that the resident was biting it. The [NAME] stated that they held Resident #1's jaw to get the resident to release the MD's hand. The [NAME] stated that they did not try to pry Resident #1's mouth open or to squeeze it. The [NAME] stated that they did not hold Resident #1 down. The [NAME] stated to not recall whether the MD gave Resident #1 an injection while they were in the room. On 11/23/2022 at 12:16 PM, the Director of Nursing (DON) was interviewed and stated that the facility's policy and procedure states that a doctor may treat a resident even if the resident objects and had decisional capacity if not doing so would be detrimental to the resident health. On 12/20/2022 at 12:01 PM the Administrator was interviewed and stated that a resident has the right to refuse treatment but if their refusal interferes with the comfort of another resident, the facility must protect the second resident. If a resident's refusal causes harm to the resident and they cannot make the right decision for their own safety, the facility must protect the resident from themself. The Administrator stated to have been aware that Resident #1 was refusing wound care and had been given Haldol despite their refusal of the injection. The Administrator stated that if the facility's Medical Director had assessed the resident's situation and decided that the resident needed to have their wounds taken care of to prevent sepsis, their refusal of the Haldol injection was overridden by their need to have it to submit to wound treatment. On 12/21/2022 at 1:24 PM, a follow up interview was conducted with the DON who stated that the facility was aware of Resident #1's noncompliance with wound care and personal hygiene prior to admission. The DON stated that the facility implemented care plans and care plan meeting. Stated that Resident #1 also refused psychiatrist and psychologist consults. The DON further stated that the Medical Doctor got involved because Resident #1 refused all interventions. The DON verbalized that they tried to transfer Resident #1 to the hospital via 2PC (Two Physician Certificate), but when the Emergency Medical Team and police interviewed Resident #1, they stated that Resident #1 has capacity to make their own decision. The DON stated that the Ethics Committee would only meet when a resident does not have capacity and does not have a responsible party. The DON stated that the Ethics Committee did not meet to discuss Resident #1's noncompliance. 10 NYC RR 415.3(e)(1)(ii)

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure safe food storage and infection control was practiced. Specifically, (1) expired pancake and waffle syrup, gallon bottles of distilled vinegar, and teriyaki sauce were observed in the dry storage room and expired cottage cheese was observed in the refrigerator, and (2) staff did not perform hand hygiene after handling a cup that touched the floor and in between serving residents lunch trays. This was evident during the Kitchen Observation and Dining Task. The findings are: 1.The facility policy titled 4.6 -Refrigerator Storage implementation/revision date [DATE] documented upon receipt, immediately refrigerate perishable foods (eggs, milk, etc.). Rotate older items to the front so that they are used first. Date the opened, unused portions of packaged foods to ensure they will be used first. The facility policy titled 4.4- Dry Storage implementation/revision date [DATE] documented new stock must be stored behind the old stock so older items will be used first. Products should be dated to ensure First In- First Out. The expiration dates must be checked on commercial formulas such as enteral feedings or supplements. The policy does not mention checking the expiration dates of other items stored in the dry storage area. On [DATE] between 09:31 AM and 10:12 AM during the tour of the dry storage room, the following was observed: seven bottles of 1 gallon pancake and waffle syrup with a best by date of [DATE]- unopened, 4 gallons of distilled white vinegar with a best by date of [DATE] and a bottle of teriyaki sauce lot #TK16720 with a best if used by date of [DATE]. On [DATE] at 09:48 AM, during an additional kitchen tour of the refrigerator #4, two 5-pound plastic containers of Hood 1% low fat cottage cheese were observed with a date of [DATE] stamped below the lid of both containers. On [DATE] at 10:27 AM, an interview was conducted with Dietary Aide (DA) #1 who stated they are in charge of the storeroom and they do not use the syrup and vinegar anymore but they did not discard it. DA #1 also stated that items are supposed to be used until the expiry date and they have to notify the supervisor before any food item is discarded. On [DATE] at 10:25 AM, an interview was conducted with the Food Service Director (FSD) who stated the facility no longer uses the large bottle of the pancake and waffle syrup and instead use individual sized pouches of syrup. The FSD also stated that both items are expired. On [DATE] at 10:17 AM and 3:24 PM, the Dietary Supervisor (DS) was interviewed and stated that the storeroom person checks food items and dates should be on the box of when the item was received. The DS also stated that they last checked dry storage last Friday and there were no expired items. The DS further stated that they check dates of items in the kitchen ,d+[DATE] times a week and they depend on the storeroom person to do their checks. The DS further stated they had checked the dates on the cottage cheese recently. On [DATE] at 3:27 PM, a follow-up interview was conducted with the Food Service Director (FSD) who stated the two containers of cottage cheese are expired and they did not check them properly. The FSD also stated that do refrigerator checks when they are ordering once a week and when they do inventory. On [DATE] at 11:00 AM, a follow-up interview was conducted with (DA) #1 who stated that they did not notice the date on the 2 containers of cottage cheese. The DA #1 further stated that had the items been used timely, it would not have had time to expire. 2. The facility policy titled Hand Hygiene effective ,d+[DATE] and revised [DATE] documented the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. During dining observations conducted on the 5th Floor unit on [DATE] from 12:26 PM -12:38 PM, the following was observed: Certified Nursing Assistant (CNA) #1 picked up a dropped coffee cup off the floor and placed it on the coffee tray on the meal cart after they dropped off a tray for a resident before they picked up the dropped coffee cup off the floor. CNA #1 picked up a new coffee cup with bare hands and dispensed coffee into the new cup for resident #163 without performing hand hygiene at 12:28PM. From 12:29 PM, CNA # 1 then delivered trays to three and moved an overbed table before removing the lid off of ice-cream for another resident. CNA #1 did not perform hand hygiene and then proceeded to remove the wrapping off a salad, remove the lid off an ice-cream, prepared coffee and gave a weighted spoon to Resident #76. CNA #1 then retrieved two trays from the meal cart and delivered to two other residents in their rooms before retrieving a tray from the meal cart for Resident #117 who was seated in the hallway. CNA #1 prepared coffee and removed a lid from the soup and placed a spoon in the soup and provided Resident #117 with a fork. CNA #1's hands were bare and no hand hygiene was observed being performed during meal service. On [DATE] at 2:18 PM, an interview was conducted with CNA # 1 who stated that they were was supposed to do hand hygiene and were in the middle of giving a resident food so that is the reason why they did not do hand hygiene. CNA #1 stated they did perform hand hygiene after distributing all the lunch trays but should have washed or sanitized their hands in between residents. On [DATE] at 4:26 PM, the Registered Nurse Supervisor (RNS) #2 was interviewed and stated staff should be cleaning hands between resident trays to prevent the transmission of germs to residents and between residents. RNS #2 also stated they emphasize to staff that this should be done during dining when trays are passed out as they do not want to spread germs between residents. 415.14 (h)

Based on observations, record reviews, and interviews conducted during the Recertification survey from 12/12/22 to 12/19/22, the facility did not ensure each resident remained free from physical restraints. Specifically, there were no ongoing re-evaluation assessments conducted for the need for bilateral upper and lower side rails for Residents #58 and #112. The two residents were observed on several occasions in bed with bilateral upper and lower side rails in use. This was evident for 2 out of 7 residents reviewed for Physical restraints out of a sample of 39 residents. The findings are: The facility policy titled Restraints/Devices Physical dated 4/2/19 documented a physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the Resident's body that the Resident cannot remove easily and restricts freedom of movement or normal access to the Resident's body; it cannot be removed by the Resident in the same manner as it was applied by staff. The Resident is assessed by Rehab Therapy for the use of the device. The Physician orders the use of the device and reason for use and Licensed Nurse/Rehab put orders in the Resident's chart and update Resident's care plan. 1.Resident #58 had diagnoses which included Athetoid Cerebral Palsy, Dementia, and Cerebrovascular Accident (CVA). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident had impaired cognition and required total assistance of two persons for transfers and toilet use. The MDS also documented that bed rails were not used for this resident. On 12/12/22 between the hours of 9:55 AM and 12:56 PM, Resident #58 was observed in bed, alert and awake. Padded bilateral upper and lower side rails were observed while the resident in bed. The resident appeared confused and could not communicate verbally. On 12/13/22 between the hours of 10:33 AM and 12:30 PM, Resident #58 was again observed in bed, alert and awake. Padded bilateral upper and lower side rails were up while the resident in bed. The resident occasionally moved their legs and arms involuntarily. Physician's Order dated 5/28/18 renewed 11/29/22 documented the following: Bilateral lower and upper side rails up to define bed boundaries due to involuntary movements secondary to diagnoses of Athetoid Cerebral Palsy and also to aid during turning and positioning. The Siderail assessment dated [DATE] documented that the resident does not have the ability to rise from bed independently without a side rail. The assessment also documented that the resident/family/HCP expressed a desire to have side rails raised while in bed. Siderail Assessment Section 3 which was the physical assessment of the resident's ability to utilize the side rail was incomplete. The section of the assessment titled Conclusions which indicated the need for siderail use was also incomplete. On the Siderail Assessment completed 8/11/22, the section of the assessment titled Conclusions which indicated the need for siderail use was incomplete. The Siderail assessment dated [DATE] documented that side rails are used as a bed boundary due to presence of involuntary movement related to resident's neurological condition. This does not restrict freedom of movement in bed. The section of the assessment titled Conclusions which indicated the need for siderail use was incomplete. An inactive comprehensive care plan titled Restraint dated 11/17/2017, last revised 1/23/20 documented the following interventions: Apply as per MD order, explain to resident/family risk/benefit and alternative, observe for changes in ADL, cognition and/or behavior, release side rails every 2 hours for 15 minutes for Range of Motion (ROM) exercise, toileting, and ambulation. The CCP titled Devices dated 9/20/22, last updated 12/13/22 documented that Bilateral lower and upper side rails up to define bed boundaries due to involuntary movements secondary to diagnoses of Athetoid Cerebral Palsy and also to aid during turning and positioning. The CCP further documented that the resident CCP & Safety committee evaluation as needed. There was no documented evidence the ongoing evaluation of the continued use of the physical restraint was conducted by the interdisciplinary team. On 12/15/22 at 10:41 AM, an interview was conducted with the assigned CNA #6 who stated that Resident #58 cannot stay in bed without the side rails. If they place Resident #58 in a chair, the resident slides down. The resident is safer while in bed with the side rails with padding. The resident throw hands and legs often. CNA #6 also stated that when they pull the rail down, they cannot move away because the resident will fall out of the bed. On 12/16/22 the Licensed Practical Nurse (LPN) #4 was interviewed and stated Resident #58 has involuntary body movements and moves often while in bed so they need the side rails. LPN #4 also stated that they make sure that the resident is in bed and ensure the CNAs repositioned the resident every 2 hours. The resident had no recent fall or injury. On 12/16/22 at 12:38 PM, Registered Nurse (RN) #3 was interviewed and stated Resident #58 has involuntary body movements that may cause the resident to fall out of bed. They also stated that the resident moves around and up and down, and the side rails are there to prevent falls. RN #3 also stated that the side rails assessment is supposed to be completed every quarter and it is the responsibility of the nursing department to have them completed. RN #3 also stated that the rehab only get involved in the beginning of the siderail use but with residents who have been using rails for a long time, the nursing staff is responsible to complete the ongoing assessment of the rails. RN #3 further stated that if the resident is able to get out of bed independently it is not considered a restraint. If the family/resident agrees to side rails, then we continue with the rest of the assessment. On 12/19/22 at 01:56 PM, an interview was conducted with the Medical Doctor (MD) who stated that they see Resident #58 at least once a week. The MD also stated that Rehab recommended that resident have four side rails as Resident #58 always has involuntary movements and they have tried using pillows before but that did not work. The MD further stated that the nursing and rehab are responsible for the on-going assessment of the side rails. 39136 2. Resident # 112 was admitted to the facility with the diagnoses, which include Anoxic Brain Damage and Epilepsy. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 112 is severely impaired-never/rarely made decisions and required extensive assistance with two people for bed mobility, transfer, and toilet use and one person assist for personal hygiene. On 12/12/2022 at 10:15 AM and 12/13/2022 at 9:28 AM, Resident #112 was observed lying in bed with four side rails up with blue padding. On 12/14/2022 at 9:35 AM, 12/15/2022 at 10:26 AM, and 12/16/2022 at 9:44 AM, Resident #112 was observed sleeping in bed with four side rails up and blue padding. A Physician Order dated 01/26/2022, revised 11/29/2022 documented bilateral lower and upper side rails up to define bed boundaries due to involuntary movements. A Physician Order dated 01/26/2022, revised 11/29/2022 documented bilateral bed rails wedge padding to define bed boundaries due to involuntary movements. The Comprehensive Care Plan (CCP) titled Device, initiated on 11/28/2017-revised 07/22/2022 documented that Resident #112 had a diagnosis of Epilepsy and Anoxic Brain Damage. Resident # 112 has bilateral upper and lower side rails and bilateral bed rails wedge padding. The interventions included Occupational therapy/Physical therapy evaluation/screen, evaluating the need for continued use of the device quarterly/as necessary and appropriate, and maintaining family contact concerning the use of the device. The care plan note dated 07/22/2022 documented that Resident #112 was still noted with mild involuntary movement. Bilateral lower and upper side rails up with padding as ordered to define bed boundaries due to involuntary movements. The care plan note dated 12/15/2022 documented that Resident # 112 is maintained on the bilateral lower and upper side rails with paddings due to involuntary movement. The bed is at the lowest height position. Side Rails assessment dated [DATE] documented bilateral side rails with padding used in bed mobility to define bed boundaries secondary to involuntary movements. Review of the medical records from 02/04/2022 to 12/15/2022 revealed no documented evidence of the ongoing evaluation for the continued use of the bilateral lower and upper side rails and wedge padding. On 12/15/2022 at 12:12 PM, an interview was conducted with Certified Nursing Assistant (CNA) # 4 who stated that Resident #112 has bilateral lower and upper side rails up because the resident has involuntarily body movements. The resident will fall out of the bed if the side rails are not there. CNA #4 also stated that Resident #112 kicks at times and can get hurt and the padding is there to prevent the resident from injuring themselves. On 12/15/2022 at 12:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that Resident #112 has involuntary movement, that is why bilateral lower and upper side rails up are used. LPN #2 also stated that Resident # 112 always moves in bed when awake but is sturdy when sleeping. On 12/19/2022 at 2:05 PM, an interview was conducted with the Medical Doctor (MD). The MD stated that rehab recommended that Resident #112 have four side rails. Resident # 112 has involuntary movement at times and sometimes hits the side rails, so the padding serves as protection for the resident. Resident # 112 had been noted with a bruise on the hands before and it was assumed that the resident might have hit part of the body on the bed. The MD also stated that the use of the bed rail is not considered as a restraint but as protection for the resident. On 12/19/2022 at 9:59 AM, an interview was conducted with the Director of Nursing (DON) who stated that Resident #112 has involuntary movements, and that is why the resident has four side rails up. The side rails are mainly used because of the involuntary movement. The DON also stated the side rails assessment is incorporated with the quarterly evaluation, but it had not been completed; the last one was completed on 02/04/2022. 415.4(a)(2-7)

Based on interview and record review conducted during a Recertification and Complaint survey (NY00303408) conducted from 12/12/22 to 12/19/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report an allegation of resident-to-resident abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for two allegations for 2 of 2 residents reviewed for Abuse out of a sample of 39 residents. (Resident #49 and Resident #148) The findings are: The undated policy and procedure titled Abuse Prevention documented the facility ensures that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported in adherence with the current regulatory guidelines for incident reporting set forth by the NYSDOH: immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #148 had diagnoses which include Depression, Psychotic Disorder, and Aphasia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident had moderately impaired cognition. Resident #49 had diagnosis which included Cerebrovascular Accident, Hemiplegia and Diabetes Mellitus. The Annual Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact and had no behavioral concerns. There was no psychosis, behavioral concerns, rejection of care or wandering noted on the assessment. The facility Accident/Incident Investigation Summary of Investigation dated 10/4/2022 documented the following: the incident occurred on 10/4/2022 at 7:50 PM and occurred at room [ROOM NUMBER], resident alert and confused. Incident type: behavior problem. Incident description: Resident #148 was noted to have picked up rolling stool and threw it at another resident striking the other resident on their left knee. A Nursing progress note dated 10/5/2022 at 12:05 AM documented at 7:50 PM, Resident #49 was sitting outside their room in their wheelchair. Another resident picked up a rolling stool and threw it at Resident #49 and it struck Resident #49 on their left knee. Resident #49 was noted with swelling and discoloration to their left knee. Ice pack was applied. Doctor was notified of incident with new order for x-ray of left knee, ice pack to left knee for 15 minutes every 2 hours for 24 hours, Tylenol 650mg every 6 hours as needed for pain. Resident #49 was noted to have called 911 for police assistance. Officers arrived and talked to Resident #49 with no further incident. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report for complaint NY00303408 documented the Assistant Director of Nursing reported the altercation which occurred between Resident #148 and Resident #49 on 10/04/2022 at 7:50 PM to NYSDOH on 10/06/2022 at 3:58 PM. The allegation of resident-to-resident abuse was reported 44 hours and 08 minutes after the reported incident. On12/15/22 at 04:51 PM, Registered Nurse (RN) #2 was interviewed and stated they were working the 4-11 shift and they were called to the unit by the Licensed Practical Nurse (LPN) #1. They were told that Resident #148 picked up a stool and threw it across the hall hitting Resident #49 who was sitting in their wheelchair striking them on their knee. RN #2 stated the Assistant Director of Nursing (ADON) was contacted right away and notified that the incident had occurred and they were informed by the ADON that they had to do the two incident reports. On 12/16/22 at 04:33 PM, the Assistant Director of Nursing (ADON) was interviewed and stated RN #2 communicated with them after the incident as they were offsite at the time. The ADON also stated they were informed that Resident #148 threw something across the hallway and Resident #49 who was sitting in doorway, was hit, and had discoloration or redness to knee after the incident. The ADON further stated that the reporting time frame for abuse is 2 hours and 24 hours if not clear-cut case. The ADON also stated that they have access to the reporting system from home to report incidents and this incident may have been reported by the Administrator. On 12/16/22 at 04:45 PM, the Director of Nursing was interviewed and stated they were informed of the incident with Resident #148 and Resident #49 but they were not working at the time of the incident and the ADON and Administrator addressed the issue. The DON also stated that the reporting time frame for an allegation of abuse which caused bodily injury is within 2 hours and if allegation of abuse within 24 hours without bodily injury. On 12/19/2022 at 02:31 PM, the Administrator was interviewed and stated that they are aware of the incident as they were called and notified. For incident reporting the ADON, DON and Administrator are the backup reporting person. The Administrator also stated that for a resident to resident incident, they have 24-48 hours to report to the Department of Health. The Administrator further stated that for incidents of abuse the reporting time frame is a 2 hours and the facility has had no issues with timely reporting of incidents and staff are good at letting the Administrator know what is happening. 415.4(b)(1)(i)

Based on record review and staff interview conducted during a Recertification survey from 12/12/2022 to 12/19/2022, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, 1). the MDS did not accurately document falls for a resident with a history of falls, and 2). MDS assessments did not accurately document that four side rails were used with a resident. This was evident for 1 of 4 residents reviewed for Accidents and 2 of 7 residents reviewed for Physical Restraints out of a of 39 sample residents. (Resident #37, #112, and #58). The findings are: The facility policy titled Minimum Data Set (MDS) Completion Policy and Procedure last revised 07/2022 documented the purpose to identify each resident's needs, problems, and strengths in order to establish a course of action through an individualized comprehensive care plan. To achieve the highest possible level of functioning through proper implementation of the care plan. The MDS Assessor/Coordinator responsibilities include checks the ARD for accuracy, the assessment needs to represent an accurate picture of the resident's status during the observation period. 1). The Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's manual Version 1.17.1 October 2019 documented Section J: Health conditions: Fall history on admission/entry or reentry under rationale falls are a leading cause of injury, mobility, and mortality in older adults. A previous fall, especially a recent fall, recurrent falls and falls with significant injury are most important predictors of risk for future falls and injurious falls. The manual also documented that the steps for assessment include a review of all relevant medical records received from facilities, also review any medical records received for evidence of one or more falls. Resident #37 had diagnoses which included Dementia, Cerebrovascular Accident and Diabetes Mellitus. The Nursing Progress note dated 5/23/2022 at 3:52 PM documented Resident #37 status post fall incident. Resident continues with complaint of pain to left leg. Xray to left leg done this tour with impression of Fracture to Lower Femur. MD made aware and ordered to transfer resident to hospital. The Nursing Progress note dated 5/31/2022 at 11:16 PM documented Resident #37 was admitted from the hospital due to fall with left distal femur fracture status post open reduction internal fixation of left femur on 05/25/2022. The Significant Change MDS completed on 6/7/2022 documented in Section J: J1900- no falls. There was no documented evidence that the fall with major injury was captured on the MDS assessment. The Nursing Progress note dated 8/1/2022 at 12:33 PM documented Resident #37 s/p fall to the floor via Hoyer lift during transfer. The Quarterly MDS dated [DATE] documented in Section J1700A that the resident had no falls in the last month, J1700B that the resident had no falls in last 2-6 months. There was no documented evidence that the fall sustained on 8/1/22 was captured on the subsequent MDS assessement. On 12/16/2022 at 12:52 PM, the Director of MDS (DMDS) was interviewed and stated there is only 1 full time Assessor and 1 Coordinator and two Per Diem assessors who do not have a fixed schedule. On 12/19/22 at 01:53 PM, the MDS Assessor (MDSA) was interviewed and stated Resident #37 had a fall on 8/1/2022. The look back period is from 6/7/2022 -8/29/2022. It should have been coded as a fall and was not coded as a fall. The MDSA also stated they had training on MDS accuracy in 2021. On 12/19/22 at 02:12 PM, the Director of MDS (DMDS) was re-interviewed and stated they review MDS assessments and do random check on RAI for completeness. MDS assessors should be coding the MDS correctly. The DMDS also stated they are aware that the resident had a fall and but was not aware that it was not captured on the MDS. 33315 2. Resident #58 had diagnoses which included Athetoid Cerebral Palsy, Dementia, and Cerebrovascular Accident (CVA). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident had impaired cognition and required total assistance of two persons for transfers and toilet use. The MDS also documented that bed rails were not used for this resident. On 12/12/22 between the hours of 9:55 AM and 12:56 PM, Resident #58 was observed in bed, alert and awake. Padded bilateral upper and lower side rails were observed while the resident in bed. The resident appeared confused and could not communicate verbally. On 12/13/22 between the hours of 10:33 AM and 12:30 PM, the Resident #58 was again observed in bed, alert and awake. Padded bilateral upper and lower side rails were up while the resident in bed. The resident occasionally moved their legs and arms involuntarily. Physician's Order dated 5/28/18 renewed 11/29/22 documented the following: Bilateral lower and upper side rails up to define bed boundaries due to involuntary movements secondary to diagnoses of Athetoid Cerebral Palsy and also to aid during turning and positioning. Section P of the MDS did not document that bed rails were used with Resident #58. 39136 Resident # 112 was admitted to the facility with the diagnoses, which include Anoxic Brain Damage and Epilepsy. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 112 is severely impaired-never/rarely made decisions. The resident is dependent and required extensive assistance with two people for bed mobility, transfer, and toilet use and one person assist for personal hygiene. On 12/12/2022 at 10:15 AM and 12/13/2022 at 9:28 AM, Resident #112 was observed lying in bed with four side rails up with blue padding. On 12/14/2022 at 9:35 AM, 12/15/2022 at 10:26 AM, and 12/16/2022 at 9:44 AM, Resident #112 was observed sleeping in bed with four side rails up and blue padding. A Physician Order dated 01/26/2022, revised 11/29/2022 documented bilateral lower and upper side rails up to define bed boundaries due to involuntary movements. A Physician Order dated 01/26/2022, revised 11/29/2022 documented bilateral bed rails wedge padding to define bed boundaries due to involuntary movements. The Comprehensive Care Plan (CCP) titled Device, initiated on 11/28/2017 documented that Resident # 112 has Epilepsy and Anoxic Brain Damage. Resident # 112 has bilateral upper and lower side rails and bilateral bed rails wedge padding. The interventions include Occupational therapy/Physical therapy evaluation/screen, evaluating the need for continued use of the device quarterly/as necessary and appropriate, and maintaining family contact concerning the use of the device. The care plan note dated 07/22/2022 documented that Resident # 112 was still noted with mild involuntary movement. Bilateral lower and upper side rails up with padding as ordered to define bed boundaries due to involuntary movements. Section P of the MDS did not document that bed rails were used with Resident #112. On 12/15/2022 at 12:12 PM, an interview was conducted with Certified Nursing Assistant (CNA) # 4 who stated that Resident # 112 has bilateral lower and upper side rails up because the resident has involuntary body movements. On 12/15/2022 at 12:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) #2 LPN who stated that Resident # 112 has involuntary movement, that is why the resident has bilateral lower and upper side rails up. On 12/19/2022 at 2:05 PM, an interview was conducted with the Medical Doctor (MD). The MD stated that rehab recommended that Resident # 112 have four side rails. Resident # 112 has involuntary movement at times. Resident # 112 has had the four side rails up since admission. On 12/19/2022 at 9:49 AM, an interview was conducted with the Director of MDS (DMDS). The DMDS stated they use the RAI manual to complete the MDS assessment. Resident #112 care plan documented that the side rails are not a restraint but a device to define bed boundaries. In addition, based on the RAI manual, the side rails are not considered a restraint. They are not restricting the resident, that is why it was not coded on the MDS. On 12/19/2022 at 9:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the side rails are not used as a restraint. They follow the RAI guideline, that is why the side rails were not coded in the MDS. 415.11

Based on the record review and interview conducted during a Recertification survey from 12/12/2022 to 12/19/2022, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the review of their Comprehensive Care Plan (CCP). Specifically, resident and their representatives were not invited to participate in the review and revision of the residents' care plan. This was evident 2 of 4 residents reviewed for Care Planning out of 39 sampled residents. (Resident #112, and #37) The findings are: The facility policy and procedure, Invitations Comprehensive Care Plan (CCP) dated 12/07/2021, documented that resident are scheduled for CCP during the following times: initial assessment, quarterly, annually, or for a significant change in status. The facility's policy is to extend an invitation to residents and family members/Next of Kin (NOK) for the initial assessment, annual assessment, and significant change. If the resident and family request to be invited to the quarterly assessment meeting, an invitation will also be extended. 1.Resident # 112 was admitted to the facility with the diagnoses, which include Anoxic Brain Damage and Epilepsy. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 112 was severely cognitively impaired-never/rarely made decisions. On 12/13/2022 at 11:41 AM, an interview was conducted with Resident #112's Next of Kin (NOK) who stated that they were not invited to the care plan meeting. The NOK also stated that the facility used to invite them to attend meetings but did not do so anymore. An Annual Care Plan meeting note dated 02/10/2022 documented that a care plan meeting was held to discuss the plan of care. The social worker could not invite the NOK by phone to the meeting. A message was left to contact the facility for updates on Resident #112. Quarterly Care Plan meeting notes dated 05/12/2022, 08/04/2022 and 10/05/2022 documented that care plan meetings were held with the interdisciplinary team to discuss the plan of care/complete the quarterly care plan. The attendance record had no documented evidence that Resident #112's NOK was invited to or attended the meeting. There was no documented evidence that the resident's representative had been invited to participate in care planning meetings and participated in the review and revision of the care plan. On 12/16/2022 at 10:37 AM, an interview was conducted with the Director of Social Services (DSS) who stated that Resident #112's NOK was invited to the annual care plan meeting but could not attend. The DSS also stated that residents and families are invited to the initial, annual, and significant change care plan meetings. They do not invite the family or the resident to the quarterly meeting, which is why Resident #112's family was not invited. The DSS further stated that inviting the resident or the family representative to the quarterly meeting was not the facility policy and they were not aware that resident/family members are to be invited to all care plan meetings. On 12/19/2022 at 12:55 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that residents and family representatives do not participate in the quarterly assessment. On admission, the family is told there will be a quarterly meeting for the resident. The family can request to attend the meeting. On 12/19/2022 at 9:59 AM, an interview was conducted with the Director of Nursing (DON) who stated that on admission, residents' families are informed that they have quarterly meetings, so if they have concerns, they will review them with them. The DON also stated they inform the family that they have a review every 90 days and that the regulation says that the family is to be invited to the annual meeting. It does not say the family should be invited to the quarterly meeting. 42101 2. Resident #37 was admitted with Nontraumatic intracerebral hemorrhage, Unspecified Vascular Dementia and Peripheral Vascular Disease. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition and required limited to extensive assistance with most activities of daily living (ADLs). The resident participated in the assessment and no family or significant other or guardian or legal representative participated in the assessment. The Significant Change Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition and required supervision to total assistance with activities of daily living (ADLs). The resident participated in the assessment and no family or significant other or guardian or legal representative participated in the assessment. An interview was conducted with Resident #37 on 12/13/2022 at 09:55 AM, who stated that they are in charge of their own care and that resident representative emergency contact #1 (EC#1) is informed when anything happens to them and they cannot recall the last time they went to a care planning meeting. The Quarterly CCP meeting note dated 1/27/2022, 04/07/22 and 9/8/2022 documented which members of the interdisciplinary team including Social Services, Activities/Therapy, Recreation staff, Rehab staff, Nursing staff and a Dietitian participated in the care planning meetings. There was no documented evidence that the resident or their representative were invited to or attended the care planning meeting and participated in the review and revision of the care plan. On 12/19/2022 at 03:23 PM, the Social Worker was interviewed and stated that residents are invited to the initial, annual, and significant change meetings and if the resident has questions or concerns about care they can be included in an ad hoc meeting. The SW also stated that the facility policy is that residents are not invited to participate in quarterly meetings. On 12/19/2022 at 4:14 PM, the Director of Social Services (DSS) was interviewed and stated residents are invited to the initial, comprehensive, annual, and ad hoc meetings. The DSS stated that during the quarterly meetings, if there are no changes, the resident is discussed with the team and the family is notified after the meeting. 415.11(c)(1)

Based on observations, interviews, and record review conducted during the Recertification survey from 12/12/22 to 12/19/22, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 of 3 residents reviewed for Mobility out of 39 sampled residents (Resident #208). Specifically, there was no documented evidence that Resident #208 right knee orthosis was applied in accordance with a physician's order. The findings are: The facility policy titled Adaptive Devices dated 1/15/20 and revised 02/14 2022, documented that as part of the procedure, a Medical Doctor's order will be obtained with the wearing schedule, inservice will be given to the nursing Staff, and nursing instructions will be updated. Resident #208 was admitted to the facility with diagnoses that included Dependence on respirator [ventilator] status, Cerebral infarction, and Acute respiratory failure with hypoxia. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that resident had severely impaired cognition, required total assistance of 2 persons for bed mobility and toilet use, extensive assistance of 2 persons for transfer, and had impairment on both sides of the lower and upper extremities. The Physician's order dated 10/17/22 and renewed 12/06/22 documented resident to wear right knee orthosis for 8 hours daily with close monitoring for skin breakdown, redness, or irritation after removal. On 12/13/22 at 10:20 AM, Resident #208 was observed receiving Range of Motion exercises with a therapist. There was no right knee Orthosis observed applied to resident's knee On 12/15/22 at 11:56 AM, Resident #208 was observed in bed, awake. There was no right knee Orthosis observed applied to resident's knee. There was no documented evidence in the Certified Nursing Assistant Accountability Record (CNAAR) for December 2022 of application of the right knee orthosis. The Comprehensive Care Plan (CCP) titled Self-care deficit created on 07/12/22, revised 12/17/22 documented physical limitation as evidenced by bed bound and on ventilator dependent. Goals included that the resident will not develop contractures as possible X 90 days. Interventions included range of motion to prevent contractures. A Physical Therapist's (PT) note dated 10/19/22 documented PT screen completed status post re-admission from hospital. PT note also documented to continue nursing maintenance splinting program with use of Right knee extension splint to optimize joint alignment and prevent further limitations of the joints. On 12/19/22 at 01:15 PM, Registered Nurse (RN) #1 was interviewed and said that every day they print out the CNAAR for the devices and splints and place it in a 'Splint Book'. The Certified Nursing Assistants (CNAs) sign the book indicating that the Splints are applied. RN #1 stated that this is done for checks and balances to make the CNAs aware that the devices are to be applied. RN #1 also stated that they were not aware that the splint was not on the CNAAR for Resident #208, so when they printed the sheet with the devices, it was not included. RN #1 further stated that the CNAs did not inform them that this device for Resident #208 was not being signed off and they did not cross reference the devices with the Physician's orders. RN #1 stated that the PT should have put the order in the system, to have it generated on the CNAAR. The Rehab department should have linked it and then the nurses would have signed it. On 12/19/22 at 01:34 PM, CNA #5 was interviewed and stated that they were usually assigned to Resident #208 and was not aware that they had a right knee Orthosis. CNA #5 also stated that they have a Splint book on the unit, where there is a log of all the splints and devices that are used for the residents, and these splints and devices are also recorded in the CNAAR. Devices and splints are documented once they are applied on the residents. CNA #5 further stated they did not apply a splint for Resident #208 since there was no documentation of a splint on the CNAAR, and if there was a splint and they were unable to document for it, they would let the Charge Nurse know to have it corrected. On 12/19/22 at 01:46 PM, the Senior Physical Therapist (SPT) was interviewed and stated that when the PT places an order for a splint, the Nurses will pick up the order and then enter it on the CNAAR. The order should be linked so the CNAs can document and sign off that the splint was applied. The SPT also stated that if the order is not linked to the CNAAR, there is no place for the CNAs to sign and this is an issue. If no one is notified that the splint or devices are not linked, then it goes unattended. The SPT further stated that once the order is picked up, then the Nursing department would have to link it to the CNAAR and had they been made aware of the situation, it would have been resolved, and it would not have been missed. On 12/19/22 at 02:36 PM, the Director of Nursing (DNS) stated that when a resident is admitted , the Rehab department would assess the need for a Splint and once it is needed, they would coordinate with Nursing and obtain a physician's order for the splint. The DNS also stated that the Nursing department would activate the instructions to be reflected on the CNAAR and there is a backup system whereby they have a Splint Binder on the unit, as a reminder to the CNAs, to apply the devices. The DNS further stated that both the Rehab and Nursing department ensure that the orders are in place for the devices, and that they are linked to the CNAAR. The DNS stated that they cannot say why Resident #208's device was not linked to the CNAAR and this should have been checked since there was a Physician's order for the device. 415.12(e)(2)

Based on observations, record review and staff interviews conducted during an abbreviated survey, the facility did not ensure that a resident's wishes, as expressed in his advance directives, were honored. Specifically, a resident (Resident #1) who had executed both a Living Will and a Health Care Proxy at a time when he had capacity, indicated that it was his express desire to refuse any treatment, other than comfort measures, in the event of an irreversible terminal illness from which there was no hope of recovery. Contrary to the resident's wishes, the facility provided aggressive, life-sustaining treatment at the express direction of the resident's health care agent, and did not advocate on behalf of Resident #1's right to refuse treatment as expressed in his Living Will and Health Care Proxy. As a result, the resident received unwanted treatment in the facility for two years up until the time of his death. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 656 The findings are: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 (a resident assessment tool) dated [DATE] documents that the resident is not alert or oriented and is only responsive to tactile stimulation. He requires total assistance with Activities of Daily Living (ADL), is incontinent of bowel and bladder and bed-bound. He requires assist of two with bed mobility, transfers and incontinence care. The resident is also assessed as at high-risk for pressure sores. A record review of an initial Social Work Note dated [DATE] documents that there are no advance directives for Resident #1. This is also documented in a Social Work Quarterly Note dated [DATE]. A review of the resident's Patient Activity Log dated [DATE] revealed that during the period beginning [DATE] to [DATE] the resident was discharged to the hospital on three occasions. On [DATE] and [DATE] the resident was discharged to the hospital for respiratory distress and on [DATE] the resident was discharged for fever. For these three hospitalization s there was no documented evidence of any Health Care Proxy or Living Will. The Comprehensive Care Plan dated [DATE] documents that the facility was provided with the resident's Health Care Proxy information. A review of the resident's Health Care Proxy, signed and witnessed on [DATE], reveals that he appointed his agent in the following order: the primary agent was his spouse, who expired in January, 2009; his son, who is a physician and works in the facility, as the first alternate agent; and another son as his second alternate agent. A review of the facility's Advance Directives Check-Off form dated [DATE] and signed by the Social Worker revealed only a Health Care Proxy was checked as available. The section on the form for "Living Will" was left blank. Further review of the Patient Activity Log revealed that there were five additional hospitalization s on [DATE], [DATE], [DATE], [DATE] and [DATE]. Among the reasons for discharging the resident to the hospital were [MEDICAL CONDITION], respiratory distress, sub-arachnoid hemorrhage and [DEVICE] replacement. A copy of Resident #1's Living Will was obtained from the Social Worker on [DATE]. A review of both the Living Will and Health Care Proxy revealed they were both signed, witnessed and became effective on [DATE]. The Living Will states the following: "In the event I have an irreversible, terminal illness from which there is no hope of recovery, I direct that the life-sustaining procedures that may be withheld or withdrawn shall include, but are not limited to: Surgery, Antibiotics, Cardiac Resuscitation, Respiratory Support, Artificially Administered Feeding and Fluids. I further direct that treatment be limited to comfort measures only, even if they shorten my life." The Living Will goes on to state that "These directions express my legal right to refuse treatment. Therefore, I expect my family, doctors, and all those concerned with my care to regard themselves as legally and morally bound to act in accord with my wishes and in doing so to be free from all liability for having followed my directions." A review of the resident's Health Care Proxy states the following: "I have fully discussed with my agent and his/her successor my wishes concerning artificial nutrition and hydration and, if I am suffering from an irreversible illness, I do not want to receive artificial nutrition nor artificial hydration, except for comfort measure only and not to extend my life." The resident further states, in his Health Care Proxy, that "I direct my agent to make health care decisions in accordance with my wishes and instructions as stated above or as otherwise known to him or her." Interim Physician Visit Notes and [MEDICAL CONDITION] Medicine Progress Notes from [DATE] to [DATE] document unsuccessful attempts to wean the resident from the ventilator. A [DATE] note indicates the resident cannot be weaned from the ventilator "secondary to chronic [MEDICAL CONDITION] and multi-organ failure." A Comprehensive Care Plan dated [DATE] documents that bilateral hand mittens were placed on the resident as he pulls out [MEDICAL CONDITIONS], with periods of restlessness. A [MEDICAL CONDITION] Medicine Assessment and Plan of Care Progress Note dated [DATE] states, in part, that "Given the extent of his medical problems and nature of his illness, there is no reasonable expectation that he can achieve liberation from the ventilator." A review of a Certificate of Death dated [DATE] documented that the resident expired on [DATE] at 1:16 AM. A telephone interview was conducted with the facility's Social Worker on [DATE]. The Social Worker stated that Resident #1 had both a Living Will and a Health Care Proxy. She stated that the Living Will was not placed in the resident's medical records at the request of the resident's health care agent. She further stated that she was aware of the wishes of the resident, as outlined in the Living Will, but said the health care agent "supercedes" those wishes. A second interview was conducted with the Social Worker at the facility on [DATE] at 9:40 AM. She stated that Resident #1 is total care and has a Health Care Proxy. The Social Worker again stated that the Living Will was not placed in the resident's medical records at the request of the resident's health care agent. She provided a copy of the Living Will, which she had kept in her office. There is no documented evidence that the Social Worker, who had knowledge of the existence of the Living Will and its contents, challenged the decisions of the health care agent, on behalf of the resident, with respect to life sustaining medical interventions. On the contrary, the Social Worker stated that the wishes of the resident, as expressed in the Living Will, were superseded by the decisions of the health care agent. A telephone interview was conducted with the resident's health care agent on [DATE] at 4:15 PM. The health care agent stated that he is not bound by the Living Will because his father (the resident) was not suffering from an "irreversible terminal illness." He further stated that the health care decisions he made on behalf of his father were consistent with his father's wishes. When asked for the basis for that belief, he recounted an episode involving his mother (resident's wife) and his father. His mother had succombed to a terminal illness. When she was on her deathbed, the agent said his father (the resident) implored him to call [DATE]. Based on that episode, the health care agent said he believes his father would have wanted the same response for himself if he was in a similar predicament. However, the health care agent acknowledged that his father did not verbalize that he wanted to change his instructions, as reflected in the Living Will and Health Care Proxy. He stated, "it's not like he said 'this is what I want.' " On [DATE] a telephone interview was conducted with the second alternate health care agent. He is also the resident's son and the brother of the health care agent. He indicated that he was extremely distressed over the medical treatment that his father was receiving at the facility. He said he was well aware of his father's wishes, which were clearly stated in the Living Will and Health Care Proxy. He said his father would have never wanted the artificial, life-sustaining medical interventions that were currently in place, and would never have wanted to live out his last days in the condition that he currently is in. He also indicated that he was very upset that his father's health care agent (his brother) was not respecting his father's wishes. He further stated that he was aware that Cardio-Pulmonary Resuscitation had been performed on his father, and that this represented a total disregard for the written instructions in the Living Will. Resident #1's health care agent failed to honor the resident's wishes as expressed in the Living Will and Health Care Proxy by allowing and approving life-sustaining interventions such as artificial ventilation and [DEVICE] feeding. An interview was conducted with the resident's Attending Physician on [DATE] at 10:55 A.M. The Physician stated that he was aware of the Living Will, which he said was in the resident's medical records. During the interview, the Physician was advised that the [MEDICAL CONDITION] Attending Physician had documented that the resident had no reasonable expectation that he could achieve liberation from the ventilator. The Physician was asked why he continued to provide extraordinary, life-sustaining medical treatment to the resident if he was aware of the resident's opposition to such interventions, as expressed in the Living Will. The Physician explained that the resident had a proxy, who was the resident's son; that he received directions from the proxy; and that he did not question the decisions of the proxy. The Physician further stated that the Living Will is subject to interpretation and that the proxy can change the instructions. 415.3(e) (1) (ii)

Based on record review and interviews conducted during an abbreviated survey, the facility did not provide the necessary social services to ensure that a resident's health care choices were honored and that the ramifications of those choices were explained to the resident's designated health care agent. Specifically, a resident (Resident #1) who had executed both a Living Will and a Health Care Proxy at a time when he had capacity, indicated that it was his express desire to refuse any treatment, other than comfort measures, in the event of an irreversible terminal illness from which there was no hope of recovery. Contrary to the resident's wishes, the facility provided aggressive, life-sustaining treatment at the express direction of the resident's health care agent, and did not advocate on behalf of Resident #1's right to refuse treatment as expressed in his Living Will and Health Care Proxy. As a result, the resident received unwanted treatment in the facility for two years up until the time of his death. This resulted in actual harm that is not Immediate Jeopardy Complaint ID Number: NY 656 The findings are: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 (a resident assessment tool) dated [DATE] documents that the resident is not alert or oriented and is only responsive to tactile stimulation. He requires total assistance with Activities of Daily Living (ADL), is incontinent of bowel and bladder and bed-bound. He requires assist of two with bed mobility, transfers and incontinence care. The resident is also assessed as at high-risk for pressure sores. A record review of an initial Social Work Note dated [DATE] documents that there are no advance directives for Resident #1. This is also documented in a Social Work Quarterly Note dated [DATE]. A review of the resident's Patient Activity Log dated [DATE] revealed that during the period beginning [DATE] to [DATE] the resident was discharged to the hospital on three occasions. On [DATE] and [DATE] the resident was discharged to the hospital for respiratory distress and on [DATE] the resident was discharged for fever. For these three hospitalization s there was no documented evidence of any Health Care Proxy or Living Will. The Comprehensive Care Plan dated [DATE] documents that the facility was provided with the resident's Health Care Proxy information. A review of the resident's Health Care Proxy, signed and witnessed on [DATE], reveals that he appointed his agent in the following order: the primary agent was his spouse, who expired in January, 2009; his son as the first alternate agent; and another son as his second alternate agent. A review of the facility's Advance Directives Check-Off form dated [DATE] and signed by the Social Worker revealed only a Health Care Proxy was checked as available. The section on the form for "Living Will" was left blank. Further review of the Patient Activity Log revealed that there were five additional hospitalization s on [DATE], [DATE], [DATE], [DATE] and [DATE]. Among the reasons for discharging the resident to the hospital were cardiac arrest, respiratory distress, sub-arachnoid hemorrhage and [DEVICE] replacement. A copy of Resident #1's Living Will was obtained from the Social Worker on [DATE]. A review of both the Living Will and Health Care Proxy revealed they were both signed, witnessed and became effective on [DATE]. The Living Will states the following: "In the event I have an irreversible, terminal illness from which there is no hope of recovery, I direct that the life-sustaining procedures that may be withheld or withdrawn shall include, but are not limited to: Surgery, Antibiotics, Cardiac Resuscitation, Respiratory Support, Artificially Administered Feeding and Fluids. I further direct that treatment be limited to comfort measures only, even if they shorten my life." The Living Will goes on to state that "These directions express my legal right to refuse treatment. Therefore, I expect my family, doctors, and all those concerned with my care to regard themselves as legally and morally bound to act in accord with my wishes and in doing so to be free from all liability for having followed my directions." A review of the resident's Health Care Proxy states the following: "I have fully discussed with my agent and his/her successor my wishes concerning artificial nutrition and hydration and, if I am suffering from an irreversible illness, I do not want to receive artificial nutrition nor artificial hydration, except for comfort measure only and not to extend my life." The resident further states, in his Health Care Proxy, that "I direct my agent to make health care decisions in accordance with my wishes and instructions as stated above or as otherwise known to him or her." Resident #1's health care agent failed to honor the resident's wishes as expressed in the Living Will and Health Care Proxy by allowing and approving life-sustaining interventions such as artificial ventilation and [DEVICE] feeding. Interim Physician Visit Notes and Pulmonary Medicine Progress Notes from [DATE] to [DATE] document unsuccessful attempts to wean the resident from the ventilator. A [DATE] note indicates the resident cannot be weaned from the ventilator "secondary to chronic respiratory failure and multi-organ failure." A Comprehensive Care Plan dated [DATE] documents that bilateral hand mittens were placed on the resident as he pulls out the trach and trach tubing, with periods of restlessness. A Pulmonary Medicine Assessment and Plan of Care Progress Note dated [DATE] states, in part, that "Given the extent of his medical problems and nature of his illness, there is no reasonable expectation that he can achieve liberation from the ventilator." A review of a Certificate of Death dated [DATE] documented that the resident expired on [DATE] at 1:16 AM. A telephone interview was conducted with the facility's Social Worker on [DATE]. The Social Worker stated that Resident #1 had both a Living Will and a Health Care Proxy. She stated that the Living Will was not placed in the resident's medical records at the request of the resident's health care agent. She further stated that she was aware of the wishes of the resident, as outlined in the Living Will, but said the health care agent "supercedes" those wishes A second interview was conducted with the Social Worker at the facility on [DATE] at 9:40 AM. She stated that Resident #1 is total care and has a Health Care Proxy. The Social Worker again stated that the resident had a Living Will but it was not placed in the resident's medical records at the request of the resident's son, who is the health care agent. The Social Worker provided a copy of the Living Will, which she had kept in her office. There is no documented evidence that the Social Worker, who had knowledge of the existence and the contents of the Living Will, challenged the decisions of the health care agent, on behalf of the resident, with respect to those life sustaining medical interventions which were not consistent with the resident's wishes. On the contrary, the Social Worker stated that the wishes of the resident, as expressed in the Living Will, were superseded by the decisions of the health care agent. There is also no documented evidence that the Social Worker, who had knowledge and access to the resident's Health Care Proxy and Living Will, sought to counsel the resident's designated health care agent as to the ramifications of the resident's health care choices as expressed in his advance directives. The resident's Plan of Care lacked any documented evidence of discussions with the resident's health care agent or the resident's family regarding the resident's wishes and the ramifications of the resident's choices. As a result, the resident was subjected to medical interventions that he specifically stated he wanted to avoid, both in his Living Will and Health Care Proxy, such as artificial respiration, nutrition and hydration. On [DATE] a telephone interview was conducted with the second alternate health care agent. He is also the resident's son and the brother of the health care agent. He indicated that he was extremely distressed over the medical treatment that his father was receiving at the facility. He said he was well aware of his father's wishes, which were clearly stated in the Living Will and Health Care Proxy. He said his father would have never wanted the artificial, life-sustaining medical interventions that were currently in place, and would never have wanted to live out his last days in the condition that he currently is in. He also indicated that he was very upset that his father's health care agent (his brother) was not respecting his father's wishes. He further stated that he was aware that Cardio-Pulmonary Resuscitation had been performed on his father, and that this represented a total disregard for the written instructions in the Living Will. There is no evidence that the Social Worker insisted that the Living Will be made part of the resident's medical records after the resident's health care agent instructed the Social Worker to remove the Living Will from the chart. 415.5(g) (1) (i-xv)

Based on record review and interviews conducted during an abbreviated survey, the facility did not conduct an appropriate medical evaluation of a resident's condition and review the appropriateness of the resident's medical regimen. Specifically, a resident (Resident #1) who had executed both a Living Will and a Health Care Proxy at a time when he had capacity, indicated that it was his express desire to refuse any treatment, other than comfort measures, in the event of an irreversible terminal illness from which there was no hope of recovery. Contrary to the resident's wishes the attending physician ordered, and the facility provided, aggressive, life-sustaining treatment at the express direction of the resident's health care agent, including artificial ventilation and feeding, at a time when there was no expectation that the resident could survive without artificial means. As a result, the resident received unwanted treatment in the facility for two years up until the time of his death. This resulted in actual harm that is not Immediate Jeopardy Case ID Number: NY 656 Refer to F 155, F 250 and F 490. The findings are: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] Medicine Assessment and Plan of Care Progress Note dated [DATE] states, in part, that "Given the extent of his medical problems and nature of his illness, there is no reasonable expectation that he can achieve liberation from the ventilator." Interim Physician Visit Notes and [MEDICAL CONDITION] Medicine Progress Notes from [DATE] to [DATE] document unsuccessful attempts to wean the resident from the ventilator. A [DATE] note indicates the resident cannot be weaned from the ventilator "secondary to chronic [MEDICAL CONDITION] and multi-organ failure." A review of a Certificate of Death dated [DATE] documented that the resident expired on [DATE] at 1:16 AM. An interview was conducted with the resident's Attending Physician on [DATE] at 10:55 A.M. The Physician stated that he was aware of the Living Will and its contents, which he said was in the resident's medical records. During the interview, the Physician was advised that the [MEDICAL CONDITION] Attending Physician had documented that the resident had no reasonable expectation that he could achieve liberation from the ventilator. The resident was also receiving artificial feeding through a [DEVICE]. The Physician was asked why he continued to provide extraordinary, life-sustaining medical treatment to the resident if he was aware of the resident's opposition to such interventions, as expressed in the Living Will. The Physician explained that the resident had a proxy, who was the resident's son; that he received directions from the proxy; and that he did not question the decisions of the proxy. The Physician further stated that the Living Will is subject to interpretation and that the proxy can change the instructions in the Living Will. There is no evidence in the facility's records that the Attending Physician sought clarification from the Social Worker in determining the appropriateness of the resident's medical care in light of the resident's expressed wishes, in his Living Will and Health Care Proxy, to refuse treatment in the event of an illness or condition from which there was no hope of recovery. 415.15(b) (2) (iii)

Based on record review and interviews the facility's Administrator did not ensure that the Governing Body of the facility developed policies and that procedures were implemented in order to protect the rights of residents who had executed advance directives. Specifically, a resident (Resident #1) who had executed both a Living Will and a Health Care Proxy at a time when he had capacity, indicated that it was his express desire to refuse any treatment, other than comfort measures, in the event of an irreversible terminal illness from which there was no hope of recovery. Contrary to the resident's wishes, the facility provided aggressive, life-sustaining treatment at the express direction of the resident's health care agent. The Administrator was aware of the resident's wishes and the actions of the resident's health care agent, but did not recognize the need to take appropriate measures to ensure that the resident's treatment was consistent with his Living Will and Health Care Proxy. As a result, the resident received unwanted treatment in the facility for two years up until the time of his death. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 656 Refer to F 155, F 250 and F 386 The findings are: A review of Resident #1's Living Will and Health Care Proxy revealed they were both signed, witnessed and became effective on [DATE]. The Living Will states the following: "In the event I have an irreversible, terminal illness from which there is no hope of recovery, I direct that the life-sustaining procedures that may be withheld or withdrawn shall include, but are not limited to: Surgery, Antibiotics, Cardiac Resuscitation, Respiratory Support, Artificially Administered Feeding and Fluids. I further direct that treatment be limited to comfort measures only, even if they shorten my life." The Living Will goes on to state that "These directions express my legal right to refuse treatment. Therefore, I expect my family, doctors, and all those concerned with my care to regard themselves as legally and morally bound to act in accord with my wishes and in doing so to be free from all liability for having followed my directions." A review of the resident's Health Care Proxy states the following: "I have fully discussed with my agent and his/her successor my wishes concerning artificial nutrition and hydration and, if I am suffering from an irreversible illness, I do not want to receive artificial nutrition nor artificial hydration, except for comfort measure only and not to extend my life." The resident further states, in his Health Care Proxy, that "I direct my agent to make health care decisions in accordance with my wishes and instructions as stated above or as otherwise known to him or her." The facility's attorney was interviewed on [DATE] at 12:12 PM. She stated that the facility contacted her in April, 2010 in order to review Resident #1's Living Will and Health Care Proxy. The attorney stated that the resident's first alternate health care agent told her he believes he is abiding by his father's (the resident's) wishes. It was her opinion that the actions of the resident's health care agent were consistent with the wishes of the resident. She further stated that the facility would not have admitted the resident if they knew that the interventions, which were already in place, were against the resident's wishes. The lawyer went on to say that the facility would not have wanted to incur the expense of having to pay lawyers to go to court. She added that the facility had done everything they could to provide the best care. An interview was conducted with the Administrator on [DATE] at 10:00 AM and on [DATE] at 10:25 AM. During her interviews, the Administrator stated that there was a rift in the family between the first alternate heath care agent and the second alternate health care agent, both of whom are the resident's sons. She said this rift pre-dates the resident's admission to the facility. The Administrator also stated that she was not aware of any particular health care issues in treating the resident and, according to the resident's health care agent, there have been no issues in providing care to the resident. An examination of the facility's records revealed a letter, dated [DATE], and sent by the resident's first alternate health care agent. The agent is a physician who works in the facility and the letter was sent on his professional stationery and was addressed to the facility. The letter directs the facility not to release any of the resident's medical records to the second alternate health care agent and to other members of the resident's family. The letter was subsequently rescinded. A review of a Certificate of Death dated [DATE] documented that the resident expired on [DATE] at 1:16 AM. 415.26