Every finding on record at Willow Point Rehabilitation and Nursing Center

Based on observations, record review, and interviews during the recertification survey conducted 6/09/2025-6/13/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of one (1) main kitchen reviewed. Specifically, the main kitchen had dented cans in use; dishes were not air dried; food was not discarded in a timely manner; and food was stored less than 18 inches from the ceiling. Additionally, food was uncovered while being transported through the North Lower Level hallway. Findings include: The facility policy Dented Cans, revised 4/2023, documented there was a designated place in the storeroom for dented cans, which were then destroyed to prevent the use of spoiled or contaminated food. The Food and Nutrition Services Department does not use foods in dented or damaged cans. The facility policy Dishware Storage, revised 5/2023, documented dishware would be stored appropriately to prevent food soil, dust, or any other debris from adhering to the surface. After coming out of the dish machine, dishware would be air dried prior to storage. The facility policy Labeling and Dating, revised 5/2023, documented all foods would be appropriately wrapped, labeled, and dated based on food storage guidelines. All food would be labeled, dated, and securely covered, and use by dates were monitored and followed. Dented Cans: During an observation on 6/9/2025 at 10:29 AM, the dry storage room had two dented #10 cans of chocolate pudding and one dented #10 can of vanilla pudding. During an interview on 6/13/2025 at 12:33 PM, Kitchen General Manager #28 stated all staff should be checking for dented cans. Dented cans could have a break which could allow in air causing possible contamination. Dishwashing: During an observation of the dish room on 6/9/2025 at 10:23 AM, there were sixty clear dessert bowls stacked upright and together. The bowls were wet and not air drying due to their upright position. Twenty-four pan muffin tins were stored upright. During an interview on 6/13/2025 at 12:33 PM, Kitchen General Manager #28 stated dishes should be air dried upside down to avoid growth of bacteria in standing water. To avoid contamination, dishes should not be wiped dry with a cloth. Expired and Unlabeled Food: During an observation on 6/9/2025 at 10:13 AM the special reach in cooler contained twelve servings of puree apricots dated 6/2/25. During an observation on 6/11/2025 at 9:23 AM the sandwich cooler had four plastic four-ounce containers of pureed chicken and four regular chicken salads with no labeled dates. During an interview on 6/13/2025 at 12:33 PM, Kitchen General Manager #28 stated once items were taken out of their original container they were dated. Staff should check the food dates every day to ensure no outdated food was served. It was the responsibility of all kitchen staff to check dates. They stated it was important to rotate food for food safety reasons. Food Storage: During an observation on 6/9/25 at 10:10 AM the walk-in freezer contained one sheet pan of apple crumble and two sheet pans of frosted cake stored less than three inches from the ceiling. During an interview on 6/13/2025 at 12:33 PM, Kitchen General Manager #28 stated food should be stored off the floor. There should be space between the product and ceiling to maintain air flow in the freezer and avoid contamination. Uncovered Food in Hallway: The following observations were made of uncovered food transported on the North Lower Level hallway: - on 6/10/25 at 12:38 PM, Certified Nursing Aide #23 transported Resident #173's lunch tray from the dining room to their room. The beets on the tray were uncovered. - on 6/10/25 12:43 PM, Unit Helper #17 transported Resident #45's lunch tray from the dining room to their room. The beets on the tray were uncovered. - on 6/10/25 12:58 PM, Certified Nursing Aide #24 transported Resident #158's lunch tray from the dining room down the hall to their room. The beets on the tray were uncovered. - on 6/11/25 12:46 PM, Certified Nursing Aide #25 transported Resident #105's lunch tray from the dining room down the hall to their room. The coleslaw on the tray was uncovered. - on 6/11/25 12:47 PM, Certified Nursing Aide #26 transported Resident #90's lunch tray from the dining room down the hall to their room. The coleslaw on the tray was uncovered. - on 6/12/25 12:44 PM, Licensed Practical Nurse #19 transported Resident #45's lunch tray from the dining room down the hall to their room. The broccoli and cauliflower on the tray was uncovered. During an interview on 6/11/25 at 1:18 PM, Food Service Associate #27 stated they did not have lids for the clear square dishes the coleslaw was served in. They stated they were trained to cover hot food to keep the food hot. They stated they were not told to cover cold food. During an interview on 6/12/25 at 1:03 PM, Kitchen General Manager #28 stated the sides of vegetables were plated in the kitchenettes and foodservice staff set them on the resident trays. Nursing transported meal trays to residents either in the dining room or by carrying the down the hall to the residents' rooms. All items should be covered, including coleslaw, broccoli and cauliflower mix, and beets. Food service staff only plated the meals. Nursing staff checked the items to make sure they had everything, put drinks on the tray, and the lids on the tray. Nursing should cover the items. Food should be covered during transport to prevent debris and contamination. During an interview on 6/12/25 at 2:05 PM, Licensed Practical Nurse #19 stated once food service plated the meal, nursing put covers on hall trays. All items should be covered, including coffee, juices, and hot items. Items such as beets, coleslaw, and cauliflower and broccoli mix should go under the insulated cover when transported in the hallway, so food was not exposed to contamination and or got cold. During an interview on 6/13/25 at 12:08 PM, Infection Control Preventionist #29 stated staff should be covering all food items leaving the dining room. It was important for food to be covered while traveling down the hallway to prevent expose to pathogens. During a follow-up interview on 6/13/25 at 12:33 PM, Kitchen General Manager #28 stated food prepped prior to meal service was covered in the kitchen by food service staff. When food was plated in the kitchenettes and brought down the hall nursing was responsible for covering the food. The kitchen provided insulated lids. They stated there were no lids for the square clear dishes or ceramic dishes, but nursing staff should place those items under the insulated dome plate covers. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00344862) surveys conducted 6/9/2025-6/13/2025, the facility did not ensure accommodation of resident food preferences for two (2) of two (2) (Residents #127 and #195) reviewed. Specifically, Residents #127 and #195 were missing preferred food items on their meal trays. Findings include: The facility policy Food Preferences, revised 5/2023, documented resident food and beverage preferences were obtained upon admission and periodically as needed to assist Food and Nutrition Services department in providing preferred food and beverages to enhance/maintain quality of life and nutritional status. 1) Resident #127 had diagnoses including Pick's disease (a form of dementia), mild protein calorie malnutrition, and dysphagia (difficulty swallowing). The 1/4/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required set up assistance with eating, was unable to speak, weighed 95 pounds, had an unplanned 5% or more weight loss, and received a mechanically altered diet. The Comprehensive Care Plan initiated 5/3/2021and updated 4/9/2024 documented Resident #127 had a self-care deficit with interventions including eating meals in the dining room with close supervision at meals. The resident had an alteration in nutritional status and interventions included encouraging fluids and honoring food preferences. Resident #127's meal tickets dated 6/9/2025-6/12/2025 documented 4 ounces of strawberry ice cream for lunch daily. During observations on 6/10/2025 at 1:25 PM and 6/11/2025 at 1:13 PM, Resident #127 did not have the 4 ounces of strawberry ice cream on their lunch meal tray 2) Resident #195 had diagnoses including mild protein calorie malnutrition, anorexia (lack of appetite), and major depressive disorder. The 4/2/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision or touching assistance with eating, and received a mechanically altered diet. The 10/15/2024 physician order documented the resident was on a Consistent Carbohydrate Diet with No Added Salt mechanical soft diet with regular consistency liquids. The 5/28/2025 Registered Dietitian #31 progress note documented a history of poor intakes with a body mass index of 17.4 in the underweight category. During an observation on 6/9/2025 at 1:09 PM, Resident #195's lunch meal ticket documented 4 ounces of cottage cheese. The resident did not have 4 ounces of cottage cheese on their lunch tray. During an observation on 6/10/2025 at 1:08 PM, Resident #195's lunch meal ticket documented one half salad sandwich in addition to one half chicken salad. The resident did not have an additional half salad sandwich on their lunch tray. During an interview on 6/10/2025 at 1:48 PM, Certified Nurse Aide #30 stated the food was sent to the kitchenette from the main kitchen. The food service worker serving from the kitchenette was responsible for ensuring all items on the meal ticket were on the meal tray. Resident #127 was losing weight and had a poor appetite, but always ate their strawberry ice cream. They usually ate the ice cream first. Resident #195 was losing weight and had a poor appetite and almost always ate their half sandwich. During an interview on 6/13/2025 at 8:42 AM, Clinical Care Coordinator #15 stated food service workers set up the trays and made sure they were accurate. Staff that delivered the trays completed the final check for accuracy. Residents should receive everything on their tray that was on their meal ticket. Residents #127 and #195 were both at risk for weight loss and should get all items listed on their meal tickets. During an interview on 6/13/2025 at 9:09 AM, Food Service Worker #36 stated meals were prepared and set up in the main kitchen. The entrees were brought up in a hot box and plated in the kitchenette. There were times items that were missing from the resident's trays, and they called the kitchen for a replacement. Nursing staff was responsible for putting ice cream on trays because they were not able to leave the kitchenette area, and the freezer was located outside the kitchenette. During an interview on 6/13/2025 at 9:24 AM, Registered Dietitian #32 stated the food service worker in the pantry was the first line and ensured adaptive equipment and meals tickets were accurate. Once the tray was placed in the window the staff passing the tray confirmed accuracy before it was given to the resident. Fluids and ice cream were passed by nursing staff. Cottage cheese was put on the tray from the main kitchen. Residents #127 and #195 were both monitored for weight loss and poor appetites. If Resident #127 enjoyed strawberry ice cream they should have it on their tray. Resident #195 liked cottage cheese, and a half sandwich every day for lunch, and it was important for them to be on the tray. During an interview on 6/13/2025 at 9:42 AM, Food Service Worker #35 stated they were responsible for putting every item on the tray in the main kitchen before it was delivered to the kitchenettes including cottage cheese. They did not put ice cream on the trays in the kitchen because there were freezers on the unit and nursing staff was responsible for ice cream if it was on the ticket. 10NYCRR 415.14(d)(3)(4)

Based on observations, record review, and interviews during the recertification survey conducted 6/9/2025 - 6/13/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of two (2) residents (Resident #197) reviewed. Specifically, Resident #197 did not have a care plan for anticoagulant (blood thinner) use. Findings include: The facility policy Care Plans, revised 2/2002, documented the interdisciplinary team met after each admission of a resident and on a regular basis to evolve a comprehensive plan of care which would best meet the individual needs of the resident. The comprehensive care plan was developed for each resident within 48 hours of admission and included goals, medications, treatments, and diet and was reviewed with the residents and/or their representative and documented in the electronic medical record. Resident #197 had diagnoses including stroke and pulmonary embolism (blood clot in the lung). The 6/5/2025 Minimum Data Set assessment documented the resident had intact cognition; required supervision for transfers, bed mobility, and walking; and was on anticoagulant therapy. The 5/31/2025 active physician orders documented Resident #197 received apixaban (anticoagulant) 5 milligrams twice a day for deep vein thrombosis (blood clot) prophylaxis with a start date of 3/19/2025. The Comprehensive Care Plan did not include the use of anticoagulant therapy, or the risks associate with its use. During an observation on 6/9/2025 at 11:11 AM, Resident # 197 was in bed and had an orange size yellow bruise on their right forearm near the wrist. During an observation and interview on 6/10/2025 at 11:02 AM, Resident #197 had an orange size yellow bruise on their right forearm near the wrist. There was a larger purple and blue bruise on the left upper arm toward the shoulder. They stated they always had bruises because they were not steady on their feet and always bumped into things. During an interview on 6/12/2025 at 9:28 AM, Certified Nurse Aide #8 stated they were responsible for the hands-on care for the residents which included bathing, dressing, feeding, toileting, oral care, and more. They used the care card for individual care instructions for each resident which was generated by the care plan. If a resident was on anticoagulant therapy, they could bruise more easily and should be monitored for bleeding. They did not recall if Resident #197 was at risk for bruising or bleeding, but the resident did have a lot of bruises because they bumped into the walls a lot. During an interview on 6/12/2025 at 10:23 AM, Licensed Practical Nurse #9 stated care plans were completed on admission by the interdisciplinary team including social Work, dietary, physical therapy, and nursing. The nursing section was completed by the clinical care coordinators or registered nurses. If a resident was on anticoagulant therapy, it should be documented on the care plan so staff could monitor the resident for bleeding and bruising. Resident #197 received anticoagulant therapy, and it was not documented on the care plan and should be. During an interview on 6/13/2025 at 8:42 AM, Clinical Care Coordinator #15 stated they were responsible for completing and updating care plans on admission, quarterly, and with any significant change. If a resident was on anticoagulant therapy, it should be documented in the care plan, so staff could monitor the resident for the risk of bleeding. Resident #197 was on anticoagulant therapy which should have interventions documented in the care plan and did not because the resident was new to the facility. They stated they were trying to update the care plans as the residents had their care plan meetings. During an interview on 6/13/2025 at 10:03 AM, the Director of Nursing stated registered nurses were responsible for completing and updating the care plans individually for each resident. If a resident was on anticoagulant therapy, they expected it be documented in the resident's care plan so staff could properly care for the resident and monitor for bleeding. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00371020) surveys conducted 6/9/2025-6/13/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (2) of six (6) residents (Residents #127 and #226) reviewed. Specifically, Residents #127 and #226 were not provided with facial grooming/shaving care. Findings include: The facility policy Activities of Daily Living, last revised 3/2015, documented the facility provided residents with Activities of Daily Living care and support in accordance with current standards of practice, State and Federal regulations, and based on the resident's assessed needs, personal preferences, and goals of care. Facial hair was groomed per the resident's preference and/or needs. 1) Resident #127 had diagnoses including Pick's disease (a form of dementia), depression, and anxiety. The 3/28/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, and was dependent for most activities of daily living. The Comprehensive Care Plan initiated 5/3/2021 and updated 10/17/2024 documented Resident # 127 had a self-care deficit with interventions including assistance of one for hygiene and weekly showers. The resident's care instructions (Kardex) documented the resident required assistance of one with AM/PM care, weekly shower, and as needed. The resident was nonverbal and used a notebook to communicate. Resident #127 was observed in their room on 6/9/2025 at 10:58 AM and in the dining room on 6/11/2025 at 1:16 PM with several one-inch long grey chin hairs. During an observation and interview on 6/12/2025 at 9:13 AM the resident was in bed and had several one-inch-long grey hairs on their chin. They shook their head no when asked if they liked the chin hair and touched the hair with their hand and made a frowning face. When asked if they would like it shaved, they smiled and shook their head yes. During an interview and observation on 6/12/2025 at 10:46 AM, Certified Nurse Aide #8 stated their assigned residents were washed, dressed, and groomed daily, and showered weekly according to the shower schedule. Grooming included combing hair, oral care, and shaving. Resident #127 received did not refuse care. They did not shave the resident because they did not notice any facial hair. Certified Nurse Aide #8 entered the resident's room and stated the resident had facial hair and they should have noticed it. 2) Resident #226 had diagnoses including dementia and depression. The 5/21/2025 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and required partial/moderate assistance of one for most activities of daily living. The Comprehensive Care Plan, initiated 5/20/2025, documented the resident had an alteration in activities of daily living function related to impaired balance. Interventions included showers weekly and assistance of one for all hygiene care. The resident's care instructions (Kardex) documented the resident required assistance of one and received weekly showers. The following observations of Resident #226 were made: - on 6/9/2025 at 10:43 AM and 6/10/2025 at 10:56 AM with multiple white chin hairs approximately one inch long. - on 6/11/2025 at 11:26 AM, with multiple white chin hairs approximately one inch long. Resident #226 stated they did not like the chin hairs as they looked like a man and wanted them shaved. They were not sure when their shower day was. - on 6/12/2025 at 8:36 AM, with multiple white chin hairs approximately one inch long. The resident stated they received a shower the evening prior but was not shaved. They stated they were not able to shave themself and wished they were shaved because they felt like a man when they had facial hair. The certified nurse aide activities of daily living log documented hygiene care was provided on 6/11/2025 on the evening shift by Certified Nurse Aide #38. During an interview on 6/12/2025 on 9:51 AM, Certified Nurse Aide #38 stated they were responsible for resident care which included weekly showers, hair shampooing, oral care, feeding, dressing, and shaving residents. Last evening Resident #226 received their shower, and they did not shave the resident as they had three showers to give and did not have time to shave the resident. During an interview and observation on 6/12/2025 at 10:23 AM, Licensed Practical Nurse #9 stated certified nurse aides were responsible for providing activity of daily living care and residents should not have to ask to be shaved. If staff noticed a resident required shaving, they should ask the resident and shave them if the resident wanted to be shaved. If a female resident had facial hair, it could be embarrassing. During an interview on 6/13/2025 at 8:42 AM, Clinical Care Coordinator #15 stated they expected residents to be groomed according to their care plan or Kardex. Residents should be offered shaving daily. Dignity could be an issue for residents with unwanted facial hair. 10 NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted 6/9/2025-6/13/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during one (1) of four (4) lunch meal observations. Specifically, during the lunch meal observation on 6/11/2025 Food Service Aide #27 did not perform hand hygiene after removing their gloves. Findings included: The facility policy Hand Hygiene, revised 5/2025 documented hand hygiene would be performed at a minimum after handling trash, handling soiled linen or supplies, and after contact with blood, bodily fluids, and visibly contaminated surfaces. During a lunch meal observation on the North Lower Level on 6/11/2025 at 12:31 PM, Food Service Aide #27 was serving the lunch meal. While plating a resident tray, they dropped a towel on the floor, picked up the towel with their gloved hand and continued serving the meal without changing their gloves. They stopped serving and changed their gloves without performing hand hygiene. During an interview on 6/11/2025 at 1:18 PM, Food Service Aide #27 stated they were nervous and forgot to change their gloves and perform hand hygiene when they picked the towel up from the floor. They stated they received education on handwashing and knew it was important to prevent the spread of infections to residents. During an interview on 6/12/2025 at 1:03 PM, Kitchen General Manager #28 stated food service staff received education on hand hygiene on hire and annually. They stated staff should change their gloves and wash their hands after picking items up off the floor. If they did not do this, it was an infection control issue. During an interview on 6/13/2025 at 12:08 PM, Licensed Practical Nurse Infection Control Preventionist #29 stated all staff members should wash their hands or use alcohol-based hand rub during glove changes. If they picked something off the floor with a gloved hand, they should perform hand hygiene and put on new gloves prior to returning to their task. It was important to help decrease/ lessen the spread of infections. All staff were educated on hand hygiene upon hire and annually. 10 NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted 6/9/2025-6/13/2025 the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records for four (4) of four (4) residents (Residents #1, #93, #141, and #208) reviewed. Specifically, Residents #1, #93, #141, and #208 identifying and personal information was posted in a public area visible to others. Findings include: The facility policy Corporate Compliance Code of Conduct, revised 7/2018, documented all employees had the responsibility of protecting the confidentiality of resident information. Employees should not reveal in any form of communication (verbal, written, fax, electronic) any personal or confidential information such as diagnosis or treatments. The facility policy Resident Rights, revised 3/2018, documented resident medical, social, and financial records would be released only to those staff members who needed them. During observations on 6/10/2025 at 12:37 PM, 6/11/2025 at 10:31 AM, and at 12:36 PM personal identifying information for Residents #1, #93, #141, and #208 was posted in a public area on the North Lower-Level unit dining room on a pole near the doorway and meal serving area. Resident #1's, #93's, and #141's identifying information included their last name and hospitalization frequency. Resident #208's identifying personal information included their last name and level of assistance required for eating. During an interview on 6/11/2025 at 11:16 AM, Certified Nurse Aide #18 stated the sign posted on the pole in the main dining room was to alert staff to know which residents ate in their rooms. Residents #1, #93, and #141 were hospitalized recently and staff needed to ensure they were in the facility prior to providing them meal trays. Resident #208 required assistance with eating and the sign indicated their need for assistance at meals. During an interview on 6/13/2025 at 8:51 AM, Registered Nurse Unit Manager #20 stated resident health information should not be posted in public spaces and all resident information should be kept private and secure. They made the sign for staff, but did not know it was posted in the dining room. They stated they were unsure who posted the list, or how long it was posted. They did not ask the residents if they wanted the information posted in the dining room because they did not know the information was going to be posted in a public space. During an interview on 6/13/2025 at 9:28 AM, the Corporate Compliance Officer stated resident information should never be posted in a public space and should be kept secure and private. Resident health information was shared on a need-to-know basis. All staff were trained upon hire and annually on protecting resident health information. During an interview on 6/13/2025 at 9:50 AM, the Director of Social Worker stated resident health information should not be posted in public spaces and the facility was obligated to protect resident health information. Residents had a right to determine who their health information was shared with. If resident health information was posted in a public space, the resident's information was not private. 10NYCRR 415.3(d)(1)(ii)

Based on record review and interview during the abbreviated survey (NY00339000), the facility did not ensure all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and did not ensure further potential abuse was prevented for 1 of 3 residents (Resident #1) reviewed. Specifically, - certified nurse aide #5 witnessed alleged abuse by licensed practical nurse #4 towards Resident #1 and did not report the alleged abuse immediately resulting in licensed practical nurse #4 continuing to have access to residents for the remainder of the shift while the investigation was pending. - Statements from staff, given the facility, documented additional potential abuse and those allegations were not investigated. - The resident was not assessed by a qualified professional timely following allegation of abuse. Findings include: The Abuse Prevention Policy, modified 3/20/2019, documented the facility must ensure that all alleged violations involving mistreatment, neglect, exploitation, or abuse are reported immediately to the Administrator. The facility shall document that all alleged violations were thoroughly investigated and shall prevent further potential abuse while the investigation is in progress. The Abuse Reporting and Investigation policy, modified 2/5/2019, documented: - any employee who suspected or witnessed abuse, neglect, or mistreatment or has reasonable cause to believe abuse occurred must immediately report to the supervisor. - The Supervisor will notify the designated registered nurse and Administrator on call. - The Supervisor or designated registered nurse will immediately assess the resident for injury or harm. - Written statements from staff who cared for and/or were responsible for the management of the resident's care before and after the incident will be obtained. - Interviews will be conducted by nursing supervisors of the resident(s) involved, all witnesses, and all others as indicated. Resident #1 had diagnoses including anxiety disorder, major depressive disorder, and mild cognitive impairment. The 3/5/2024 Minimum Data Set assessment documented the resident had intact cognitive function and did not exhibit behavioral symptoms. The resident required substantial/maximum assistance with dressing, bathing, hygiene, and required moderate assistance with transfers. The 4/12/2024 at 4:48 AM, licensed practical nurse #4's progress note documented the resident refused a shower and was washed up in bathroom. In the process, the resident bit certified nurse aide #6 and broke their skin and then was hitting licensed practical nurse #4 while wrapping their legs. The 4/12/2024 facility investigation documented: - Licensed practical nurse #4 told the resident if they refused to take a shower they had to be washed and wrung out wet washcloths over the resident's head. The resident became agitated, pushed the nurse, and licensed practical nurse #4 then took approximately 4 wet washcloths and shoved them into the resident's face. - The resident became angry and certified nurse aide #5 reported seeing arms flying and the call bell cord became entangled and pulled from the wall. - Licensed practical nurse #4 again shoved multiple washcloths into the resident's face. - Certified nurse aide #5 asked licensed practical nurse #4 to leave the bathroom and completed care with the resident without issue. - Licensed practical nurse #4 returned and Resident #1 stated they wanted the nurse out of their room. - Licensed practical nurse #4 insisted on applying the resident's leg wraps, the resident was resistive, hit the nurse and asked the nurse to give them 5 minutes, and the nurse insisted on applying the leg wraps. - Certified nurse aide #5 reported this occurred between 4:00 AM and 4:45 AM on 4/12/2024. - Certified nurse aide #5's statement documented the incident as noted in the investigation and additionally noted that certified nurse aide #6 entered the bathroom and held Resident #1's hands to stop them from hitting licensed practical nurse #4 when they were re-applying the leg wraps. - Licensed practical nurse Supervisor #7's statement documented at 7:00 AM on 4/12/2024, certified nurse aide #5 reported alleged abuse by licensed practical nurse #4 towards Resident #1. Licensed practical nurse Supervisor #7 updated the Director of Nursing and the protocol for abuse and neglect prevention was initiated. There was no documented evidence the allegation that certified nurse aide #6 held the resident's hands was investigated. Licensed practical nurse #4's timecard documented they clocked in on 4/11/2024 at 6:40 PM and clocked out on 4/12/2024 at 7:30 AM. There was no documented evidence licensed practical nurse #4 was prevented from having access to Resident #1 or other residents following the incident (4:00 AM- 4:45 AM) until they left the facility at 7:30 AM. The 4/12/2024 Director of Nursing's progress note at 8:00 AM, documented it was a late entry and at approximately 7:00 AM, staff reported inappropriate physical contact between staff and the resident during care. The immediate intervention was a registered nurse assessment, and no injuries were noted. The staff member was removed from care and an investigation was initiated. The 4/12/2024 Quality Assurance Accident/Incident Report completed by registered nurse #8 at 10:30 AM, documented they were called to the unit to assess the resident. The resident denied pain and had no bumps or bruising on their head. Staff reported to licensed practical nurse Supervisor #7 that a staff member had put washcloths in the resident's face 2 times while the resident was refusing care and became combative. The 4/12/2024 registered nurse #8's progress note at 11:05 AM, documented the were called to the unit to assess the resident. During an interview with registered nurse #8 on 4/18/2024 at 12:23 PM, they stated they were called to the unit to assess the Resident #1 on 4/2/2024 at approximately 10:30 AM. Registered nurse Manager # 9 called them to complete the assessment. They were unaware of any delays in doing the assessment and began the assessment shortly after being asked. During an interview with certified nurse aide #6 on 4/18/2024 at 2:46 PM, they stated on 4/12/2024 when they entered the resident's room, they held onto one of the resident's arms and the resident turned and bit the aide, and the aide left the room. Certified nurse aide #6 returned approximately 15 to 20 minutes later in response to yelling in the bathroom. Licensed practical nurse #4 was putting leg wraps on the resident and the resident was yelling at the nurse to get away. Certified nurse aide #6 stated they did not hold the resident's hands while the nurse applied the leg wraps. Certified nurse aide #6 reported they were not questioned by anyone at the facility about the incident and was not asked to provide a written statement. During an interview with certified nurse aide #5 on 4/19/2024 at 8:32 AM, they stated on 4/12/2024, the resident woke up around 4:00 AM. They attempted to have the resident take a shower and the resident refused. Certified nurse aide #5 witnessed licensed practical nurse #4 commit suspected abuse during the time they attempted to provided care. Certified nurse aide #5 also witnessed certified nurse aide #6 hold the resident's arms when the resident was hitting licensed practical nurse #4. The incident took place from approximately 4:15 AM to 4:45 AM. Certified nurse aide #5 was not able to call for a Supervisor while the incident was occurring as they wanted to stay with the resident. After the incident, certified nurse aide #5 did not report it as they did not want to be obvious in leaving the unit. Certified nurse aide #5 stated they also did not feel comfortable calling for a Supervisor or notifying someone to report the incident. When their shift ended at 7:00 AM, they went to see licensed practical nurse Supervisor #7 and reported what happened with Resident #1. The aide stated they thought what they witnessed was abuse and knew they had to report it, and they were not aware of any policy about when it had to be reported. During an interview with licensed practical nurse #4 on 4/19/2024 at 10:00 AM, they stated on 4/12/2024, the resident refused their shower, and they assisted in washing the resident in the bathroom. The nurse stated they could not recall removing the resident's leg wraps or any refusals of care until the resident hit them when they were nearly done wrapping their legs. They could not recall certified nurse aide #6 being in the resident's bathroom as they applied the leg wraps. Licensed practical nurse #4 continued to work until the end of their shift. They were not notified to leave the floor prior to the end of the shift and continued to provide resident care. During an interview with the Director of Nursing on 4/19/2024 at 10:30 AM, they stated the protocol for incidents of suspected abuse was to report immediately to a Supervisor. The purpose of immediate reporting was to ensure resident safety and removal of the accused staff pending investigation. Once the resident was safe and certified nurse aide #5 was able, they should have reported it immediately, not 2 hours later. The Director of Nursing did not address the delayed reporting with certified nurse aide #5. Once and incident of suspected abuse was reported, the resident should be assessed immediately by a registered nurse. Immediate assessment was important in order to observe for any injuries or redness. The Director of Nursing was unaware of the reason the resident was not assessed until approximately 10:30 AM, as they were in receipt of the allegation at approximately 7:00 AM. The Director of Nursing did not notice certified nurse aide #5's statement that certified nurse aide #6 held the resident's while the nurse continued to wrap their legs and the resident was resisting and hitting the nurse. The Director of Nursing stated that could be a means of restraint and they did not ask certified nurse aide #6 about the incident or obtain a statement. During an interview with registered nurse #9 on 4/30/2024 at 10:25 AM, they stated they were covering the resident's unit on 4/12/2024 and learned about the incident that morning. They were delayed in going to see the resident due to the resident being in an activity. They were hesitant to interrupt the resident and eventually did have them leave in order to obtain their statement. Registered nurse #8 was also present and completed the assessment after registered nurse #9 obtained the resident's statement. The registered nurse stated assessments should be done immediately following an incident or allegation and they should not have delayed doing so. The resident was not injured and reported no emotional distress. 10NYCRR 415.4(b)

Based on record review and interview during the abbreviated survey (NY00339000), the facility did not promote and facilitate the resident's right to self-determination through support of resident choice, including the resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 refused care and staff continued to provide care following multiple refusals. Findings include: The undated Resident Rights policy documented each resident had the right to be treated with dignity and respect in recognition of their individual preferences; to refuse treatment and be free from abuse. Resident #1 had diagnoses including anxiety disorder, major depressive disorder, and mild cognitive impairment. The 3/5/2024 Minimum Data Set assessment documented the resident had intact cognitive function and did not exhibit behavioral symptoms. The resident required substantial/maximum assistance with dressing, bathing, hygiene, and required moderate assistance with transfers. The resident's comprehensive care plan documented: - on 5/13/2021, the resident had an activities of daily living self-care performance deficit and could be resistive to care. Interventions included: assistance of 1 for morning/evening care, weekly shower, and dressing; offer one to one support, and if behavior continued, redirect or reapproach as needed and as the resident allowed. - On 7/23/2021, the resident had a behavior problem, was non-compliant with waiting for staff assistance, and had a history of false allegations toward others. Interventions included: explain procedures before starting; allow the resident time to adjust; approach and speak in calm manner; and divert attention. - On 1/6/2024, the resident had potential for physical aggression and had poor impulse control. Interventions included: anticipate needs; analyze triggers; engage calmly in conversation; if response was aggressive, staff to walk away calmly and approach later. The 4/12/2024 facility investigation documented: - Resident #1 refused their shower and certified nurse aide #5 asked licensed practical nurse #4 to assist in encouraging the resident to take a shower. After refusing again, certified nurse aide #5 suggested they assist the resident in washing in the bathroom and the resident agreed. - Licensed practical nurse #4 attempted to remove the resident's leg wraps (elasticized bandages wrapped around lower legs for management of swelling) and the resident became agitated and hit the nurse. - The resident was transferred from their bed to a wheelchair and then to the bathroom and on the toilet. The resident refused to stand up to remove their brief. - Licensed practical nurse #4 told the resident they must be washed and wrung out wet washcloths over the resident's head. The resident became agitated, pushed the nurse, and licensed practical nurse #4 then took approximately 4 wet washcloths and shoved them into the resident's face. The resident became angry and certified nurse aide #5 reported seeing arms flying and the call bell cord became entangled and pulled from the wall. Licensed practical nurse #4 again shoved multiple washcloths into the resident's face. - Certified nurse aide #5 asked licensed practical nurse #4 to leave the bathroom and completed care with the resident without issue. - Licensed practical nurse #4 returned and Resident #1 stated they wanted the nurse out of their room. Licensed practical nurse #4 insisted on applying the resident's leg wraps, the resident was resistive, hit the nurse, and asked the nurse to give them 5 minutes, and the nurse insisted on applying the leg wraps. Statements obtained by the facility and included in the 4/12/2024 investigation documented: - Resident #1's statement, written by registered nurse Manager #9, included they did not want to take a shower and said they would take one the following day. The nurse told the resident they would take one this day, the resident said no. In the bathroom, the nurse started scrubbing their head and the resident said no, and the nurse continued. The resident said they will take a shower the next day, the nurse was insistent and continued to wash the resident. The resident bit the aide who came near them (certified nurse aide #6) and they were doing everything I didn't want. The nurse threw the washcloth in the resident's face. The nurse also hit the top of their head, but it did not hurt. - Certified nurse aide #5's statement documented the incident as noted in the facility investigation. Additionally, certified nurse aide #5 documented they held hands with the resident when licensed practical nurse was removing their leg wraps. The resident asked them to let go, and the aide said they would if they stopped hitting the nurse. Certified nurse aide #6 entered the bathroom and held Resident #1's hands to stop them from hitting licensed practical nurse #4 when they were re-applying the leg wraps. - Licensed practical nurse #4's statement stated the tried to assist the certified nurse aide in getting the resident into the shower chair and the resident refused. The nurse attempted to wash the resident's head or hair and took a defensive approach after the resident grabbed at them and threw a washcloth. The resident hit the nurse when they were reapplying their leg wraps. During an interview with Resident #1 on 4/18/2024 at 1:40 PM, they stated on 4/12/2024 they did not want to take a shower and told the staff they would take one the next day. The resident got irritated and wanted to be left alone. Licensed practical nurse #4 took off their leg wraps when they told them no, they did not want the nurse near them. The nurse took the wraps off anyway. In the bathroom, the nurse pushed washcloths in my face. The resident stated when certified nurse aides #5 and 6 held their hands, it was like a restraint and they did not want the nurse near them. During an interview with certified nurse aide #6 on 4/18/2024 at 2:46 PM, they stated they heard screaming and yelling from Resident #1's room and responded. Certified nurse aide #5 was heard telling the resident to stop hitting licensed practical nurse #4. The resident was heard saying stop and that they did not want a shower. Licensed practical nurse #4 told the resident they had to take a shower. The shower chair was outside the bathroom, and they kept telling the resident they had to take a shower. When certified nurse aide #6 approached, they held onto one of the resident's arms and the resident turned and bit the aide, and the aide left the room. They stated it seemed as if the resident was getting more agitated by the nurse and aide trying to get them into the shower chair. Certified nurse aide #6 returned approximately 15 to 20 minutes later in response to more yelling in the bathroom. Licensed practical nurse #4 was putting leg wraps on the resident and the resident was yelling at the nurse to get away. The nurse said they had to do it and the resident continued to tell them to get away from them. Certified nurse aide #6 stated they did not hold the resident's hands while the nurse reapplied the leg wraps. The aide was unaware of a specific care plan and stated when a resident refused care, staff should honor that request and reapproach later. During an interview with certified nurse aide #5 on 4/19/2024 at 8:32 AM, they stated on 4/12/2024, the resident was found awake and sitting on their bed at approximately 4:00-4:15 AM. The aide brought the shower chair into the room. The resident said they did not want to take a shower and the aide continued to encourage them to take a shower. Licensed practical nurse #4 entered the room told the resident they did not take a shower last week and needed to take one that day. The resident refused again, and the nurse said they would remove their leg wraps. The resident said no, and the nurse proceeded to remove the wraps. The resident began hitting the nurse and certified nurse aide #5 held their hand and talked to the resident asking them not to hit the nurse. They held the resident's hand like a friend and did not restrain them. The resident agreed to go into the bathroom in their wheelchair. Certified nurse aide #5 stated they thought they could place the shower chair under the resident when they stood in the bathroom. When the resident stood up, they brought the shower chair closer to try to put it under them, and the resident said they were not getting in that chair and sat down on the toilet. The nurse started washing the resident, who became agitated and combative with the nurse. The aide asked the nurse to leave but the nurse returned shortly after. The resident said they did not want the nurse in there and did not want the nurse touching them, and the nurse insisted on applying their leg wraps. The resident asked for a few minutes, and the nurse insisted on doing it at that time. Certified nurse aide #6 returned, the resident was hitting licensed practical nurse #4 as they continued to wrap the resident's legs. Certified nurse aide #6 held the resident's hands so the nurse could finish wrapping their legs. Certified nurse aide #5 was unaware of a specific care plan and stated when a resident refused care, staff should listen to them, leave them as long as they were safe, and reapproach later. During an interview with licensed practical nurse #4 on 4/19/2024 at 10:00 AM, they stated on 4/12/2024, the resident refused their shower, and they assisted in washing the resident in the bathroom. The nurse stated they could not recall removing the resident's leg wraps or any refusals of care until the resident hit them when they were nearly done wrapping their legs. During an interview with the Director of Nursing on 4/19/2024 at 10:30 AM, they stated if a resident was resistive to care or refusing, staff should ensure their safety and leave them alone. Staff should report to a nurse and try to reapproach later or ask another staff member who may have a different approach. Staff should not have tried to get the resident to sit in the shower chair by swapping it out with the wheelchair, as the resident had already refused the shower. When certified nurse aide #5 said certified nurse aide #6 held the resident's hands, that was not an appropriate intervention. That could be considered restraining the resident and they should have stopped what they were doing. 10 NYCRR 415.5(b)(1,3)

Based on record review and interview during the abbreviated survey (NY00339000), the facility did not ensure residents were free from abuse, including but not limited to corporal punishment and any physical restraint not required to treat the resident's medical symptoms, for 1 of 3 residents reviewed (Resident #1). Specifically, licensed practical nurse #4 pushed multiple wet washcloths into the resident's face when the resident declined to receive care and certified nurse aides #5 and 6 held the resident's hands while licensed practical nurse #4 provided care that the resident declined. Findings include: The Abuse Prevention Policy, modified 3/20/2019, documented the facility will not permit residents to be subjected to abuse by anyone, including staff members and residents will be provided with appropriate clinical care and treatment and will be cared for according to the individualized care plan. Resident #1 had diagnoses including anxiety disorder, major depressive disorder, and mild cognitive impairment. The 3/5/2024 Minimum Data Set assessment documented the resident had intact cognition, did not exhibit behavioral symptoms, and did not resist care. The resident required substantial/maximum assistance with dressing, bathing, hygiene, and moderate assistance with transfers. The resident's comprehensive care plan documented: - on 5/13/2021, the resident had an activities of living self-care performance deficit and could be resistive to care. Interventions included: assistance of 1 for morning/evening care, weekly shower, and dressing; offer one to one support, if behavior continued, redirect or reapproach as needed and as the resident allowed. - On 1/6/2024, the resident had potential for physical aggression and had poor impulse control. Interventions included: anticipate needs; analyze triggers; engage calmly in conversation; if response is aggressive, staff to walk away calmly and approach later. The 4/12/2024 facility investigation documented: - Resident #1 refused their shower and certified nurse aide #5 asked licensed practical nurse #4 to assist in encouraging the resident to take a shower. - Licensed practical nurse #4 attempted to remove the resident's leg wraps (elasticized bandages for the management of swelling) and the resident became agitated and hit the nurse. - Licensed practical nurse #4 told the resident they must be washed and wrung out wet washcloths over the resident's head. - The resident became agitated, pushed licensed practical nurse #4 and licensed practical nurse #4 took approximately 4 wet washcloths and shoved them into the resident's face. - The resident became angry and certified nurse aide #5 reported seeing arms flying and the call bell cord became entangled and pulled from the wall. - Licensed practical nurse #4 again shoved multiple washcloths directly into the resident's face. - Certified nurse aide #5 asked licensed practical nurse #4 to leave the bathroom and completed care with the resident without issue. - Licensed practical nurse #4 returned and insisted on applying the resident's leg wraps. The resident was resistive, hit the nurse, and the nurse insisted on applying the leg wraps. - The resident was assessed with no injury noted after the incident and social services interviewed the resident who had recall of the event and was not fearful of staff or peers. Statements obtained by the facility and included with the 4/12/2024 investigation included: - Resident #1's statement, documented by registered nurse Manager #9, included they did not want to take a shower and said they would take one the following day. Licensed practical nurse #4 told the resident they would take a shower that day and the resident said no. In the bathroom, licensed practical nurse #4 started scrubbing the resident's head and the resident said no, and the nurse continued. Licensed practical nurse #4 threw the washcloth in the resident's face. The nurse also hit the top of their head, but it did not hurt. - Certified nurse aide #5's statement documented the incident as noted in the investigation and additionally noted they held hands with the resident when licensed practical nurse #4 was removing their leg wraps. The resident asked them to let go, and the aide said they would if they stopped hitting the nurse. Certified nurse aide #6 entered the bathroom and held Resident #1's hands to stop them from hitting licensed practical nurse #4 when they were applying the leg wraps. - Licensed practical nurse #4's statement documented they tried to assist with getting the resident into the shower chair and the resident refused. Licensed practical nurse #4 attempted to wash the resident's head or hair and took a defensive approach after the resident grabbed at them and threw a washcloth. The resident hit the nurse when they were applying the leg wraps. The 4/12/2024 at 11:37 AM Director of Social Services' progress note documented they followed up with the resident regarding the incident. The resident reported they were doing fine and added it will be forgotten. They did not present with any signs of distress. During an interview with Resident #1 on 4/18/2024 at 1:40 PM, they stated on 4/12/2024 they did not want to take a shower and licensed practical nurse #4 pushed washcloths in my face. The resident stated when certified nurse aides #5 and 6 held their hands, it was like a restraint and they did not want the nurse near them. The resident stated they were angry when it happened, but not fearful of staff. They stated they had no current concerns with staff and just wanted to get past it. During an interview with certified nurse aide #6 on 4/18/2024 at 2:46 PM, they stated on 4/12/2024, they heard screaming and yelling from Resident #1's room and went to assist. When certified nurse aide #6 approached the resident, certified nurse aide #6 held onto one of the resident's arms and the resident turned and bit them. Certified nurse aide #6 left the room and returned approximately 15 to 20 minutes later in response to more yelling in the bathroom. Licensed practical nurse #4 was putting leg wraps on the resident and the resident was yelling at the nurse to get away. The nurse said they had to do it and the resident continued to tell them to get away from them. Certified nurse aide #6 stated they did not hold the resident's hands while the nurse applied the leg wraps. During an interview with certified nurse aide #5 on 4/19/2024 at 8:32 AM, they stated on 4/12/2024, the resident refused a shower and licensed practical nurse #4 said they would remove their leg wraps. The resident said no, and the nurse proceeded to remove the wraps. The resident began hitting the nurse and certified nurse aide #5 held their hand telling the resident they could not hit the nurse. The resident told the aide to let go; the aide told them only if they agreed to stop hitting. They stated they held the resident's hand like a friend and not in a restraining manner. In the bathroom, licensed practical nurse #4 wrung out water from the washcloths over the resident's head. The resident became upset and pushed the nurse. Licensed practical nurse #4 then took several wet washcloths and mushed them into the resident's face. The resident's and nurse's arms were flying around, washcloths were being thrown, and the call bell came out of the wall. Certified nurse aide #5 asked licensed practical nurse #4 to leave and by then the nurse had again shoved multiple wet washcloths into the resident's face. Licensed practical nurse #4 returned shortly after and insisted on applying the resident's leg wraps. Certified nurse aide #6 returned, the resident was hitting licensed practical nurse #4 as they continued to wrap their legs. Certified nurse aide #6 held the resident's hands so the nurse could finish wrapping their legs. During an interview with licensed practical nurse #4 on 4/19/2024 at 10:00 AM, they stated on 4/12/2024, the resident refused their shower, and they assisted in washing the resident in the bathroom. The nurse stated they could not recall removing the resident's leg wraps or any refusals of care until the resident hit them when they were nearly done wrapping their legs. During an interview with the Director of Nursing on 4/19/2024 at 10:30 AM, they stated when they investigated they found that licensed practical nurse #4 abused Resident #1. Their findings were based on Resident #1's report and certified nurse aide #5's statement. The Director of Nursing stated when certified nurse aide #5 noted they held the resident's hands, it was explained that was in a friend-like manner and not perceived as restraining the resident. They did not notice certified nurse aide #5 included that certified nurse aide #6 held the resident's while the nurse continued to wrap their legs and the resident was resisting and hitting the nurse. The Director of Nursing stated that could be a means of restraint. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024, the facility failed to vaccinate eligible residents with the pneumococcal vaccination (a vaccination developed to minimize the risk of acquiring, transmitting, or experiencing complications of pneumonia) for 44 of 245 residents who consented to the pneumococcal vaccine. Specifically, from 9/5/2023 through 3/25/2024, Residents #12, #14, #17, #18, #24, #27, #31, #43, #45, #57, #63, #74, #82, #95, #102, #103, #108, #109, #117, #118, #126, #129, #134, #165, #173, #177, #186, #192, #213, #214, #215, #216, #219, #222, #224, #226, #229, #235, #484, #533, #585, #586, #587, and #633 consented to and had medical orders to receive the pneumococcal vaccine and did not receive it. Subsequently, 7 of the 44 residents (Resident #24, #95, #109, #126, #215, #229, and #484) were diagnosed with pneumonia and one resident (Resident #95) was hospitalized twice for the treatment of pneumonia. Additionally, a request to purchase the pneumococcal vaccine was submitted by the Director of Nursing and was denied by the fiscal officer; and the Medical Director was not notified the vaccine was not available. This placed 44 residents at the facility at risk for serious harm or death that was Immediate Jeopardy. Findings include: The facility policy Purchase Order Expenditures revised 8/12/2019 documented the requesting department sends a completed Departmental Purchase Request Form or a facility Blanket Purchase Order Encumbrance Request form to fiscal along with any backup from vendors. All paperwork is given to the Deputy of Fiscal to initial and approve. The facility policy EMR (Electronic Medical Record)-Physician/Nurse Practitioner/Physician Assistant Orders updated 1/2019 documented nursing staff would process new, renewed, revised, or discontinued medication, treatment, and ancillary orders provided by the physician/nurse practitioner/physician assistant using the electronic medical record. The facility policy Physician Calls updated 2/2009 documented physician should be notified of changes to include but not limited to change in resident's condition, a resident fall, accident and/or incident to verify orders, and clarification of orders. The facility policy Standing Orders for Administering Pneumococcal Vaccines to Nursing Home Residents dated 9/2022 documented standing orders from the Medical Director to administer pneumococcal vaccines to consenting adult nursing home residents enable nurses to assess the need for vaccination and to vaccinate consenting adults. The procedure included assess adults for need of vaccination; screen for contraindications and precautions; provide vaccine information statements and obtained signed informed consent; administer pneumococcal vaccine; document the dose, date, time, the site the vaccination was given, the lot number, expiration date, and the brand of the vaccine administered. A 12/5/2023 supplier order summary documented 4 boxes of pneumococcal vaccine 0.5 milliliter unit doses (10 count= 40 doses) with an estimated total of $10,158.56. The items were in stock, and the facility could receive the order by the following day. A 12/6/2023 facility Request Form for Departmental Purchase Order documented the Nursing Department requested 4 boxes of pneumococcal vaccine for a cost of $10,158.56. The order was needed as soon as possible for resident and staff immunizations. The form was signed for approval by the Administrator and Assistant Director of Nursing. The form documented after approval, send to Fiscal Department. An electronic mail chain dated 1/23/2024 (1 month and 3 weeks later) documented: - At 11:17 AM, from Infection Preventionist/licensed practical nurse to the Deputy Administrator of Fiscal, questioning where the pneumococcal vaccine purchase order was as they had a lot of pending vaccinations to give. - At 11:51 AM, the Deputy Administrator of Fiscal responded to the facility accountant asking if the request was the same, they had questioned the pricing. - At 11:53 AM, the facility accountant responded, yes it was over $10,000. - At 11:59 AM, the Deputy Administrator of Fiscal to keyboard specialist, the vaccine order was sent back due to it being over $10,000. It would need to be a state contract or group purchasing contract if exceeding $10,000. Residents #12, #14, #17, #18, #24, #27, #31, #43, #45, #57, #63, #74, #82, #95, #102, #103, #108, #109, #117, #118, #126, #129, #134, #165, #173, #177, #186, #192, #213, #214, #215, # 216, #219, #222, #224, #226, #229, #235, #484, #533, #585, #586, #587, and #633 signed consent forms and had medical orders to receive the pneumococcal vaccine. There was no documented evidence they received the vaccine as ordered. Resident #95 had diagnoses including pneumonia and diabetes. The 12/5/2023 Minimum Data Set documented the resident was cognitively intact, and the pneumococcal vaccine was not up to date and the pneumococcal vaccine was not received because it was not offered. A 11/29/2023 physician order documented pneumovax (pneumococcal vaccine) as indicated. A facility pneumococcal conjugate vaccine consent form dated and signed by the resident's representative and witnessed by a nurse (illegible signature) on 12/13/2023 documented the resident wished to receive the pneumococcal vaccine. The November and December 2023 and January, February, and March 2024 medication administration records did not include orders for the pneumococcal vaccine or administration of the vaccine. A 1/24/2024 at 6:13 PM licensed practical nurse #52 progress note documented the resident was experiencing shortness of breath and shaking all over. Oxygen was increased to 5 liters per minute and oxygen saturation (amount of oxygen carried in blood) would not go above 76%. The on call physician was notified and ordered the resident be sent to the hospital. The resident was transported to the hospital by emergency medical services. A 1/25/2024 at 5:14 AM, licensed practical nurse #12 progress note documented the resident was admitted to the hospital for pneumonia. A 1/25/2024 at 2:32 PM licensed practical nurse #38 progress note documented the resident returned from the hospital and was receiving antibiotics for pneumonia. A 2/23/2024 at 7:27 PM licensed practical nurse #11's progress note documented the resident was experiencing tremors. Their oxygen saturation was 77% and their temperature was 102 degrees Fahrenheit. The attending physician was notified, and the family requested the resident be sent to the hospital. 911 was called and the resident was sent to the hospital. A 2/24/2024 at 3:04 AM licensed practical nurse #53 progress note documented they were informed by the hospital the resident was admitted for pneumonia. A 3/1/2024 nurse practitioner #13 progress note documented the resident was seen for a readmission visit after they were admitted to hospital for institutional acquired pneumonia and was started on intravenous antibiotics. The 3/7/2024 at 10:53 AM, licensed practical nurse #11's nursing progress note documented the resident was readmitted to the facility with a diagnosis of pneumonia. Resident #215 had diagnoses including congestive heart failure, chronic obstructive pulmonary disease (lung disease), and chronic respiratory failure. The 10/23/2023 Minimum Data Set documented the resident was cognitively intact, their pneumococcal vaccine was not up to date, and the vaccine was not offered. A facility pneumococcal conjugate vaccine consent form dated and signed by the resident and witnessed by a nurse (illegible signature) on 10/16/2023 documented the resident wished to receive the pneumococcal vaccine. A 10/16/2023 physician order documented pneumovax as indicated. The October, November and December 2023 and January and February 2024 Medication Administration Records did not include orders for the pneumococcal vaccine or administration of the vaccine. A 2/18/2024 at 7:44 PM licensed practical nurse #16 progress note documented the resident was on droplet precautions and was receiving antibiotics for pneumonia. A 2/21/2024 nurse practitioner #20 progress note documented the resident was seen for a routine follow up after they were treated for respiratory syncytial virus [RSV] (a respiratory virus) with superimposed pneumonia and was started on an antibiotic on 2/18/2024. The March 2024 medication administration record documented pneumococcal vaccine inject intramuscularly one time only, administer upon arrival from the pharmacy with a start date of 3/20/2024. On 3/23/2024 at 11:31 AM licensed practical nurse #14 documented with a code 9- other /see progress note. Licensed practical nurse #14's progress note documented pneumococcal vaccine was to be administered upon arrival from the pharmacy. During an interview on 3/25/2024 at 3:16 PM, Resident #215 stated they recalled consenting for the pneumococcal vaccine, and they always took any available vaccines. They were concerned about dying. They felt the pneumococcal vaccine would help them because they required oxygen every day and had a history of bronchitis. Resident #126 had diagnoses including dementia, heart disease, and history of pulmonary embolism (blood clot that blocks blood flow to the lung). The 11/15/2023 readmission Minimum Data Set documented the resident was cognitively intact, the pneumococcal vaccine was not up to date, and was not offered. A facility pneumococcal conjugate vaccine consent form dated and signed by the resident and witnessed by a nurse (illegible signature) on 9/27/2023 documented the resident wished to receive the pneumococcal vaccine. A facility pneumococcal conjugate vaccine consent form dated and signed by the resident's representative (Health Care Proxy) and witnessed by a nurse (illegible signature) on 11/9/2023 documented the resident wished to receive the pneumococcal vaccine. A physician order dated 11/9/2023 documented pneumococcal vaccine as indicated. The November, December 2023 and January, February 2024 medication administration record did not have documented orders for the pneumococcal vaccine or that it was administered. A 2/5/2024 nurse practitioner #15 progress note documented the resident had respiratory viral testing completed and was found to have underlying pneumonia and was treated with antibiotics. The March 2024 medication administration record documented pneumococcal vaccine inject intramuscularly one time only, administer upon arrival from the pharmacy with a start date of 3/20/2024. On 3/21/2024 at 12:04 AM registered nurse #3 documented 9- other/see progress note. Registered nurse #3's progress note documented the vaccine was on order and had not been delivered from the pharmacy. During an interview on 3/25/24 at 2:45 PM, Resident #126's spouse and health care proxy stated Resident #126 had pneumonia in January or February 2024. They wanted the pneumonia shot and could not recall signing a consent for the pneumonia vaccine. INTERVIEWS: During an interview on 3/20/2024 at 12:02 PM, licensed practical nurse/Infection Preventionist #5 stated the pneumococcal vaccine needed to be ordered. There were over 10 residents that had consents for pneumococcal vaccine but there were no vaccines available in the facility. There were issues with a vaccine shortage due to cost in October 2023. They spoke to the Deputy Administrator of Fiscal in January 2024 via electronic mail and again today via telephone and they were still working on contract pricing for the pneumococcal vaccines. During an additional interview on 3/22/2024 at 8:39 AM, licensed practical nurse/Infection Preventionist #5 stated they were responsible for all vaccines for staff and residents. They could not recall the exact date they ran out of the pneumococcal vaccine, but it was prior to September 2023. They had 45 residents with pneumococcal vaccine consents that did not receive the vaccine. During an interview on 3/25/24 at 11:08 AM, the Assistant Director of Nursing stated the pneumococcal vaccine was not available for the residents. They had not received it from the pharmacy but were scheduled to receive it later this day. The Fiscal department rejected the cost of the vaccines, and the ball was dropped due to poor communication. They stated they were responsible for ordering the vaccine, but they could not approve the cost of anything. During a follow-up interview on 3/25/2024 at 11:10 AM, licensed practical nurse/Infection Preventionist #5 stated residents consented to vaccines and their immunization record was updated in their medical record. The vaccines were standing orders that were signed by the Medical Director. They ordered the vaccines on December 6, 2023, and were not able to get them due to the cost. Residents were more susceptible to pneumonia and could have negative health impacts due to their medical diagnoses. The vaccine was recommended for the residents. The pneumococcal vaccine could protect them but did not prevent the illness. During an interview on 3/25/2024 at 11:13 AM, Administrator #1 stated they had a new Deputy Administrator of Fiscal who made the request for the pneumococcal vaccinations, but the County could take a long time to approve anything. The Administrator stated they just approved the pneumococcal vaccines at a cost of $10,897.30 and it would be delivered from the pharmacy today. They stated nobody really knows what could happen if a resident did not receive the pneumococcal vaccination, and they had residents who were diagnosed with pneumonia. During a telephone interview on 3/25/2024 at 11:15 AM, the Medical Director stated the infection control nurse was responsible for keeping them up to date with resident vaccination rates. They were not aware there were several residents who consented to having the pneumonia vaccine and were not vaccinated. The staff did their part to order the vaccines, but the purchase order was not authorized due to the cost of the vaccine. They stated today the facility was in the process of getting 46 vaccines and the residents would receive their vaccines that day. Residents over the age of 65 had a higher risk of getting pneumonia and if not vaccinated, pneumonia could progress with complications that could require hospitalization . It was the residents' choice to be vaccinated and they should receive it if requested. During an interview on 3/25/2024 at 2:07 PM, Administrator #1 stated they did not have the exact details of when the vaccine purchase order was denied but thought it may have started in June of 2023. The Infection Preventionist submitted another purchase request in December 2023 and was told because the cost was over $10,000 it needed to go to the legislature and that could take 2 months. They stated the Deputy Administrator of Fiscal should have told the Infection Preventionist how to order the vaccine differently to keep the cost lower. The Medical Director was not made aware of this issue until today, 3/25/2024. The residents should have been provided with the pneumonia vaccine if they wanted it. During an interview on 03/25/24 2:38 PM, licensed practical nurse/Infection Preventionist #5 stated the last successful order was 6/6/2023. They expected if an order was not approved, they would be notified. They stated they called the fiscal department 3-4 times after initial email on 1/23/24 and was told the order was declined due to cost. During an interview on 3/25/24 at 3:17 PM, the Deputy Administrator for Fiscal Services stated nursing submitted the vaccine purchase request on 11/7/2023 via electronic mail. The problem was the request was over the $10,000 limit. It should have been ordered, but they were supposed to follow the financial rules of the county. They sent licensed practical nurse/Infection Preventionist #5 the listing of those groups the facility could order from in November and December of 2023. The last successful order of a pneumococcal vaccine was in 2023. They thought the purchase order date was 6/13/23 for 3 boxes. During an additional interview on 3/26/2024 at 11:05 AM, the Medical Director stated they assumed the vaccinations were being provided to the residents. Nursing staff obtained the consents from the residents to administer the vaccines and they assumed the vaccines were given. The residents over age 65 were at a 10 times higher risk of developing pneumonia. During an interview on 3/27/24 at 2:25 PM, the Deputy Administrator of Fiscal stated there was a hold on purchasing through the county for fiscal year end, 12/8/2023-1/8/2024. They were trying to find a vendor that would honor their price. The Administrator should get quotes from the established vendors, and then follow up to see if anyone would honor their price. They stated that the urgency of the lack of vaccines was not conveyed to accounting. They could have put in an emergency order like they did during COVID, but it was not presented as urgent. ____________________________________________________________________________ Immediate jeopardy was identified, and the facility Administrator was notified on 3/25/24 at 7:00 PM. Immediate jeopardy was removed on 3/27/2024 at 2:45 PM prior to survey exit based on the following corrective actions taken: -On 3/25/2024 on the evening shift, all 44 residents who had signed consent to receive the pneumonia vaccine were vaccinated. The facility reviewed their immunization and vaccination policies and made revisions. -On 3/26/2024, an outside consultant provided education about the federal requirements for the pneumonia vaccine. The education was attended by the Administrator, the Deputy Director of Fiscal Services, the Assistant Director of Nursing, the Deputy Administrator for Administrative Services, and the Infection Preventionist. - Confirmation was made that all 44 residents that requested and consented to have the pneumonia vaccine had been vaccinated on 3/25/2024. - The Director of Nursing, Infection Preventionist, and staff educator provided education to all licensed nurses. - The education included the policy related to pneumonia vaccination, communication with a provider and obtaining medical orders for vaccines, communication with providers on vaccines that were ordered and were not available, the pneumonia vaccine order should be entered into the electronic record and once delivered administered timely, purchasing and ordering vaccines. Additional re-education focused on new admission related to pneumonia vaccine status and the signed declination with education for the resident who declined. A posttest was initiated to ensure retention of the training information. 88.1 % of the staff were successfully educated with a plan to educated employees that were not scheduled to work or out on leave to be educated prior to resuming work duties. - Future vaccine purchasing denials due to cost related issues would be reviewed by the Administrator and referred to the fiscal officer for further review and approval. - The Administrator and the Director of Nursing planned to conduct an audit and the results would be reviewed by their quality assurance and performance improvement committee for six months. 10NYCRR 415.19(a)(1-3) 48632

Based on observation, record review and interview during the recertification and abbreviated (NY00314754, NY00319010, NY00320020, NY00327419, NY00331182, and NY00334923) surveys conducted 3/18/2024-3/29/2024 the facility failed to provide adequate supervision to prevent accidents for 4 of 10 residents (Residents #114, #174, #191, and #213) reviewed. Specifically, Residents #114, #191, and #213 were subjected to physical aggression and sexually abusive behaviors by Resident #174 and the facility failed to develop or implement strategic interventions for Resident #174 to protect other residents from victimization. Subsequently, Resident #174 pushed Resident #114 causing Resident #114 to sustain a hip fracture; Residents #174 and #213 were found in sexually inappropriate situations three times; and Resident #174 pushed Resident #191 causing them to hit their head against a wall causing an abrasion. This resulted in harm to Residents #191 and #114 that was not immediate jeopardy. Findings include: The facility policy Abuse Prevention modified 3/2019 documents the facility would not permit residents to be subjected to abuse by other residents. Residents will be provided with appropriate clinical care and treatment and will be cared for according to the individualized care plan. Incidents of resident-to-resident altercations must be reported to the Administrator and addressed by the interdisciplinary team members and care planned accordingly. In such instances the resident that is the perpetrator and all residents who may be vulnerable to the perpetrating resident must have their care documented with immediate safety action taken. The facility policy Behavior Protocol-Handling Problem Behaviors modified 2/2019 documents that all disciplines will implement appropriate strategies to eliminate problem behaviors which may cause emotional and physical problems to both residents and staff. Staff will document in the electronic medical record interventions which were used to attempt to eliminate the behavior, indicating if the interventions were successful. The attending physician/nurse practitioner will be consulted for further recommendations and/or interventions/orders. Resident #174 had diagnoses including frontotemporal neurocognitive disorder (dementia caused by damage to neurons in the frontal and temporal lobes of the brain), aphasia (difficulty expressing themself), and wandering. The 3/15/2023 Minimum Data Set documented the resident had severe cognitive impairment and did not exhibit physical or verbal behavioral symptoms directed toward others. The 9/5/2023 Minimum Data Set assessment documented the resident had intact cognition, verbal behaviors directed toward others for 1-3 of 7 days, other behavioral symptoms not directed toward others for 1-3 of 7 days, wandered for 1-3 of 7 days, was independent with most activities of daily living, received a daily antidepressant, and used a wander alarm. Resident #174's comprehensive care plan initiated 10/10/2022 and updated 2/27/2023 documented the resident had confusion, wandered, had potential to be verbally aggressive, liked to kiss peers on the forehead and rub back/shoulders, had dementia, had potential for physical aggressiveness, and had behavior problems. Interventions included remind of socially acceptable behaviors, invite to small groups, music in room, 1:1 supervision if needed, independent activity materials provided, walk, TV, care magazines, movies, assess for fall risk, wander risk tool at admission/quarterly/as needed, distract, redirect, wander detection device on right ankle, intervene immediately, encourage to visit peers in public areas, avoid taking inappropriate behaviors lightly, separate residents if sexually inappropriate behaviors noted, medications as ordered, remove from situation, and close door if masturbating. Resident #114 had diagnoses including impulsiveness, emotional lability (rapid, often exaggerated changes in mood), and aphasia (difficulty speaking). The 3/21/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not wander, and required supervision when walking in the corridor and locomotion on the unit. Resident #191 had diagnoses including dementia, anxiety, and insomnia. The 6/1/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, had physical and verbal behavioral symptoms directed toward others for 1-3 of 7 days, wandered for 4-6 of 7 days, required supervision of 1 for walking in the corridor and locomotion on the unit, did not use mobility devices, and used a wander alarm daily. Resident #213 had diagnoses including Alzheimer's disease, restlessness and agitation, and wandering. The 11/15/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not wander, required partial/moderate assistance with walking, and did not use a wander alert device. Nursing progress notes for Resident # 174 documented: - from 1/9/2023 -2/19/2023, the resident exhibited aggressive behaviors including throwing items, slamming, and kicking their door, standing in the hall naked, wandering the unit, becoming impatient and agitated with other residents, swinging at staff, touching other residents, and allowing other residents to touch them, - on 1/20/2023 the resident was examined by the physician with a new order for Celexa (antidepressant). - on 2/24/2023 at 5:04 PM, staff witnessed Resident #174, and another resident enter Resident #174's room and close the door. Staff entered and witnessed the other resident rubbing Resident #174's genitals, both residents were fully clothed. The residents were separated, and Resident #174 was placed on 1:1 supervision, monitored for 72 hours, and the physician was notified. - on 2/27/2023 at 2:10 PM, the physician was updated on the resident's behaviors and a new order was to discontinue Celexa and start Prozac 20 milligrams daily for inappropriate sexual behaviors. - from 2/24/2023-3/1/2023, documented 1:1 supervision continued - on 3/1/2023 at 11:00 AM, 1:1 supervision was completed. Resident #174's comprehensive care plan was revised on 2/27/2023. Another resident was witnessed rubbing Resident #174's genitals over their pants, both residents were fully clothed. Interventions included avoid taking inappropriate behaviors lightly or dismissing as a fluke. Provide 1:1 supervision if indicated. A 3/2/2023 psychiatric nurse practitioner #21 progress note documented the resident was seen per request of staff for frontotemporal dementia with behaviors and sexually inappropriate behaviors. Staff reported sexually inappropriate behaviors of masturbating, and giving attention to other residents, including rubbing their backs. The resident had not touched anyone on private areas of the body. Otherwise, staff did not report any aggression. There was an episode where staff found the resident with a female in their room who was rubbing the resident's genitals over their pants, but both residents were fully clothed, and they were separated. Selective serotonin reuptake inhibitors (antidepressants) can help manage behaviors associated with dementia. If sexually inappropriate behaviors continue, they would recommend starting Tagamet twice a day. The resident would be followed in 2-4 weeks. Nursing progress notes documented: -on 3/4/2023 at 9:43 PM, staff were watching the resident with females as the resident had been petting their hands all day. Staff made sure the resident was not taking anything further. - on 3/12/2023 at 1:08 PM, the resident was following another resident around attempting to play with their hair, at one point staff intervened with gentle direction. - on 3/15/2023 at 1:16 PM, the physician increased Prozac to 30 milligrams daily. - on 3/17/2023 at 2:19 PM, walking around trying to get another resident to go in their room. They proceeded to follow the resident around and was redirected back to their room. - from 3/18/2023-4/13/2023 episodes of slamming and hitting the door, throwing things in their room, and becoming agitated with other residents. A 4/5/2023 physician #18 progress note documented the resident had frontotemporal dementia with negative behaviors and poor impulse control. The increased dose of Prozac would be continued. The resident was definitely doing better according to aides with regards to negative behaviors and mood lability. A 4/14/2023 Accident/Incident Report for Resident #174 completed by registered nurse Unit Manager #24 documented at 7:00 AM, staff heard a thud and found Resident #114 on the floor against the closet of Resident #174's room. Resident #174 was standing near Resident #114 and stated they pushed Resident #114 because they were in their room. Immediate interventions included registered nurse assessment and aggressive behavior monitoring for 72 hours. A 4/14/2023 Accident/Incident Report for Resident #114 completed by Registered Nurse Unit Manager #24 documented at 7:00 AM, Resident #114 was found in Resident #174's room on the floor. Resident #114 stated Resident #174 pushed them. Neuro checks were at baseline, no injury to head, moving all extremities, and without pain. Transferred with assistance of 2 and resident complained of left hip/leg pain once weight bearing. The resident was transported to bed in a wheelchair and was awaiting transport to hospital for evaluation. A 4/14/2023 at 12:44 PM, Registered Nurse Unit Manager #24's progress note documented they called the hospital to check on the status of Resident #114 and was told the resident had a left hip fracture and was waiting for orthopedics. Resident #114's comprehensive care plan initiated 8/23/2022 documented the resident had potential to be physically aggressive related to anger at placement may strike at others. Interventions included to intervene when agitated before escalation and guide away from source of distress. A 4/14/2023 at 2:36 PM, social worker #26 progress note documented they spoke to Resident #174 following the incident with their peer. The resident reported they pushed Resident #114 out of their room. Resident #174 was reminded to ask staff for help if they were bothered or concerned. Resident #174's 4/14/2023 updated comprehensive care plan documented the resident had potential for physical aggressiveness and pushed a peer who wandered into their room causing a fall. Interventions included move peers out of harm's way, remind resident they could cause harm, privacy curtain on doorway, stop sign across door to prevent peers from entering room, may close door for privacy and to keep peers from entering room. Resident #114's comprehensive care plan initiated 4/14/2023 documented the resident had potential to be a victim of abuse related to another resident's intrusive behavior. Resident was found on the floor of Resident #174's room. Interventions included provide environmental barriers to ensure safety-stop sign placed in doorway of Resident #174 to deter Resident #114 from entering. A 4/15/2023 physician #18 progress note documented Resident #174 had aggressive behaviors and poor impulse control, at times. The resident was more mellow with increased dose of Prozac. The plan was to continue the present dose of Prozac 30 milligrams daily and the resident was doing better with negative behaviors and mood lability. A 5/10/2023 physician #18 progress note documented the resident had occasional issues with poor impulse control, verbally and physically. The resident was not perceived as a danger to staff or others. The increase in Prozac seemed to have helped. Nursing notes for Resident #174 documented: - on 5/10/223 at 3:16 PM, the resident was redirected by staff for trying to remove other residents from their room. The resident was reminded to seek staff assistance. The stop sign in doorway was replaced as the resident kept removing and placing it in their closet. - on 5/18/2023 at 10:22 PM the resident was observed trying to kiss another resident on the mouth. Typically, the resident would kiss on the cheek. - on 5/28/2023 at 9:50 PM, the resident became agitated with another resident when they took the stuffed animals they were playing with. Resident #174 followed the resident and raised their arms toward them, but staff quickly intervened and separated the residents. - on 5/30/2023 at 3:14 PM the resident threw a stuffed animal at another resident A 7/4/2023 Accident/Incident Report completed by illegible name and title documented at 7:15 PM, Resident #191 was in Resident #174's room. Resident #174 was telling Resident #191 to leave the room. Resident #191 left the room and Resident #174 pushed Resident #191 on the upper back, causing Resident #191 to shuffle forward. Resident #191 did not fall. Resident #191 was assessed without injury and redirected away from Resident #174. Resident #191 was redirected to their room without further issues. Both residents would be monitored for a minimum of 72 hours for signs of fearfulness or change in behavior. Resident #191 would be monitored for a minimum of 72 hours for aggressive behavior. The plan of care was followed. Resident #191's care plan was updated on 7/4/2023 to include the resident was subject to physical aggression from peers. Interventions included resident would be free of physical aggression by peers. The care plan did not identify new interventions to ensure the resident was free from aggression by peers. Resident #174's care plan was revised on 7/4/2023 to include the resident had potential to be physically aggressive (initiated 2/27/2023) and pushed a peer up against the wall. There were no additional documented interventions. The 7/7/2023 physician #18 progress note documented Resident #174 had their own room and occasionally had negative behaviors with other residents wandering into their room. Staff did their best to avoid the situation. Resident #174 was usually peaceful but became agitated when others wandered into their space. A gradual dose reduction of medication was not currently indicated. Nursing notes for Resident #174 documented: - on 7/27/2023 at 9:17 PM the resident attempted to hit another resident and was redirected. - on 8/4/2023 at 10:46 PM the resident kept throwing a book across the room and ripping out pages. When asked by staff to go to their room they started slamming and kicking the door and kicked a staff in the legs. - on 8/7/2023 psychiatric nurse practitioner #21 was updated on the resident's aggressive behavior and ordered gabapentin 100 milligrams three times daily for agitation. - No negative behaviors were documented from 8/8/2023-8/31/2023. - on 9/1/2023 at 10:32 PM the resident was yelling at another resident, was asked to go to their room, and began kicking the door of their room. - on 9/11/2023 at 7:40 PM the resident had a verbal altercation with another resident. - on 10/5/2023 at 6:31 AM, note states, at 1:30 AM the resident was sitting next to a female resident who was sleeping. The resident attempted to place their hands inside of the female resident's inner thigh. A 10/9/2023 Accident/Incident Report completed by Registered Nurse Unit Manager #24 documented at 3:15 PM Resident #191 was witnessed in Resident #174's room falling to the floor, hitting the right side of their head on the wall as they fell . Resident #174 was standing over Resident #191 then walking away. Resident #191 was crying and would not give a statement. The nurse practitioner examined Resident #191. The resident had a small abrasion on the right ear that required treatment. The resident was wandering per usual shortly thereafter. The care plan was followed, and the plan was to monitor for 72 hours. An unsigned narrative included with the report documented Resident #174 stated they pushed Resident #191 because they were in their room. Both residents would be monitored for a minimum of 72 hours for signs of fearfulness, change in behavior, and aggression. Resident #174 was placed on aggressive behavior charting for a minimum of 72 hours. Resident #191's care plan was revised to include pushed by peer on 10/9/2023. There were no documented revised interventions to ensure the resident remained free of accident hazards. Resident #174's care plan was revised to include they pushed their peer on 10/9/2023. There were no documented revised interventions to protect other residents from aggressive behaviors. On 11/3/2023 at 9:54 PM the resident was reported to be standing over a peer while sleeping and was redirected. The 11/8/2023 nurse practitioner #20 progress note documented Resident #174 could be easily irritable and agitated with staff and other residents. The resident was currently on gabapentin and Prozac. Typically, the resident was easily redirected. The plan was to continue gabapentin and Prozac and non-pharmaceutical interventions. No gradual dose reduction of medication was indicated. A 12/10/2023 Accident/Incident Report completed by illegible name and title documented at 3:45 PM the Supervisor and unit nurse notified them Resident #213 was observed in the dining room sitting on Resident #174's lap. Resident #174 was fondling Resident #213's breasts. The residents were separated. There were no signs of physical or emotional trauma. The included unsigned narrative documented Resident #174 had demonstrated physical behaviors directed toward others as evidence by masturbating with their door open, mutual touching of genitals, had potential to be physically aggressive, went into other resident's rooms, and was exit seeking. Both residents would be monitored for a minimum of 72 hours for any change in behaviors, fearfulness, or aggression. Resident #213's care plan initiated 12/12/2023 documented the resident had the potential for being a victim of abuse related to another resident's behavior, inappropriate closeness, and intrusive behavior. Interventions included redirect resident away from male peers with known history of sexually inappropriate behavior, discourage from rubbing and kissing peers, encourage, and praise appropriate interactions with peers, and encourage attendance at activities to prevent boredom. Resident #174's care plan was revised on 12/10/2023 to include resident was noted rubbing Resident #213 on the outside of their shirt while sitting on their lap. There were no revised interventions to protect other residents from inappropriate behaviors. A nursing progress noted dated 12/11/2023 at 3:31 PM document Resident #174 was agitated. The resident was given space and left alone to calm down. The resident went to their room and returned for breakfast. The resident was seen touching a peer and staff intervened. The 1/3/2024 physician #19 progress note documented Resident #174 had increased outbursts and behaviors with staff and other residents. Staff had stated they have not noted any changes in resident behaviors that would be detrimental. The resident was easily redirected and able to maintain independence. The resident had good behavioral control with Prozac 10 milligrams daily and gabapentin 100 milligrams three times a day for agitation. The resident followed directions and was primarily aphasic (did not speak clearly). Aggressive behaviors had been controlled with current medication dosages. Nursing staff had no concerns with overall behaviors. An Accident/Incident Report dated 2/20/2024 completed by illegible registered nurse documented at 2:15 PM Resident #174 was found with a peer laying across them fully clothed on Resident #174's bed. Resident #174's hand was on the resident's groin. Staff immediately separated the residents. Immediate interventions included registered nurse assessment, separation of the residents, and behavior forms were initiated. A nursing note dated 2/22/2024 at 10:34 AM documented Resident #174 was rubbing a couple of residents' knees while sitting on the couch in the TV area. The residents were asleep on the couch. A nursing note dated 2/24/2024 at 9:51 PM documented Resident #174 was lying in their bed with another resident who was fully clothed. Resident #174 had their pants down with an erect penis. The residents were separated. Resident #174 was placed on 30-minute safety checks. An Accident/Incident Report dated 2/24/2023 at 8:15 PM completed by illegible licensed practical nurse documented they were called to the unit for witnessed sexually inappropriate behavior. Resident #213 was in Resident #174's room. Resident #174 had their pants down with an erect penis. The residents were separated immediately, and Resident #213 denied pain or discomfort. Immediate interventions included the residents were separated, 15-minute checks, registered nurse assessment and transfer to appropriate unit when available (did not indicate which resident would be transferred). There was no documented evidence Resident #174's comprehensive care plan was revised to include interventions to keep other resident's safe from aggression and sexual contact by Resident #174. A nursing progress note dated 2/25/2024 at 9:24 PM documented the resident exited the dining room with their pants halfway down and had an erection. At 9:35 PM the resident was found standing in another resident's room while the other resident was sleeping. The other resident's blanket was pulled down and their brief was exposed. Resident #174 was redirected and encouraged not to go in other's rooms. During an interview on 3/20/2024 at 9:47 AM, certified nurse aide #22 stated for a resident-to-resident incident, staff tried to keep them away from each other post incident. They received dementia training about 3 months ago and were taught to redirect using various methods, try to deescalate the situation, remove the residents from the situation, and walk with the residents. Those techniques were also used to prevent residents from wandering into others' rooms. The facility had used stop signs in the past, but the facility stopped using them on the dementia unit. The aide did not know why the stop sign usage stopped. Resident specific interventions were listed on a resident's care instructions. The dementia unit had multiple residents that wandered. Resident #174 was sexually inappropriate at times and the facility implemented a door sensor in the room doorway about 3 weeks ago. The aide stated that Resident #114 was wandering the unit the morning of 4/14/2023. The aide was providing care to another resident on 4/14/2023 when they heard a thud in Resident #174's room, entered the room, saw Resident #114's feet as they were leaning against the wall by the closet, and Resident #114 was moaning. Resident #174 stepped out of the room after Resident #114 stated Resident #174 pushed them and left the room. There was no stop sign on the door prior to the incident. Resident #174 had not been aggressive with any residents prior to that incident. Resident #174 usually exited their room to get a staff member to deal with the situation. Staff tried to supervise the resident's room at least every 20-30 minutes. Staff used a 1:1 intervention frequently on the unit. Resident #174 could be sexual and had a door sensor on their room. Resident #213 also had sexual behaviors and they were moved for that reason. When the door sensor alarm went off, they checked to see if another resident went into Resident #174's room. The door sensor was implemented about a month ago. They tried to keep eye on the door and check but there were no set times and tried every 20-30 minutes. During an interview on 3/21/2024 at 12:11 PM, certified nurse aide #23 stated resident-specific interventions were documented in the care instructions. The main interventions used were reapproach, redirect, offer food/fluids, and intervene. Resident #191 was frequently in other residents' spaces and wandered the unit. Staff tried to keep a close eye on residents but that depended on staffing numbers. Resident #174 was a younger resident who still had a lot of sexual urges/needs. Prior to putting a door sensor on Resident #174's room door recently, staff frequently rounded the unit and tried to keep an eye on their room. Resident #174 only lashed out if certain residents went into their room. Resident #174's room door was usually kept closed and they previously had a stop sign across the doorway. The aide did not know what happened to it. Resident #213 was moved off the unit as they had liked to get intimate with male residents, particularly Resident #174. During an interview on 3/21/2024 at 1:10 PM, Registered Nurse Manager #24 stated there were independent activities kept on the dementia unit to use as distraction for some residents. Unit staff tried to keep known aggressive residents away from residents they tended to target. Staff had tried stop signs and curtains as deterrents from wanderers going into others' rooms. The residents took them down. Staff checked on each resident at least every hour. Door sensors were also implemented. Resident #174 had behaviors of verbal and physical aggression and was sexually inappropriate at times. The resident attended a lot of supervised activities. Resident #174 did not like other residents in their room and pushed them when they entered. Resident #174 removed barriers that staff put across their doorway to deter others from entering. Staff encouraged Resident #174's door to be closed until Resident #213 was found in the room in inappropriate manners. Resident #114 sustained a fractured hip when Resident #174 pushed them in their room. Resident #174 admitted to pushing the resident. The Manager thought that was the first time Resident #174 was physically aggressive with another resident. Staff attempted to supervise Resident #174 and their room but could not always be in the hallways as they had to provide resident care. Resident #174 now had a door sensor to alert staff that someone was going in or out of their room. Resident #174 was impulsive in the moment and quickly reverted to calmness post incident. Behavioral interventions were discussed as needed as an interdisciplinary team during morning reports. During an interview on 3/21/2024 at 3:53 PM, the Director of Nursing stated when there were resident-to-resident interactions on the dementia unit, they expected staff to use a lot of activities, keep residents in sight as much possible, engage the resident, and constant rounds when providing care. Staff were expected to redirect each resident before an incident could occur. Alarms were to alert staff of a potential situation and nurses were usually in the hallway giving medications. Staff were not able to be in the hallway at all times. Behavioral interventions were in the care plan and care instructions. Resident #114 broke their hip when they entered Resident #174's room and was pushed. That could have been prevented if staff saw Resident #114 ambulating on the unit and enter the room. Resident #191 sustained an abrasion when they were pushed and hit their head while in Resident #174's room. The incidents with Resident #174 and Resident #213 could have been prevented if staff saw them together prior to being inappropriate. In each instance, the residents were placed on hourly checks for 72 hours. Resident #213 was moved to a different unit to prevent reoccurrences. During an interview on 3/21/2024 at 4:41 PM, physician #4 stated Resident #114 sustained harm of a fractured hip and Resident #191 sustained an abrasion when they were pushed by Resident #174. 10 NYCRR 483.25(d)

Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024 the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 5 of 5 certified nurse aides (certified nurse aides #35, #41, #42, #43, and #44) reviewed. Specifically, there was no documented evidence certified nurse aides #35, #41, #42, #43, and #44 had performance reviews at least once every 12 months. Findings include: The facility policy titled Staff Evaluations, last modified 11/9/2018, documented the facility would provide ongoing feedback to all staff members regarding their performance at specific intervals to encourage continuous improvement as needed. All staff members would receive an annual performance evaluation. If there were any identified areas of weakness, they would be referred to staff education to address the identified areas and assist with performance improvement. Annual performance evaluations were documented as follows: - Certified nurse aide #35: 1/2/2022. - Certified nurse aide #41: 12/29/2021. - Certified nurse aide #42: 1/2/2022. - Certified nurse aide #43: 2/22/2023. - Certified nurse aide #44: 2/17/2023. There was no documented evidence certified nurse aides #35, #41, #42, #43, and #44 had annual performance evaluations since the above noted dates. During the quality assurance interview on 3/29/2024 at 12:17 PM the Administrator stated the Director of Nursing oversaw all the nursing department evaluations and nursing disciplinary actions. During a follow-up interview on 3/29/24 at 1:20 PM the Administrator stated per regulation, certified nurse aides were required to have 12 hours of in-service training annually, with an annual performance evaluation and in-services based on their evaluation deficiencies. During an interview on 3/29/2024 at 1:42 PM certified nurse aide #46 stated they did not know what a performance evaluation meant. They did not recall anyone evaluating them specific to their job. During an interview on 3/29/2024 at 1:47 PM certified nurse aide #35 stated their last performance evaluation was at least a year-and-a-half ago. During an interview on 3/29/2024 at 1:55 PM certified nurse aide #47 stated they used to have annual performance evaluations but had not had any since the COVID pandemic. It had been at least a couple of years since their last annual performance evaluation. During an interview on 3/29/2024 at 2:07 PM the Assistant Director of Nursing stated the certified nurse aide annual performance evaluations were done by the Clinical Care Coordinators (Nurse Managers) on the units. Most of the Clinical Care Coordinators were licensed practical nurses. During an interview on 3/29/2024 at 2:12 PM the Director of Nursing stated the Personnel Coordinator tracked and let Clinical Care Coordinators know when certified nurse aides were due for their annual performance evaluations. They did annual performance evaluations on Nurse Managers, Supervisors, and ancillary staff. They were aware that certified nurse aide performance evaluations were not getting done as required. 10 NYCRR 415.26 (d) (7)

Based on record review and interview during the recertification survey conducted 3/18/2024-3/29/2024, the facility did not ensure that licensed nurses had the appropriate competencies and skill sets necessary to provide nursing care and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well- being for each resident for 4 of 4 licensed nurses (licensed practical nurses #31, #45, #48, and registered nurse #51) reviewed. Specifically, licensed practical nurses #31, #45, #48 and registered nurse #51 did not receive routine competency evaluations that covered key skill-set areas including accessing venous access devices, vacuum assisted wound closure devices (wound VACs), hand hygiene, and medication administration. Deficiencies were identified in the areas of Parenteral/IV (intravenous) fluids (F694), Free from Significant Medication Errors (F760), Quality of Care (F684), and Infection Control (F880). Findings Include: The Facility Assessment for 2023 documented annual in-services and competencies were coordinated and scheduled monthly throughout the year. Licensed nurse competencies included person-centered care, medication administration, resident assessments, and caring for persons with dementia and mental health disorders. The facility training document Intravenous (IV)- Scope of Practice dated 1/2018 documented the purpose was to delineate the scope of practice to ensure a consistent knowledge base and demonstration of competency. Licensed practical nurses may perform basic [intravenous] maintenance if they had completed the intravenous maintenance course, demonstrated competency, and a registered nurse was present in the facility. The facility policy Staff Education dated 11/9/2018 documented staff would be provided ongoing educational opportunities that met requirements of the New York State Department of Health and that promoted the growth and reinforce procedures for the nursing home. All employees would be required to receive training upon hire at general orientation and annually on the topics of infection control, safety, resident rights, abuse, corporate compliance, dementia, and quality assurance. The undated facility training document The Practice of Intravenous Therapy by Licensed Practical Nurses in Acute Care Settings documented the provision of intravenous therapy by a licensed practical nurse must be under the direct supervision of a registered nurse who is assigned to the patient care unit at all times that the licensed practical nurse administers [intravenous] therapy. Nursing Personnel Records documented the most current annual competencies as follows: 1) Licensed practical nurse #48 had orientation competencies completed on 4/18/2023, there were no documented competencies for medication administration skills, administration through an intravenous access device, intravenous access device identification, or wound vacuums. 2) Registered Nurse #51 had orientation competencies completed on 7/3/2023 and 7/5/2023, there were no documented competencies for administration through an intravenous access device, intravenous access device identification, or wound vacuums. 3) Licensed practical nurse #45 had orientation competencies completed on 2/5/2024, there were no documented competencies for administration through an intravenous access devices, intravenous access device identification, or wound vacuums. 4) Licensed Practical Nurse #31 did not have orientation competencies provided by the facility for handwashing, personal protective equipment, or medication administration. Additionally, they did not have documented competencies for administration through an intravenous access devices, intravenous access device identification, or wound vacuums. During an interview on 3/21/24 at 4:21 PM, licensed practical nurse Staff Development Coordinator #50 stated they provided education for all staff in the facility. They stated they had not done medication administration trainings or competencies. They were told by the previous Director of Nursing and Administrator that they did not have to do training due to a COVID waiver. They were not intravenous certified, and they did not provide competencies for intravenous medication administration. They would have to use a registered nurse to complete intravenous skills training. The administration reached out to licensed practical nurse #50 for all the competencies the nurses had on file. They stated that if it was not in the package provided, it did not exist. During an interview on 3/28/2024 at 9:10 AM, registered nurse #30 stated the facility offered a class through the pharmacy for intravenous knowledge, but registered nurse #30 had not experienced any competencies related to intravenous maintenance or medication administration by the education department in the facility. They clarified that competencies meant they were visually watched as they demonstrated the skills, that activity had not been done. During an interview on 3/28/2024 at 10:18 AM, licensed practical nurse #29 stated they were intravenous certified. They took the facility provided class twice, last year being the last class. Competencies were done at the end of class as part of the certification for intravenous access devices. The facility did in-services on medication administration but there were no competencies for medication administration. During an interview on 3/28/2024 at 1:54 PM, licensed practical nurse Clinical Care Coordinator #32 stated the facility had not done competencies since they returned to the facility in 7/2022. They had in-services, but competencies were not completed for the nursing staff. During an interview on 3/28/2024 at 3:42 PM, licensed practical nurse Staff Development Coordinator #50 stated that the facility had many agency staff. They provided orientation every other week on Mondays and Tuesdays. Staff nurses got 3 days of orientation, certified nurse aides got 2 days of orientation, and agency nurses got 1 day of orientation. The competencies that have a K next to competent on the checklists met they were competent by knowledge. Competent by knowledge met that the nurse or aide stated they knew the material and the processes were talked through. If they did the actual competencies, it would take 3 weeks to get through everything. If the competency was blank, but signed by licensed practical nurse #50, it documented it was competent by knowledge. There were no wound vac competencies or in-services. Handwashing was done during orientation, but no additional competencies were done. During an interview on 3/28/2024 at 4:47 PM, licensed practical nurse Nursing Supervisor #48 stated the facility did competencies when hired. Additionally, every time there was a medication error, they had to complete a competency for medication administration. The first time licensed nursing staff did an intravenous medications someone had to watch and there was a checklist for that. During an interview on 3/29/2024 at 10:47 AM, the Director of Nursing stated they could not recall the last time they had a nursing competency for medication administration. They were working on a plan to provide in-services and mandatory trainings. During an interview on 3/29/2024 at 12:19 PM, the Administrator stated that the orientation process and training tools were outdated. It was the Director of Nursing's responsibility to oversee the nurse and certified nurse aide competencies. The facility was conducting an in-service and orientation audit with a performance improvement plan. The Administrator stated there was a nurse that reviewed admission medications, and that pharmacy did consults that were reported to the Director of Nursing. There were no audits for medication administration on the units. 10 NYCRR 415.26(c)(1)(iv)

Based on record review and interviews during the recertification survey conducted 3/18/2024-3/29/2024 the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Specifically, there was not consistent communication between the governing body and the facility Administrator to ensure regulatory compliance. Multiple deficiencies including an immediate jeopardy in Influenza and Pneumococcal Immunizations (F883) were identified during the recertification survey. Findings include: The undated facility policy Quality Assurance Performance Improvement Committee (QAPI) Plan documented: - Quality assurance performance improvement addresses clinical care to continuously improve clinical care. Care data would be reviewed by the committee to proactively identify areas in need of improvement; and address resident choice to ensure decisions affecting the residents were made based on individual preference and care needs. - Administration is responsible for guiding and participating in the quality assurance performance improvement committee. - A member of the facility Advisory Board is committed to participating in the committee and providing a status report at the monthly Advisory Board Meeting. - The Committee will evaluate the program on a quarterly basis, and this will include ensuring that there are adequate resources allotted to meet their initiatives and goals. - A member of the facility Advisory Board will be designated as a liaison to the committee. The individual is vested with the responsibility to report ongoing quality assurance updates to the Advisory Board monthly. Refer to F 883 citation Influenza and Pneumococcal Vaccinations An electronic mail chain dated 1/23/2024 (1 month and 3 weeks after the pneumococcal vaccine request was made) documented: - At 11:17 AM, from the Infection Preventionist to the Deputy Administrator of Fiscal questioning where the pneumococcal vaccine purchase order was as they had many pending vaccinations to give. - At 11:51 AM, the Deputy Administrator of Fiscal responded to the facility accountant asking if the request was the same, they had questioned the pricing. - At 11:53 AM, the facility accountant responded: yes, it was over $10,000. - At 11:59 AM, the Deputy Administrator of Fiscal to the keyboard specialist the vaccine order was sent back due to it being over $10,000. It would need to be a state contract or group purchasing contract if exceeding $10,000. During an interview on 3/25/2024 at 11:08 AM, the Assistant Director of Nursing stated the Deputy Administrator was responsible for approval of supply costs. They stated if requested supplies were under a certain dollar amount the facility would cover the cost. If they went over that dollar amount, they had to go to fiscal for approval. During an interview on 3/25/2024 at 2:07 PM, the Administrator stated their Infection Preventionist put in a purchase request for the pneumococcal vaccinations and was told that anything over $10,000.00 needed to go to the legislature and that took approximately 2 months. On 3/24/2024 they authorized the payment for the vaccines without the Deputy Administrator of Fiscal approval. They told the pharmacy to charge it to their personal credit card and they would just submit an expense report later. In June of 2023 the Deputy Administrator of Fiscal should have told the Infection Preventionist how to order vaccines and methods to keep the cost below $10,000. They had recently notified the current Deputy Administrator of Fiscal that purchases for clinical health products should now go through the Administrator. During an interview on 3/25/2024 at 3:17 PM, the Deputy Administrator of Fiscal Services stated they must follow the purchasing rules of the county. They sent the Infection Preventionist a listing of groups they could order vaccinations from. Nursing put in the request for vaccines which went to the county office building. The county office reviewed the request, and they would either approve or deny via an electronic mail and would deny the request if it was over $10,000.00. 10NYCRR 415.26(b)(3)(1) 37516

Based on observation and interview during the recertification and abbreviated (NY00311514) surveys conducted 3/18/2024-3/29/2024 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents (Residents #3, #147, #195, and #212). Specifically, licensed practical nurse #45 did not perform hand hygiene between medication administrations to Residents #3, #147, #195, and #212. (Refer to F 726 Competent Nursing Staff). Findings include: The facility policy Medication Administration System last modified 11/20/2020 documented nurses perform hand hygiene immediately before preparing medications. The facility policy Hand Hygiene last modified 7/29/2020 documented hand hygiene is done before and after any contact with residents, after handling trash, after handling soiled linen or supplies, before and after personal care, before and after feeding residents, and after restroom use. Hand hygiene also applies when administering medications. The following observations were made on 3/20/2024 during a medication administration with licensed practical nurse #45: - at 9:36 AM, licensed practical nurse #45 began preparing medications for Resident #147. Medications included Celexa (antidepressant), senna plus (laxative), and artificial tears (eye drops). Licensed practical nurse #45 entered the resident's room and administered the resident's eye drops and the pills. Licensed practical nurse #45 returned to the medication cart signed off the medications as administered, and handled their pen and personal clipboard on top of the medication cart, and did not perform hand hygiene. - at 9:43 AM, licensed practical nurse #45 moved the medication cart near Resident #195's room, did not perform hand hygiene and prepared Resident #195's medications including atenolol (blood pressure medication), vitamin D3, Eliquis (blood thinner), Lasix (diuretic), fiber laxative, eye vitamin, and spironolactone (blood pressure medication). Licensed practical nurse #45 entered the resident's room, administered the medications, and returned to the medication cart, signed for the medications, handled their pen and clipboard, and did not perform hand hygiene. - at 9:51 AM, licensed practical nurse #45 moved the medication cart near Resident #45's room, did not perform hand hygiene and prepared Resident #45's medications including acidophilus (probiotic), amlodipine (blood pressure), Labetalol (blood pressure medication), Keppra (seizure medications), Protonix (treats reflux), hydralazine (blood pressure medication), Vitamin D3, baclofen (muscle relaxant), folic acid (supplement), ramipril (blood pressure medication), and sertraline (antidepressant). Licensed practical nurse #45 entered the resident's room, administered the medications, and returned to the medication cart, signed for the medications, handled their pen and clipboard, and did not perform hand hygiene. - at 10:06 AM, licensed practical nurse #45 moved the medication cart near Resident #3's room, did not perform hand hygiene and prepared Resident #3's medications including artificial tears drops, aspirin, Sinemet (treats tremors), cranberry supplement, Enulose (laxative), Keppra (seizure medication), metoprolol (blood pressure medication), Toujeo 8 units insulin injection, venlafaxine (antidepressant), and esomeprazole magnesium (acid reducer). The medications were crushed. Licensed practical nurse #45 entered the resident's room and administered the insulin in the resident's right upper arm. Licensed practical nurse #45 spooned the medications to the resident with vanilla pudding alternating with nectar thick juice. They exited the resident's room, signed off administration, handled their pen and personal clipboard, and did not sanitize their hands. Licensed practical nurse #45 did not perform hand hygiene from 9:36 AM- 10:06 AM while administering medications. During an interview on 3/20/2024 at 10:26 AM licensed practical nurse #45 stated they had sanitizer and pointed to the left side of the medication cart. They stated they did not use it in between these 4 residents and should have. If they did not have clean hands, they could pass germs between residents. During an interview on 3/22/2024 at 8:39 AM licensed practical nurse Infection Preventionist #5 stated during medication administration nurses should wash their hands or use hand sanitizer between all residents and before and after giving eye drops and known exposure to soiled items. Lack of proper hand hygiene could cause sickness. Hand washing was the number one way to stop the spread of infection. 10 NYCRR 483.80 (a)

Based on observation, record review, and interview during the recertification and abbreviated (NY00328316) surveys conducted 3/18/2024-3/29/2024 the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #223) reviewed. Specifically, Resident #223 had an order for a vacuum assisted closure device (a device that uses negative pressure for wound healing) and the device was observed unplugged and not functioning. Findings include: The facility policy titled Wounds-Nursing care of a V.A.C. (vacuum assisted closure) Pump last modified 1/9/2019 documented the vacuum assisted closure device should always be in optimum working order while being used to heal a resident. During each shift, the pump should be checked to ensure it was on. If unable to maintain integrity of the system after 30 minutes, contact the Wound Care Nurse. Resident #223 was admitted to the facility with diagnoses including surgical aftercare following surgery on the skin and subcutaneous tissue and unspecified open wound of the abdominal wall. The 1/3/2024 Minimum Data Set assessment documented the resident was cognitively intact, dependent for personal hygiene, had a surgical wound, and received surgical wound care. A 12/27/2023 hospital discharge summary documented the resident had a panniculectomy (removal of abdominal excess skin and fat tissue). A wound vacuum assisted closure device was placed. The resident subsequently was found to have necrotic (dead) foul smelling tissue and the wound was debrided (removal of dead tissue) and washed out. The wound culture was positive for the presence of several bacteria. The wound was healing well, and the resident was cleared for discharge. Discharge instructions documented dressing change as needed for vacuum assisted closure device. A 12/27/2023 at 2:16 PM registered nurse #30 initial nursing note documented the resident had an abdominal wound following necrosis at the site of the panniculectomy with a wound vac (vacuum assisted closure device). A 12/27/2023 facility admission order documented cleanse 3 abdominal wounds with normal saline, skin prep to surrounding skin, pack tunneling with white foam, cover wound beds with black foam, then transparent cover, bridge together with suction off of wound bed, then cover with a track pad, place negative pressure wound therapy with settings at 125 millimeters of mercury continuously every Monday, Wednesday and Friday and as needed. Monitor placement, suction/settings 125 millimeters of mercury, cannister every shift. The comprehensive care plan, initiated 12/27/2023, documented the resident had impaired skin integrity due to necrosis at the site of the panniculectomy with a wound vacuum assisted closure device. Interventions included monitor every shift for signs and symptoms of infection, monitor wound vacuum assisted closure device functioning, and dressing changes per physician order. A 2/12/2024 updated physician order documented cleanse mid abdominal wound with normal saline, apply skin prep (a skin protectant) to surrounding skin, pack tunnelling with white foam, cover wound beds with black foam, then transparent, bridge together with suction off the wound bed, then cover with a track pad, place negative pressure wound therapy (vacuum assisted closure device) with setting at 125 milligrams continuously. Change every Monday, Wednesday, and Friday and as needed. A 2/27/2024 physician #4 progress note documented the resident had a wound in the lower abdominal area. The resident had been treated with intravenous antibiotics for an extended duration due to wound infection. The resident was not currently on antibiotics. The wound vacuum assisted closure device was in place. Staff were spoken to in detail about the wound care treatment plan. A 3/27/2024 at 3:45 PM registered nurse #30 nursing progress note documented the resident was sent to the emergency department after a fall. A 3/27/2024 at 11:30 PM registered nurse #34 progress note documented the resident returned from the emergency department. There was no documented evidence the resident was assessed, or the wound vacuum assisted closure device was in place and functioning upon return from the hospital. The 3/1/20424-3/31/2024 medication and treatment administration records did not include wound vacuum assisted closure device orders for a dressing or for monitoring of the device. During an observation and interview on 3/28/24 at 8:46 AM, the resident was lying in bed in a gown, covered with blankets. The resident stated they fell yesterday, went to the hospital, and got back around 11:00 PM. The resident pulled back their blankets to expose the wound vacuum assisted closure device tubing and apologized for the odor as the canister gets full. The device was in the top drawer of the bedside stand. The device screen was dark and silent, the canister contained a trace amount (less than 30 milliliters) of dark red/yellow drainage, and the power cord was not plugged into an electrical outlet. During an observation on 3/28/2024 at 10:19 AM, the resident was lying on their back in bed. They returned from the hospital last night and was assisted into bed and the wound vacuum assisted closure device was placed in the top drawer of their bedside stand. They stated the nurses did not check it, just when they changed the dressing. They stated they needed the dressing done today because they were at the hospital yesterday and it was not done. The top drawer of the bedside stand contained the wound vacuum assisted closure device. The device was off, and the screen was dark with no sound emitting from machine. The device was not plugged into an electrical outlet. There was a scant amount dark red and yellow drainage in the canister. The occupational therapist entered the room with an ice pack and therapy equipment at 10:40 AM. During an observation and interview on 3/28/24 at 11:48 AM the resident was lying in bed with the wound vacuum assisted closure device on. There was thin red serosanguinous (red tinged fluid) liquid visible in the tubing. The screen display read 125 milligrams of mercury. Certified nurse aide #35 stated at the time of the observation the wound vacuum assisted closure device care was not done by the certified nurse aides. They stated they would unplug the cord and place the unit on the back of the chair when they transported the resident and plugged it in if it beeped for a low battery, but otherwise they did not touch it. During an interview on 3/28/24 at 11:55 AM, licensed practical nurse #36 stated they administered the resident's medications at around 8:00 AM that morning and they could see fluid movement in the tubing of the wound vacuum assisted closure device. They did not see anything wrong with the tubing or the machine, so they signed off on it in the treatment administration record. If there was something wrong with the machine, they would notify a registered nurse as licensed practical nurses did not do the treatment or handle the intricate controls of the device. During an interview on 3/28/24 12:07 PM occupational therapist #37 stated the resident asked them if the wound vacuum assisted closure device was working when they entered their room earlier and they went and got registered nurse #30 who came right in and assessed the unit and the resident. During an interview on 3/28/2024 at 12:09 PM registered nurse #30 stated occupational therapist #37 alerted them the resident had concerns with their wound vacuum assisted closure device. They assessed the wound vacuum assisted closure device and it was off, so they turned it on. They did not know how long it had been off. When they turned it on and it was working as ordered, so they had no concerns. During an interview on 3/28/2024 at 1:39 PM licensed practical nurse #38 stated if the wound vacuum assisted closure device was off it should be immediately assessed, and the dressing should be changed. The physician should be notified it was off especially because they did not know how long it was off. The provider should be contacted for guidance prior to just turning the device back on as it was ordered to run continuously. Healing could be delayed, and bacteria build up could cause an infection. If the wound vacuum assisted closure device was off there should have been a wet to dry dressing applied until the ordered treatment could be completed by qualified staff. During an interview on 3/28/2024 at 1:47 PM registered nurse #39 stated they were not aware the wound vacuum assisted closure device was off or how long it was off. The device should not just be turned back on without knowing how long it was off. The machine lost suction when it was off, and bacteria could develop in the dressing from the fluid back up. The nurse and medical should be notified it was off. The purpose of the device was to draw drainage away from the wound to promote healing. During a treatment observation on 3/28/24 at 1:59 PM, registered nurse #30 removed the resident's wound vacuum assisted closure device foam dressing. There was moderate serosanguinous wound drainage. The wound was pink and moist. The edges of the wound were in various stages of healing and were clean, dry, and light pink. During an interview on 3/28/2024 at 4:05 PM nurse practitioner #40 stated licensed practical nurse #30 called them around 2:00 PM this day and stated that the resident's wound vacuum assisted closure device was off and they were unsure how long it had been off. They stated the wound vacuum assisted closure device drained the fluid away from the wound to allow for wound healing. The wound vacuum assisted closure device should not be turned off until it was time for a dressing change. If the device remained off, they were concerned for a delay in the wound healing process. They stated the device should not have been turned back on once it was found to be off. 10NYCRR 415.12 48632

Based on observation, record review, and interview during the recertification survey conducted 3/18/2024 -3/29/2024, the facility did not ensure parenteral fluids (delivery of fluid or medication through a vein) were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #207) reviewed. Specifically, Resident #207 had an intravenous access device, the physician orders did not include the length of the external catheter or directions for measuring the catheter (to ensure it did not migrate or dislodge); licensed nurses did not know the type of the catheter the resident had; documentation of catheter care was inconsistent; and the care plan did not include daily care and monitoring of the device. Additionally, deficiencies related to intravenous therapy were identified in the areas of Significant Medication Errors (F760), and Competent Nursing Staff (F726). Findings include: The facility policy Intravenous Therapy - Monitoring and General Protocols revised 8/24/2023 documents all midline catheters will be evaluated for length of the external catheter and mid-arm circumference upon admission, and as needed. Documentation of measurements in [centimeters] will be in the electronic treatment administration record. Peripheral [intravenous] site needs to be changed when clinically indicated, every 7 days, or as ordered by the physician. A new sterile cap will be applied to the end of tubing and needleless connector when not in use. The facility policy Intravenous - Dressing Change for Central Vascular Access Devices and Midline Peripheral Catheter revised 8/23/2023 documents measure/note length of external catheter for all midlines, measure in [centimeters]. Measure from the hub of the catheter to insertion site of the catheter. Compare measurement to documented length of external catheter at time of insertion and/or most recent measurement. If there is a difference in measurements of the external catheter, contact physician to obtain order for chest x-ray to confirm the current tip location. Document measurements and procedures in the electronic treatment administration record; document observation and tolerance to the procedure in the progress notes. Resident #207 had diagnoses including pneumonia and sepsis (system wide infection). The 2/3/2024 Minimum Data Set assessment documented the resident was cognitively intact, required maximum assistance for activities of daily living, did not receive intravenous medications, and did not have intravenous access including peripheral, midline, or central lines. The 3/19/2024 discharge Minimum Data Set assessment documented the resident had a peripheral intravenous access and received intravenous antibiotics on admission and at discharge. The 3/13/2024 hospital discharge summary documented the resident was being discharged and would continue intravenous antibiotic therapy with ceftriaxone 2 grams daily until 3/22/2024. The resident was being discharged with an AccuCath (an intravenous catheter) given their chronic kidney disease stage an intravenous peripherally inserted central catheter was indicated. The 3/13/2024 physician orders documented: - AccuCath in left forearm for intravenous antibiotics, monitor for signs and symptoms of infection every shift - change midline dressing weekly on Thursday with [special protective covering], measure line length weekly. - Sodium chloride flush intravenous solution 0.9%, intravenously use 10 milliliters every shift to maintain intravenous patency for 9 days. - Arm circumference 10 centimeters above insertions site measured every Thursday. The comprehensive care plan initiated 3/11/2024 and revised 3/13/2024 documented the resident had a history of pneumonia. Interventions included to administer medications as ordered. A revision on 3/13/2024 documented a complicated urinary tract infection with interventions of ceftriaxone 2 grams (antibiotic) for 9 days, encourage fluids, administer antibiotic, monitor intake and output, monitor labs and diagnostics. A revision on 3/18/2024 documented the resident had respiratory syncytial virus (respiratory disease) with interventions including use of antibiotics. The comprehensive care plan did not include the use of intravenous fluids, intravenous medications, or the presence of an active intravenous access device. The 3/13/2024 health status note by licensed practical nurse #48 documented the resident was readmitted to the facility with a diagnosis of sepsis (systemic infection) secondary to urinary tract infection. The peripheral intravenous access device in the left forearm was patent and working and there were no signs or symptoms of infection at the insertion site. Intravenous ceftriaxone 2 grams was administered and was tolerated well. There was no documented evidence of a measurement of the external catheter length. The 3/14/2024 nurse practitioner #40 re-admission progress note documented the resident was hospitalized from 3/7/2024 through 3/14/2024 with diagnoses of upper gastrointestinal bleed, acute kidney injury, and sepsis pneumonia. The infection specialist recommended ceftriaxone 2 grams intravenously for 2 weeks. The resident was discharged back to the facility to continue the intravenous ceftriaxone 2 grams for sepsis pneumonia. The 3/14/2024 registered nurse #49 progress note documented the peripheral intravenous access device in the left forearm was patent and working, and there were no signs and symptoms of infection at the insertion site. There was no documented evidence of a measurement of the external catheter length. The 3/2024 Medication Administration Record documented: - Change midline dressing weekly on Thursdays with antiseptic dressing, and measure line length weekly. On 3/14/2024 licensed practical nurse #29 documented 9. The documented 9 was associated with the 3/14/2024 progress note by licensed practical nurse #29's documentation of not applicable. - Measure arm circumference 10 centimeters above insertion site. On 3/14/2024 licensed practical nurse #29 documented 9. The documented 9 was associated with the 3/14/2024 progress note by licensed practical nurse #29's documentation of not applicable. - Intravenous catheter in left forearm, monitor for signs and symptoms of infection every shift and was documented as completed on every shift. The medication administration record did not include a reference measurement of the midline catheter. During an interview on 3/20/2024 at 10:55 AM, licensed practice nurse Clinical Care Coordinator #32 stated Resident #207 had specific intravenous access device supplies for the maintenance of their midline catheter with infused green caps (disinfecting cap that is placed at the end of a vascular access device, intended to reduce the risk for infection) for infection control. The green caps went on the intravenous tubing and the intravenous hub when disconnected. During a follow up interview on 3/21/2024 at 1:18 PM, the licensed practical nurse Clinical Care Coordinator #32 stated licensed practical nurses with the specific intravenous course training were allowed to handle and administer medications through midline catheters as the end of the venous access device did not extend past the resident's shoulder. Resident #207's intravenous catheter did not go past the shoulder, which meant it was in the licensed practical nurse's scope of practice to administer medications through the device. During an interview on 3/21/2024 at 5:09 PM, licensed practical nurse #31 stated they were not aware that Resident #207 had a midline catheter as their intravenous access device, as they could not manage midline catheters. The additional orders for changing the dressing, measuring the catheter, and the circumference of the arm was not done by a licensed practice nurse. During an interview on 3/28/2024 at 9:10 AM, registered nurse #30 stated they had accessed Resident #207's intravenous access device, and it was either a peripherally inserted central catheter or a midline catheter. The venous access device could be visually identified by the external purple hubs where the medication tubing could be connected, a standard peripheral intravenous access device did not have those hubs. Resident #207 had purple hubs on their catheter. They stated if they signed the medication administration record stating they flushed the catheter then they did it. They recalled going into the resident's room and flushing a midline catheter. Upon reviewing the medication administration record to date, the resident's midline catheter had not been measured, their arm circumference was not measured, and the dressing had not been changed since their readmission. Once the intravenous infusion was completed the catheter would be flushed and a green cap applied on the purple hub. The tubing should never be without a cap. During an interview on 3/28/2024 at 10:18 AM, licensed practical nurse #29 stated Resident #207 had a standard peripheral intravenous access device. A type of intravenous catheter was the securing device. A midline catheter would be higher up on the arm; the resident's peripheral intravenous device was on the forearm. They could visually tell the difference between a peripheral device and a midline based on where it was located on the body. The gauge of the peripheral device should be in the orders. The licensed practical nurse was unable to find any documentation related to the intravenous device. The hospital discharge was 3/13/2024, therefore they assumed the intravenous insertion date was 3/13/2024. The resident had orders related to a midline catheter that was communicated was going to be discontinued because the resident did not have a midline catheter. They did not speak to a provider regarding the orders. They documented the orders were not applicable. Upon the resident's readmission, there were no assessments completed by a registered nurse, except for their wounds. Peripheral devices could be kept in place safely for at least 14 days, probably longer. The importance of monitoring an intravenous site was to watch for infection and infiltration. There was no information in the electronic medical record regarding the intravenous access device insertion date, gauge, or length of external catheter. During an interview on 3/28/2024 at 11:40 AM, licensed practical nurse #17 stated they physically saw Resident #207's intravenous access device. The stat lock (a peripherally inserted central catheter stabilization device, holds the intravenous device in place) was blue in color. The total length of the catheter was 36 centimeters total, and the hospital did not provide the external catheter length. The external length was supposed to be measured on 3/14/2024. The dressing for the intravenous device was supposed to be changed on 3/14/2024. A registered nurse needed to change the dressing, measure the external catheter, and measure 10 centimeters above the site, and measure the circumference of the resident's arm. Licensed practical nurse #48 observed the intravenous site when Resident #207 came back from the hospital. The nursing assessment in the electronic health record should be done by a registered nurse. During an interview on 3/28/2024 at 1:54 PM, licensed practical nurse Clinical Care Coordinator #32 stated they were responsible for initiating and updating residents' care plans. The Clinical Care Coordinators could initiate care plans. The resident had a care plan for the antibiotic for their urinary tract infection, but not the intravenous device. Resident #207 had their peripheral intravenous access device inserted on 3/11/2024. Resident #207 had their dressing change ordered once a week due to the antiseptic dressing. The dressing was ordered to be changed on 3/14/2024, but there was no progress note, so they were not sure why it was not completed. If the dressing was not changed the provider should be notified to get a new date and time. When the resident was readmitted licensed practical nurse #32 stated they did the admission assessment and initial progress note. The resident was a readmission, so nothing changed for them. Physical assessments could be done by a licensed practical nurse, but a registered nurse had to assess the wounds and skin. During an interview on 3/28/2024 at 4:16 PM, nurse practitioner #40 stated that the nurses should have called them for clarification of the intravenous access device. Nurse practitioner #40 was not sure if the resident had a midline or central line catheter device. There was a visual difference between a peripheral device and midline device. If the resident was planned for 2 weeks of intravenous antibiotics it would likely have been a midline or a peripherally inserted central catheter. The resident was ordered for dressing changes weekly, and they should have done. If the dressing changes were not completed as ordered, it would put the resident at risk for infection. During an interview on 3/28/2024 at 4:47 PM, licensed practical nurse #48 stated they had completed the required intravenous course that allowed them to access intravenous devices. Resident #207 had an intravenous catheter which was a peripheral device. They thought that licensed practical nurse #32 called the hospital to verify the type of device but could not recall the date that was completed. The dressing change to the intravenous site should have been changed. If there was a question about the type of venous access device, the order should have been clarified. During an interview on 3/29/2024 at 10:18 AM, the Medical Director stated if the nursing staff was not sure if the resident had a peripheral intravenous device or a midline device, they expected to be notified for clarification. If a dressing change was ordered for an intravenous device, it should have been completed. During an interview on 3/29/2024 at 10:47 AM, the Director of Nursing stated that Clinical Care Coordinators of the units were responsible for initiating and updating care plans. The only registered nurses that were assigned a unit were the Clinical Care Coordinators, however, many of the Clinical Care Coordinators were licensed practical nurses. The Assistant Director of Nursing oversaw all the units in the facility and did wound staging and assessments. Licensed practical nurses could not assess; they could observe and document. Licensed practical nurses could initiate care plans. There was no documentation indicating that a registered nurse assessed Resident #207's intravenous access device. The licensed practical nurse Clinical Care Coordinator #32 did the complete body systems assessment upon Resident #207's return from the hospital. There was no documentation that a registered nurse followed up on the licensed practical nurse's assessment document. If the intravenous device was a peripheral device, the orders for the midline should have been clarified. If the device was a midline catheter, the external catheter should have been measured and documented. If the device was a peripheral catheter, the gauge needle should have been documented. For both types of intravenous devices, there should have been a note in the medical record about the insertion date. Peripheral devices needed to be changed based on the facility policy or a specific physician's order. The Director of Nursing stated they thought the policy was that peripheral devices had to be changed after 3 days. If there was no documentation, there was no confirmation if anyone clarified whether Resident #207 had a midline or a peripheral device. 10 NYCRR 415.12(k)(2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00328316) surveys conducted 3/18/2024-3/29/2024, the facility failed to ensure that residents were free of any significant medication errors for 1 of 1 resident (Resident #207) reviewed. Specifically, Resident #207 was given an incomplete dose of an intravenous antibiotic, 1 late administration of an intravenous antibiotic, and the intravenous access site was not flushed as ordered. Additionally, deficiencies in quality of care related to parenteral/intravenous fluids, and competent nurse staffing were identified in the areas of Parenteral/IV fluids (F694), and Competent Nursing Staff (F726). Findings include: The facility policy Medication Administration System revised 11/10/2020 documented all medication orders are checked against the [electronic medication administration record] and the physician's order in the electronic medical record before administering any drugs the first time. A nurse is responsible for questioning a drug order, if, in their judgment the order is in error or if the order is not legible. At the end of each period of passing medication, the nurse would review the electronic medication administration record for accuracy and completeness, any blank spaces found constitutes a medication error. Drug errors were to be reported immediately to the nursing supervisor and attending physician. The facility policy Intravenous Therapy - Monitoring and General Protocols revised 8/24/2024 documented all physician orders for intravenous therapy would include the route; specific fluid; medication; flush solution, including amount and frequency; volume/flow rate for [intravenous] therapy; and total length of time. Rates will include the amount to be infused per column to time. A new sterile cap was applied to the end of tubing and needleless connector when not in use. All peripheral lines were to be flushed per physician orders and documented in the electronic medication administration record. Resident #207 had diagnoses including pneumonia and sepsis. The 3/19/2024 discharge Minimum Data Set documented the resident was receiving intravenous antibiotics; had peripheral intravenous access upon this admission and at discharge. The comprehensive care plan initiated 3/11/2024 and revised 3/13/2024 documented a history of pneumonia. Interventions included administer medication as ordered, and provide oxygen as needed. The comprehensive care plan revised 3/13/2024 documented a complicated urinary tract infection. The interventions included ceftriaxone 2 grams (antibiotic, did not specify intravenous or oral) for 9 days, encourage fluids, administer antibiotic, monitor intake and output, monitor labs and diagnostics. The comprehensive care plan revised 3/18/2024 documented respiratory syncytial virus (respiratory disease affecting the lungs). The interventions included use of antibiotics. There was no comprehensive care plan for the use of intravenous fluids, intravenous medications, or active intravenous access device. The 3/13/2024 nurse practitioner #15's order documented: - ceftriaxone sodium 2 grams, intravenously every 24 hours for infection/sepsis/urinary tract infection for 9 days at 8:00 PM with sodium chloride flush intravenously before and after antibiotic administration. - sodium chloride flush intravenous solution 0.9%, intravenously use 10 milliliters every shift to maintain intravenous patency for 9 days. - intravascular catheter in left forearm, monitor for sign and symptoms of infection, every shift for antibiotic. During an observation on 3/18/2024 at 10:19 AM, 1:55 PM, and 2:41 PM, there was an intravenous pole with a medication pump in Resident #207's room. There was a quarter full medication bag hanging on the intravenous pole. The intravenous tubing in the pump had the end of the tubing looped over the pump without an infection prevention cap. The 3/2024 Medication Administration Record documented ceftriaxone 2 grams intravenously every 24 hours for infection/sepsis/urinary tract infection for 9 days with a start date of 3/13/2024: - ceftriaxone was documented as administered by licensed practical nurse #54 on 3/16/2024 at 11:16 PM, more than 24 hours after the dose was administered on 3/15/2024 at 8:34 PM. - ceftriaxone was documented as administered by licensed practical nurse #31 on 3/17/2024 at 8:51 PM. The next dose on 3/18/2024 was due between 7:51 PM- 9:51 PM on 3/18/2024. The 3/2024 Medication Administration Record documented sodium chloride flush intravenous solution 0.9%, use 10 milliliters intravenously every shift to maintain intravenous access device patency for 9 days with a start date of 3/13/2024. - On 3/15/2024, there was no documentation the sodium chloride flush was administered to the resident's intravenous access device on the day shift. During an interview on 3/20/2024 at 10:55 AM, licensed practical nurse Clinical Care Coordinator #32 stated there should not be any medication left in the intravenous medication bag the next morning after the medication was given, especially if the tubing was disconnected. All medications should be disposed of after use. The pharmacy sent Resident #207's medications with instructions to administer 100 milliliters over 30 minutes. It was important for the resident to receive all the medication from the intravenous medication bag because the lack of medication could cause ineffectiveness. The physician order should include the flow rate/infusion time, but the pharmacy added the instructions to the bag. During a follow up interview on 3/21/2024 at 1:18 PM, licensed practical nurse Clinical Care Coordinator #32 stated Resident #207 had an AccuCath (an intravenous access device), which was a midline catheter and a peripheral venous access device. There was no location to document the medication completion time. The medication was administered over 30 minutes with a flush before and after. The flushes were listed together and only required one administration of the flush to be completed in the medication administration record. During an interview on 3/21/2024 at 5:09 PM, licensed practical nurse #31 stated that an intravenous antibiotic order needed to include the flush, the flow rate/infusion time, and strength. If the order was incomplete, they would call the supervisor or whoever took the order, then call the provider to get clarification. The process for the resident's intravenous medication administration was to flush the intravenous access device with 10 milliliters and check the administration button which triggered the check mark and their initials on the medication administration record, administer the medication, when it was done, they would flush the intravenous access device again. There should not be any medication remaining in the bag when the medication was done infusing. They administered Resident #207's intravenous antibiotic on 3/17/2024 but had the nursing Supervisor assist them. On 3/18/2024, they had assistance from licensed practical nurse #48. Failure to give a full dose of the antibiotic could cause the infection to come back stronger. Licensed practical nurse #31 stated they threw the medication bag away when it was done and thought they had thrown away the medication bag on the night of 3/17/2024. Upon viewing the order in the computer, licensed practical nurse #31 stated the order was incomplete and did not have a flow rate/infusion time. They stated they used the intravenous pump library (saved data from previous administrations) to administer the antibiotics. The registered nurses were responsible for setting up the pumps with the library on their first administration. Licensed practical nurse #31 stated they should have checked the medication, order, and pump together to make sure they all matched. During an interview on 3/22/2024 at 11:11 AM, the Assistant Director of Nursing stated that an order for an intravenous medication should include a flow rate/infusion time. There should not be any medication remaining in the administration bag when the infusion was complete, so the full dose was administrated to the resident. If there was medication remaining in the bag 12 hours after the medication was infused, this would be a medication error and the provider should be notified. If Resident #207 did not receive the full dose of the antibiotic this could be harmful to the resident. During an interview on 3/28/2024 at 9:10 AM, registered nurse #30 stated that a complete infusion of an intravenous antibiotic would mean the medication bag was empty. If medication remained in the bag, it would be considered a medication error. The facility policy was to administer medications in the window of 1 hour before the due time, to 1 hour after the due time. Registered nurse #30 stated they would consider the 3/16/2024 dose a medication error as it was given more than 2 hours past the medication administration window. The latest time the medication should be given would be 9:00 PM. The combination of late medications and incomplete infusions would be considered a significant medication error. This could cause the resident to be more susceptible to infection. During a telephone interview on 3/28/2024 at 12:07 PM, intravenous technician #28 stated that the physician orders should have an infusion rate. Their office had to call the provider to clarify the order. The pharmacy included directions to infuse total contents on the intravenous medications. If a medication was due to be given at 8:00 PM, the nurses had an hour before and an hour after to administer that medication. For a medication given at 11:16 PM, the next dose should have been re-timed to 11:16 PM the following day. During a follow up interview on 3/28/2024 at 1:54 PM, licensed practical nurse Clinical Care Coordinator #32 reviewed Resident #207's Medication Administration Record and stated Resident #207 did not receive all the intravenous flushes every shift as ordered, as 3/15/2024 on the day shift was missing and it should have been done. The antibiotic on 3/16/2024 was given late, as there was a 1 hour before and 1 hour after the ordered administration time to give the medication, this was a medication error. The partial dose given to the resident on 3/17/2024, was also a medication error. They were unaware of any errors with Resident #207's medication administrations. During an interview on 3/28/2024 at 4:16 PM, nurse practitioner #40 stated intravenous antibiotics were an aggressive treatment, and infusion rates should always be included in the order, if not the nurses should contact the provider for clarification. If medication was given more than 2 hours late, or if the resident received a partial dose of the intravenous antibiotic, they expected to be notified. If the resident did not receive their full dose of antibiotic this could put the resident at risk of infection. Nurse practitioner #40 stated they had not been notified of any late or partial doses of antibiotic for Resident #207. The antibiotic was ordered to treat the infection. There could be risk of increased infection if the infection went untreated. During an interview on 3/28/2024 at 4:47 PM, licensed practical nurse #48 stated they assisted licensed practical nurse #31 with the resident's intravenous administration as they were newer at intravenous administration. Resident #207 did not have an infusion rate in their order, therefore was no way to verify the medication. This was a medication error. As a supervisor, they would notify the provider. The additional dose given at 11:16 PM on 3/16/2024 was also a medication error. The provider should have been notified and the following medication administration times should have adjusted. The late dose and partial dose could cause the infection to worsen, and the late dose could cause the next dose to be given too soon. During an interview on 3/29/2024 at 10:18 AM, the Medical Director stated that medication orders should include infusion time/flow rate, it was expected that they would reach out to the provider for clarification. If the antibiotic was given more than 2 hours late or the dose was incomplete, they should be notified. The late dose and partial dose were both medication errors and staff should have notified them, and they did not. During an interview on 3/29/2024 at 10:47 AM, the Director of Nursing stated Resident #207 did not receive their intravenous flushes per physician orders, as they missed a dose on 3/15/2024. Resident #207's intravenous antibiotic was not given timely and accurately according to the physician orders, the dose on 3/16/2024 was out of that range for administration. The provider should have been notified, there should have been a progress note to go along with that communication, and there was not. Based on the lack of documentation, the nursing staff did not get clarification from the provider to give the dose late, and this was a medication error. An incomplete dose of a medication would also be a medication error, and the provider should have been notified. 10 NYCRR 415.12(m)(2)

Based on observation, record review, and interview during the abbreviated survey (NY00301138) the facility did not assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 3 of 3 residents (Residents #1, #2, and #3) reviewed. Specifically, for Residents #1, #2, and #3 there was no documented evidence bed rail assessments were completed, and consents were obtained prior to bed rail installation; there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives prior to bed rail use; and there were no care plans that included the use and monitoring of bed rails. Findings include: The facility policy Assist Rails reviewed 2/5/2019, documented the facility would provide assist rails on beds as indicated to aid the resident in turning, positioning, and bed mobility. Upon resident request and/or determination by nursing and/or rehab that an assist rail is needed, a request will be sent to maintenance to apply the assist rail (s) with specific directions as to which side of the bed the assist rail is needed. Once the resident is no longer utilizing the assist rail to aid in turning, positioning, or bed mobility, notify maintenance to remove the assist rail (s). The risk and benefit of assist rail use will be explained to the resident and/or resident's representative and documented in the progress notes. 1) Resident #1 had diagnoses including Alzheimer's disease and age-related osteoporosis (weak/brittle bones). The 8/23/2022 Minimum Data Set assessment documented the resident had severely impaired cognition, required assistance for bed mobility and transfers, and did not use bed rails. A 8/21/22 facility investigation by former Director of Nursing #6 documented the resident had complained of right wrist pain on 8/20/2022, and there was no observation of bruising or trauma to the right wrist at that time. The morning of 8/21/2022 the resident continued to complain of right wrist pain, and bruising was noted to both arms. An assessment was performed, and an x-ray of the right forearm was obtained which documented an acute fracture of the right distal ulna (bone in forearm). The investigation included the environment was observed for safety concerns, the bed was moved away from the wall, and an assist rail was removed from the right side of the bed as it could have been a potential safety hazard due to the resident's resistive and combative behavior toward staff during care. The comprehensive care plan (CCP) initiated 8/4/2016 and revised on 11/19/2021 documented the resident had an activity of daily living self-care performance deficit related to limited mobility, osteoarthritis, and weakness. Interventions included total assistance for bed mobility, use of maxi slide as needed (a device that assists with repositioning in bed), and bed against the wall per resident's preference. There was no documentation the resident utilized a bed assist rail. The care instructions (Kardex) active on 8/22/2022 did not document the resident had bed assist rails in place. There was no documented evidence the risks and benefits of bed rails were assessed for the resident, were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. 2) Resident #2 had diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) and low back pain. The 11/21/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, required maximal assistance with rolling left to right, going from sitting to lying, lying to sitting, transfers, and did not use bed rails. During an observation on 1/2/2024 at 11:40 AM, Resident #2 was in their room in a wheelchair. There were bilateral bed assist rails on the bed. The resident stated they could use the one on the right side, but not the left due to a stroke. They did not remember being educated on the risks or benefits of bed assist rails. The comprehensive care plan initiated 12/27/2022 and revised on 10/9/2023 documented the resident had an activity of daily living self-care deficit related to limited mobility and deconditioning. Revised interventions on 12/20/2023 included the use of a mechanical lift for transfers, and on 1/2/2024 substantial assistance for bed mobility, and assist rail to aid in turning and positioning with bed mobility. The care instructions (Kardex) dated 1/2/2024 documented the resident required staff assistance with a mechanical lift for transfers and did not include the use of bed assist rails. There was no documented evidence the risks and benefits of bed rails were assessed for the resident, were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. The facility provided a nursing progress note written 1/2/2024 at 4:05 PM by registered nurse #5 documenting the resident had been educated regarding the risks and benefits of using turn position assist rails. 3) Resident #3 had diagnoses including muscle weakness and repeated falls. The 12/16/2023 Minimum Data Set assessment documented the resident had intact cognition, required substantial/maximal assistance for bed mobility, was totally dependent for transfers, and did not use bed rails. During an observation on 1/2/2024 at 11:45 AM, Resident #3 was in their room in a wheelchair. The resident stated staff used a mechanical lift to assist them with transfers. Bilateral 1/4 siderails were observed on the upper half of the bed. The resident stated they used the siderails when turning side to side, did not remember any discussion regarding bed rail risks or benefits. The comprehensive care plan initiated on 10/10/2023 documented the resident had an activity of daily living self-care deficit related to limited mobility and weakness. Revised interventions on 11/16/2023 documented the resident required substantial/ maximal assistance for bed mobility and on 1/2/2024 assist rail to aid in turning and positioning for bed mobility. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. The facility provided a nursing progress note written on 1/2/2024 at 4:06 PM by registered nurse #5 documenting the resident had been educated regarding the risks and benefits of using turn and position assist rails. During an interview on 1/2/2024 at 11:50 AM certified nurse aide #1 stated resident care information was found in the Kardex in the computer and included hygiene, transfers, diet orders, turning and positioning, and need for special equipment. They stated bed rail use was found there, depending on the bed. When turning, a resident could be too close and may bump against the bed rail. They stated bed rails were used for safety, to keep residents from falling out of bed. During an interview on 1/2/2024 at 11:55 AM licensed practical nurse #2 stated care information such as transfers, eating, toileting, assistance required, and special equipment was found on the computer. A few residents had assist rails, and were care planned for them. Residents who could roll themselves may use them, after therapy assessed them for need and ability to use the bed rails safely. Bed rail use would be in the care plan and care card so staff would know. They stated residents could get caught in bed rails, they were not used as fall prevention, and could be considered a restraint. There was a rehabilitation memo book on the unit that contained communication between therapy and the unit on any changes to adaptive equipment. They stated Resident #1 sustained a right arm fracture in 2022 and they thought the fracture could have possibly occurred during care as the resident was combative and may have struck their arm on the bed rail. The care plan was changed to 2 for care and they removed the bed rail at that time to prevent reoccurrence. During an interview on 1/2/2024 at 12:26 PM, physical therapist Director of Rehabilitation#3 stated on admission all residents had an evaluation to determine their assistance needs, ambulation status, and need for assistive devices. A memo was filled out and nursing put it in the care plan. The facility used assist rails and physical therapy evaluated to make sure bed rail use was appropriate. Bed rails had safety risks including entrapment. The evaluation would be documented and communicated to nursing via memo. Nursing completed all care plan additions and subtractions. They stated they were not sure if an order was needed for bed rail use. Resident#3 has been in and out of the facility since September 2023. They stated they were not able to find a siderail evaluation for Resident #3 in the therapy notes. During an interview on 1/2/2024 at 11:50 AM, the Director of Nursing stated care information was found in the computer. Information included diet, ambulation, transfers, bed mobility, assistance needed, special equipment like booties, oxygen, and adaptive equipment. Care plans were typically updated by care managers and information was manually triggered to go to the care card (Kardex). They stated physical therapy communicated with nursing through a paper memo, the information was then added to the care plan by Nurse Managers. Physical therapy assessed residents for use of bed rails, then communicated to staff through the care plan. The care plan was reviewed quarterly. There was no specific reassessment of bed rail use scheduled. Bed rails were only used for turning and positioning, and if a resident could not use them independently, they should not be on their beds. They stated there was no medical order needed, and they were not sure if risk/ benefit education was needed. They stated they did not think bed rails required consent. They were not sure if Resident #1 had a siderail at the time of their ulnar fracture or if there was an assessment or why the assist rail was removed. . During a follow-up interview on 1/2/2024 at 2:53 PM, the Director of Nursing stated therapy should assess a resident for ability to safely use bed rails before being installed. They had been made aware of an issue identified by surveyor with residents not assessed or care planned for siderail use. They were aware care plans had been updated this day. They were not able to find an assessment for Resident #1 for siderail use at time of their ulnar fracture. They were not sure who was responsible for resident education on risk/benefit of siderails but thought it should be Nurse Managers when they updated the care plan. 10NYCRR 415.12(h)(1)(2)

Based on record review and interview during the abbreviated survey (NY00308336), the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was not administered their anticoagulation (prevents blood from clotting) medication (Eliquis) for 29 days and subsequently developed a pulmonary embolism (PE, a blood clot that travels to the lungs where it blocks blood flow). This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The facility policy Electronic Medical Record (EMR)- Physician/Nurse Practitioner/Physician Assistant Orders updated 1/2019 documented the following process for a new order: - The licensed nurse or medical professional would enter new orders under the orders tab in the EMR. - The new order would verify order date and time, category (pharmacy, diagnostic, diet, or other), the communication method used to obtain the order, and the medical professional's name who gave the order. - The order type was selected, medication or treatment and medication category, route of medication, and dose, frequency, schedule, indication for use, select start date and time; and select the end date if the medication is only being given for scheduled time frame. The facility policy Medication Administration System updated 11/2020 documented medications were administered only upon a written order (or verbal) order of a physician/nurse practitioner (NP). A nurse was responsible for questioning a drug order, if, in their judgement the order was in error. Resident #1 had diagnoses including Parkinson's disease (a progressive neurological disease) and acute embolism and thrombosis of deep veins of left lower extremity (DVT, blood clot). The 11/17/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required limited assistance for most activities of daily living, had an active diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE), and received anticoagulation medication daily. The comprehensive care plan (CCP) initiated on 11/9/22 documented the resident was at risk for cardio/pulmonary complications due to hypertension (high blood pressure), congestive heart failure (the heart does not pump blood adequately), Parkinson's disease, and orthostatic hypotension (blood pressure drops when standing up). The CCP was revised on 11/10/22 and documented the resident was admitted with diagnosis of DVT of left lower extremity, PE, pulmonary nodules (small masses in the lungs), and acute respiratory failure/hypoxia (low oxygen levels). Interventions included give medications as ordered, monitor lab work as indicated, and monitor/document/report prn (as needed) signs and symptoms of shortness of breath (SOB) upon exertion, dry cough, increased heart rate, lethargy, and disorientation. The typewritten hospital discharge medication list dated 11/10/22 documented apixaban 5 mg by mouth twice daily for 30 days for pulmonary embolism/DVT, the last dose was documented as given on 11/10/22 at 8:32 AM. 30 days had a black line through it and illegible notes were written in the right margin next to other medications to take. The nursing admission screen (a pre-printed template) dated 11/10/22 by licensed practical nurse (LPN) #10 documented the reason for admission was DVT and secondary PE. The section under medications, orders received from admitting physician, was not checked. The facility's electronically entered physician order dated 11/10/22 at 3:57 PM, documented a telephone order by physician #5 for apixaban 5 mg, anticoagulant; take by mouth, one tablet twice a day for 30 days for PE/DVT; with a start date of 11/10/22 at 7 PM-11 PM, and an end date of 12/10/22 at 6:59 PM. The order was entered by LPN #1 at 3:58 PM. Handwritten physician orders from 11/16/22 through 12/19/22 did not include a renewal order for apixaban and/or an updated order. The 11/16/22 History and Physical completed by physician #5 documented the resident fell at their home in the community and was sent to the hospital. The hospital workup revealed a PE and extensive left leg DVT, and the resident was anticoagulated (given medications to break the clots). The resident had some cramps in their left leg which would awaken the resident early in the morning. Medications were reviewed, continue Eliquis for DVT and PE. The 11/2022 and 12/2022 medication administration record (MAR) documented apixaban tablet 5 mg, give 1 tablet by mouth two times a day for PE/DVT for 30 days with a start date of 11/10/2022. The medication was administered as ordered 11/10/2022 through 12/10/2022. Apixaban was not administered from the 12/10/22 evening dose through 12/31/22. All dates and times from 12/10/22 evening through 12/31/22 were marked with an X (not scheduled to be administered). The 1/2023 MAR did not include an order for apixaban. A nursing progress note dated 1/8/23 at 9:50 AM by LPN #7 documented they were called to Resident #1's room at 8:40 AM for a syncopal episode (fainting). The resident was doing well until they stood up and they said they were going out. The resident was placed back on the bed and went unresponsive. Their body was stiff and had snoring type respirations. They were lifted in bed with the head of the bed elevated. The resident was wearing oxygen at 2 liters via nasal cannula with oxygen saturation in the 60's (percent of oxygen in bloodstream). The resident's oxygen saturation increased to 85%, they did not respond to painful stimuli, and when they opened their eyes, they deviated to the right and were hazed over. The resident was unresponsive for 4 minutes. They started to come around slowly and complained of eye pain and nausea. The resident stated they had a slight headache prior to seeing spots and then passed out. At 9:00 AM, the nursing supervisor was called and assisted with transfer to the emergency room . The physician on call was notified at 9:10 AM with orders to send the resident to the emergency room , and the family was notified of the resident's condition. At 9:11 AM, emergency medical services (EMS) was called for transfer to the emergency room at the hospital. EMS arrived at 9:18 AM and transported the resident to the hospital. A nursing progress noted dated 1/8/23 at 2:56 PM by LPN #7 documented they called the hospital for an update on the resident and the resident was being admitted to the ICU (intensive care unit) for a pulmonary embolism. The 1/9/23 facility medication/treatment incident report documented Eliquis 5 mg twice a day had a stop date ordered in the EMR for 30 days. The resident did not receive Eliquis starting on 12/10/22. As a result, the resident was admitted to the hospital on 1/8/23 with a diagnosis of PE. The Administrator and physician #5 were notified. LPN # 1, the nurse who had input the orders, was removed from care, and put on administrative leave. On 1/9/23 LPN #1 documented in a statement the admission orders were called into physician #5 with the new order for Eliquis for 30 days and they were unable to recall any other details. On 1/9/23 physician #5 was interviewed by the Assistant Director of Nursing (ADON), and they stated they did not order a 30 day stop date for Resident #1's Eliquis (apixaban). The hospital discharge summary documented the resident was hospitalized from 1/8/23-1/18/23. The resident was taken for a CT (computed tomography, a type of Xray) and noted to have decreased responsiveness. Code Blue (emergency response) was called for acute symptoms. A CT of the chest was obtained, and the report documented significant bilateral pulmonary emboli with large amount of thrombus (clot) within the right and left main pulmonary arteries. A decision was made to administer tPA (tissue plasminogen activator, used to break down blood clots). The physician documented the nursing home staff confirmed the resident was not being administered Eliquis prior to admission. During an interview with LPN #1 on 1/17/23 at 1:10 PM, they stated their current position was the Admission/Discharge nurse. Their responsibilities included making sure all medication orders were in place and to check the orders for new admissions. The LPN stated for admissions they reviewed discharge paperwork from the hospital including medication and diet orders, laboratory values and checking for follow up appointments. Once these were reviewed, they would go over the orders with the facility physician. They stated Resident #1 was admitted to the facility with a diagnosis of PE and had an order for Eliquis 5 mg for 30 days to be given twice a day. They stated they understood the doctor was going to switch the resident to aspirin (used as a blood thinner). They notified physician #5 of the start and stop date of the Eliquis order and did not write a progress note. They stated Eliquis was an anticoagulation medication and if the resident missed a dose this would be dangerous and harmful to the resident as it could lead to a blood clot. Resident #1 was sent to the hospital. During the interview the 11/10/22 hospital discharge orders were reviewed with LPN #1. The LPN stated they made the handwritten notes on the discharge orders on the right side margin to verify and note if the med was new or labs were needed when they reviewed them with the doctor. They did not cross out the 30 days. They stated they discussed the orders with physician #5 on the phone. During an interview with physician #5 on 1/18/23 at 1:01 PM, they stated they were aware of the extremely serious medication error with Resident #1. When a resident was admitted the nurse would call the provider to review the ordered medications, lab work and treatments. They said Resident #1's orders were signed off reviewed and approved by them but was unsure of exactly when. Once the orders were entered into the EMR by nurses on the day of admission, they would sign the orders a couple of days later. They stated the nurse did not notify them there was a 30 day stop date for the Eliquis. They would never be okay with a 30 day stop date for a resident with a history of DVT. They said they saw the resident when they first returned from the hospital and in December and overlooked that the Eliquis was not ordered. They stated if an ordered anticoagulant like Eliquis was not given as ordered it could lead to a DVT or recurrent PE. They stated this was what happened to Resident # 1, and they ended up in the hospital. The potential for a life-threatening problem was there when the medication was not administered. Eliquis was a medication that was intended for long term use. They did not order the 30 days stop date and was not made aware of this order. The nursing staff were documenting the resident had a DVT and PE history and they should have clarified the order with the provider. During an interview with the Medical Director on 1/20/23 at 11:58 AM, they stated they were aware of the medication error. The resident was admitted from the hospital with a clot in the leg and lung and should have been on anticoagulation medication. The facility should have questioned the way the hospital wrote the discharge orders for the anticoagulant to be stopped after 30 days. The resident was admitted with this high-risk medication ordered. The resident should have been on this medication lifelong because of their history of PE and DVT. The medication was stopped after 30 days, and the resident was readmitted to the hospital with a PE and for anticoagulation therapy. If a resident with a history of blood clots did not receive their anticoagulant medication, they were at risk to throw another formed clot and at risk for a recurrent DVT and PE. They stated the facility would need to create a process for highlighting high risk medications and ensuring their orders were accurate. During an interview with Director of Nursing (DON) on 1/20/23 at 1:30 PM, they stated they were made aware of the medication error by the Assistant Director of Nursing when the hospital had notified them the resident had been admitted . They immediately started an investigation. They stated LPN #1 was the primary nurse that reviewed the new admission orders, and they were responsible to review the orders with the physician. It was not normal for a resident with DVT history to have a 30 day stop date for their anticoagulant therapy. The medication nurses should have questioned the stop date and the lack of Eliquis. They stated this must have been an oversight due to lack of consistent staff. There were no nursing progress notes, and the nursing staff did not notice this medication had been stopped until the resident was admitted to the hospital. 10NYCRR 415.12(m)(2)

Based on observation, record review, and interview during the abbreviated survey (NY 895) conducted on [DATE], the facility did not ensure the right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 of 4 residents reviewed (Resident #1). Specifically, Resident #1 had a Do Not Resuscitate (DNR, allow natural death) order and received cardio-pulmonary resuscitation (CPR, chest compression's and artificial breathing) when they became unresponsive. CPR was initiated by certified nurse aide (CNA) #5 who was not trained or certified in CPR. After receiving CPR, the resident experienced pain that required medication for relief. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The facility's DNR policy last reviewed and revised on ,[DATE], documented in the event of cardiac or respiratory arrest CPR measures would not be initiated or carried out on a resident with a DNR order. The resident's responsiveness will be determined. Once this has been established, the staff will check the resident's medical record to determine code status. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] and reviewed by medical provider on [DATE] documented the resident had requested a DNR order. The physician order [REDACTED].#1 did not want to be resuscitated. The licensed practical nurse (LPN) progress note dated [DATE] at 11:00 PM, documented, Resident #1 was found slumped in a rocking chair. The resident was unresponsive, with agonal (gasping) breathing and was frothing at the mouth. There was no pulse, the resident's color was dusky, lips were blue, and eyes were rolled back. A vigorous sternum rub was performed without response. Resident #1 was assisted to the floor and another sternal rub was attempted without response. Oxygen was administered via nasal cannula at 5 liters (L), chest compressions were started for ,[DATE] seconds, and the resident started to respond. The resident was suctioned once with thick, white sputum present and the resident was assisted back to bed with a mechanical lift .The Nurse Practitioner (NP) was notified and ordered [MEDICATION NAME] (narcotic pain medication), 5 milligrams (mg) every 4 hours as needed for pain and shortness of breath. The facility's investigation packet dated [DATE] documented on [DATE]: - at 9:27 PM, the resident was found unresponsive, without pulse or respirations. A sternal rub was performed by LPN #3 without response. The resident was checked for an ID band and none was located. LPN #3 went to the nursing station to check the residents code status in the resident's chart and did not see Resident #1 had a DNR order and did not check the resident's MOLST. - At 9:27 PM, LPN #3 called a Code Blue. - At 9:28 PM, CPR was initiated by CNA #5 while LPN #3 called 911 and reviewed the MOLST. - At 9:30 PM, LPN #6 responded to the Code Blue announcement and relieved CNA #5 who was providing compressions. - At 9:33 PM, the AED was turned on; pads were applied, and no shock was advised. - At 9:34 PM, LPN #3 informed LPN #6 and RN #7 the resident had a DNR order. At that time, the resident was assisted to bed via a mechanical lift, placed in an upright position, and suctioned. The resident was responsive and was requesting food/fluids. The medical provider and HCP (Health Care Proxy) were notified. The HCP did not want the resident sent to the hospital, medical interventions or an investigation regarding their respiratory status. Statements attached to the facility investigation documented CNA #5 was interviewed by the Director of Nursing (DON) on [DATE] at 3:35 PM and stated LPN #3 asked her if she knew how to do CPR and she stated no. LPN #3 stated she had to do it anyway. LPN #3 was reeducated and counseled. The Medication Administration Record [REDACTED]. On [DATE] the resident received [MEDICATION NAME], 5 mg as needed at 3:24 AM for pain level of 6 out of 10, and at 7:04 PM for a pain level of 7 out of 10 on the pain scale. LPN #6 was interviewed by telephone on [DATE] at 11:40 AM and stated she heard an announcement of Code Blue and responded to the resident's room where CNA #5 was performing chest compressions on Resident #1. LPN #6 stated she initially thought CNA #5 was tired as she did not do chest compressions correctly. She stated CNA #5 did the compression's too fast and not deep enough, so she asked LPN #3 if she should take over. LPN #6 took over chest compressions and CNA #5 did respirations. Resident #1's color was grey, there was foam coming from the mouth and the resident was not breathing and did not arouse. LPN #6 continued compressions for about 1 ,[DATE] to 2 minutes when RN #7 arrived and applied the AED. No shock was advised, and the resident still did not arouse. The staff mechanically lifted the resident back to bed. Resident #1 had not aroused when she left the room. CNA #5 was interviewed on [DATE] at 3:01 PM and stated she was assigned to care for Resident #1 on the day of the incident. While she was caring for another resident, she heard LPN #3 say Resident #1 had coded. CNA #5 and LPN #3 went to the resident's room and the resident was gasping for air and unconscious. LPN #3 stated the resident had an order for [REDACTED].#3 asked if CNA #5 knew CPR and she told her she did not. LPN #3 told her they had to do it anyway, so she began doing chest compressions and heard a pop. She became concerned she was not doing it right and expressed her concern to LPN #3. She then heard another pop and got scared. At that time, LPN #6 came in the room and took over. Within a minute or two other staff arrived, and the RN Supervisor (RNS) put the AED pads on the resident. LPN #3 came into the room right after the pads were applied and reported the resident had a DNR order. CPR was stopped and the resident was mechanically lifted back to bed. Once in the bed, the resident was suctioned, and she began to arouse. She was not sure how long it all took. LPN #3 was interviewed on [DATE] at 1:15 PM and stated at around 9:25 PM, the Resident #1 came to the door of their room and said they could not breathe and asked for help. LPN #3 assisted Resident #1 to a chair and went to check if the resident had any medication orders to help with breathing. She returned to the room and noted Resident #1 was unresponsive. The resident's color was dusky, and the resident had agonal breathing. She did a sternal rub to get a response and there was none. The resident did not have an ID band on to signify her code status, so LPN #3 went to the chart, looked at the face sheet and did not see a DNR sticker. She saw CNA#5 and told her she needed help. She tried the sternal rub again without response. LPN #3 and CNA #5 placed the resident on the floor and there was no carotid (neck) pulse. The CNA #5 asked if she should start CPR and LPN #3 told her to start compressions at a 30:2 ratio. LPN #3 left the room, called Code Blue and returned with an ambu bag (bag to aid in breathing used during CPR). LPN #6 took over chest compressions. LPN #3 left the room to call an ambulance, opened the Resident #1's chart, saw the MOLST and noted the resident had a DNR order. She immediately went to the room and said the resident had a DNR order. RNS had brought in the AED and the resident was responsive by that time. LPN #3 suctioned the resident for frothy secretions and put the resident back to bed. She stated she had not seen CNA #5 before and did not realize she was not CPR certified. After the incident, the Resident #1 was complaining of pain to the right chest area. DON was interviewed on [DATE] at 11:57 AM and stated during the incident on [DATE], the resident's code status was not identified correctly as a DNR and CPR was initiated by a CNA #5 under the instruction of LPN #3. When interviewed on [DATE] at 12:19 PM, the resident's physician stated the resident had advance directives for DNR that had been in place for approximately 2 years. She was aware the staff-initiated CPR when the resident had a DNR order. After the event, staff alerted her Resident #1 was complaining of pain due to the chest compressions. She stated she would expect staff to honor the resident's advance directive wishes. 10NYCRR 415.3(e)(1)(ii)

Based on observation, staff interview and record review conducted during the extended recertification survey, it was determined for 3 of 5 sampled residents with soft belt restraints (Residents #11, 16, and 27), 1 of 2 residents in the extended survey sample with soft belt restraints (Resident # 33) and one resident outside of the sample (Resident #53), the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents related to the use of physical restraints. Specifically, the QA Committee failed to monitor the plan of action related to inappropriate application of restraints. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident's health and safety for residents with orders for soft belt restraints. Findings include: 1) Resident #11 had 2 falls when a soft belt restraint was in place (February and April 2012) and was observed during survey with the soft belt restraint applied inappropriately. When the Director of Nursing (DON) was interviewed on May 17, 2012 at 3:50 PM and the Administrator was interviewed on May 17, 2012 at 5:50 PM, they were not aware the recommended corrective action (In Service training) had not occurred. The corrective action was in place to train the staff on correct application of soft belt restraints. The soft belt was observed applied in a manner that could result in strangulation. 2) Resident #16 was observed on 2 occasions during the survey with the soft belt restraint inappropriately applied to the geri chair. A soft belt restraint is not recommended to be used in a geri chair, with the possibility of strangulation. 3) Resident #53 was observed during survey with the soft belt restraint inappropriately applied when the resident was seated in a rocking chair, with the possibility of resident strangulation.. 4) Resident #33 utilized a merry-walker and a soft belt restraint. The plan included using the soft belt restraint in a recliner chair, not recommended to be used with a soft belt restraint as it can not be secured, resulting in the possibility of resident strangulation. The DON was interviewed on May 17, 2012 at 3:50 PM. She stated a QA meeting was held on Tuesday (May 15, 2012) and they "touched on" restraints and the training on restraint application. She said she asked the In Service Coordinator for an update and said she saw the referral in a box called "working on". The DON did not recall any other reported incidents of falls related to Resident #11 and the use of the soft belt restraint. The Administrator, who is a member of the QA Committee, was interviewed on May 17, 2012, at 5:50 PM. He stated the last meeting he attended was in April, 2012 and meetings occur monthly. Once a quarter, they have restraint rounds and the last one occurred in January 2012. In summary, the facility failed to provide a QA program that monitored the use of physical restraints with the potential to cause serious harm to the health and safety of residents, following 2 reported incidents related to proper placement and securing of soft belt restraints. For further details refer to tags: F 221 Residents have the right to be free from physical restraints F 323 Residents have the right to be free from accident hazards and receive adequate supervision to prevent accidents. 10NYCRR 415.27

Based on record review, staff interview, and observation conducted during the extended standard survey, it was determined for 4 of 11 residents reviewed with restraints (Residents #2, 11, 16, and 27), 1 of 2 residents in the expanded sample (Resident #33) with soft belt restraints and 1 resident outside of the sample (Resident #53), the facility failed to maintain residents' highest practicable well-being when they: - failed to apply physical restraints appropriately; - failed to monitor the use of the restraints; - failed to ensure restraints were required to treat medical symptoms; - failed to reassess for the least restrictive restraints; and - failed to individualize restraint use for the least amount of time. Specifically, Residents #11 and 16 were physically restrained with geri chairs with soft belts that were applied incorrectly. Resident #27, was restrained, in a wheelchair, with a soft belt that was tied incorrectly. Residents #33 and 53 were restrained with soft belt restraints that were tied incorrectly, in chairs not recommended for the use of soft belt restraints. For Resident #2, there was no documented evidence restraints were required to treat medical symptoms, were reassessed as the least restrictive device, and no documented evidence the resident's surrogate was counseled regarding the risks involved with the use of restraints. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality to resident health and safety for Residents #11, 16, 27, 33 and 53, and resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #2. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY OF February 4, 2010, and February 25, 2011. Findings include: 1) Resident #11 had [DIAGNOSES REDACTED]. The resident was deaf and used sign language to communicate. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, exhibited physical behavioral symptoms toward others 1 - 3 days of the week, and exhibited verbal behavioral symptoms directed toward others 4 - 6 days of the week. The MDS recorded the resident had not limitations in her range of motion and required limited assistance of 1 person for transferring and ambulation. The MDS documented the resident did not utilize any type of physical restraint. A Notification-Restraint Consideration form dated January 19, 2012 documented the resident had a "need for restraint consideration", and requested activities, social services, dietary, physical/occupational therapy and nursing respond immediately. The nursing physical restraint evaluation dated January 19, 2012 documented the resident had falls in the past, attempted to self transfer "constantly" had an unsteady gait, and poor judgement. Nursing recommended a soft belt restraint due to poor judgement, unsteady gait and the history of falls. The assessment did not identify attempts at a less restrictive device. Restraint alternatives documented as explored included: walking the resident when restless, toileting, and providing the resident with different tasks. These alternatives were documented as unsuccessful. The comprehensive care plan dated January 19, 2012 documented the resident had a history of [REDACTED]. Recreation, social services and dietary assessments documented on January 20, 2012, the use of a soft belt restraint would not affect the resident's participation in activities and during meals (it would be released per policy). These assessments documented the soft belt restraint was necessary due to the resident's multiple unsafe self transfers. There was no documentation on these assessments regarding the use of a less restrictive device. The physical therapy/occupational therapy (PT/OT) assessment dated [DATE] documented the resident had worsening of behaviors and commented further testing was warranted to rule out an acute medical issue. Nursing progress notes dated January 20 - 22, 2012 documented the soft belt restraint was in place, the resident attempted to get up, and made several attempts to remove the soft belt restraint. On January 23, 2012 nursing documented the resident was observed "slipping from under her waist restraint" while seated in a dining room chair and was lowered to the floor. Nursing progress notes dated January 25 - February 1, 2012 documented the resident was frustrated with the soft belt, continued to attempt to self transfer, and attempted to remove the soft belt restraint. On February 3, 2012 nursing documented the resident successfully removed the soft belt restraint and it was reapplied. Monthly Restraint Re-Assessments were completed on February 3, 2012. The re-assessment documented the soft belt restraint was to be used at all times when the resident was out of bed. The re-assessments documented the soft belt restraint as the least restrictive device. There was no documented evidence the use of a less restrictive restraint was attempted. On February 4, 2012 nursing documented the resident "undid" the soft belt restraint numerous times. Nursing progress notes dated February 5 - March 9, 2012 documented the resident attempted to remove the soft belt restraint and/or succeeded in removing it on 11 days of 34 days. This included documentation on February 22, 2012 the resident "pulled soft belt" up to her shoulders. Monthly Restraint Re-Assessments were completed March 9, 2012. The re-assessment documented the soft belt restraint was to be used at all times when the resident was out of bed. The re-assessments documented the soft belt restraint as the least restrictive device. There was no documented evidence the use of a less restrictive restraint was attempted. On March 12, 2012, an activities progress note documented the resident seemed more anxious in group activities and was "trying to pull the soft belt restraint over her head." Nursing progress notes dated March 14 - April 1, 2012 documented 8 days when the resident tried to remove the soft belt restraint. These notes described the resident as trying to go under the soft belt, trying to pull the soft belt restraint off, and requesting scissors to cut it off. On April 6, 2012, an activity progress note documented the resident was "difficult to distract from her thoughts and preoccupations of trying to free herself" and was only able to be distracted for "a few minutes" before she resumed "trying to free herself from her soft belt." A Restraint Review was completed by social services and dietary on April 18 and 19, 2012, with no changes documented regarding the use of the soft belt restraint. Nursing progress notes documented the resident's attempts to remove the restraint on April 10, 20 and 21, 2012. On April 24, 2012 nursing documented the resident was observed on the floor leaning against the chair with the "soft belt on resident and chair." On April 30, 2012, the physical therapist documented the resident had a severe decline in her medical course during the past 2 months. The resident had gone from using a wheeled walker for mobility to being "primarily" wheelchair bound with the use of a soft belt restraint. The PT documented the resident was lethargic and unable to tolerate 90 degree sitting. A geri chair was issued for the resident's comfort. The progress note did not document whether or not to continue the use of the soft belt restraint. On May 9, 2012, the physical therapist documented the resident had moved from the use of a wheelchair into a geri chair and then "having to be soft belted" into the geri chair due to restless conduct and attempted transfers. The resident "required two persons extensive assistance and therapy services were not recommended as appropriate at the time." The CareTracker resident profile (an electronic record used by the certified nurse aides for providing care) dated May 16, 2012 documented the resident was issued a soft belt restraint on January 19, 2012 that was to be used at all times when the resident was out of bed. The Care Tracker instructed to release the soft belt restraint "per policy." The Care Tracker documented the resident was issued a geri chair on April 30, 2012 related to the resident's fall risk. The resident was observed throughout survey reclined in a geri chair with a soft belt restraint in place, often under her arms and across her chest. The resident was observed: - on May 14, 2012 at 12:30 PM, in the dining room, in the ger-chair with the soft belt across her chest. The resident was rocking back and forth and pulling herself forward, causing the soft belt to tighten over her chest; - on May 15, 2012 at 8:15 AM, in the dining room, in the geri chair with the soft belt across her chest; and - on May 15, 2012 at 12:25 PM, in the dining room, in the geri chair with the soft belt under her clothing and across her chest. CNA #5, who was familiar with the resident, stated in an interview on May 15, 2012 at 2:50 PM, the soft belt restraint was to be tied "bow tie like" so it could be released quickly in the case of a fire. She said if she observed the resident's restraint across her chest she would have someone (a nursing staff member) help her fix the placement. CNA #5 stated she never saw the soft belt placed under the resident's clothing and stated the resident was no longer supposed to sit in a straight back chair as she had pulled the soft belt restraint over her head. She said that had not happened since the resident used the geri chair. The resident was observed by the surveyor: - on May 15, 2012 from 3:30 PM to 3:40 PM, in the hallway across from the nurses station, reclined in the geri chair, with the soft belt in place over her shirt and across her chest; - on May 15, 2012, the resident was removed from the restraint at 3:50 PM, assisted to the bathroom and returned to the geri chair at 3:55 PM. The soft belt was reapplied under the resident's shirt and across her chest; and - on May 16, 2012 the resident was in the dining room from 12 PM to 1 PM in a geri chair, with the soft belt restraint under her shirt. The belt was untied when the resident was assisted with her meal and was retied when she was done eating. The soft belt was tied around the back of the geri chair and not secured to the chair in any way, to prevent it from sliding up the back of the chair. On May 16, 2012 between 12:55 PM and 1:15 PM, CNA #6 stated in an interview, the soft belt restraint was applied under the resident's shirt because "she would crawl right under it if she could get to it." The resident's attending physician was interviewed on May 16, 2012 at 3:30 PM. She stated the nursing staff contacted her to ask if it was all right to use a restraint as the resident exhibited more frequent agitation. The physician stated staff did not have the time to deal with the resident's behavior of frequent attempts to get out of the chair, "popping up and down". On May 16, 2012, from 5:10 PM to 6 PM, the resident was observed in the geri chair with the soft belt restraint across her chest and under her shirt. The soft belt was tied around the back of the geri chair and not secured to the chair in a way to prevent it from sliding up the back of the chair. On May 17, 2012, at 9:45 AM, the resident was observed in the hallway, reclined in a geri chair with the soft belt restraint applied under her shirt. During an interview with the physical therapist (PT) on May 17, 2012 at 11:50 AM, he stated he was not involved in the initial application of restraints, and usually assessed a restraint after it was in place. He was aware the resident had a physical decline in recent months. He said he had tried the resident with a wheeled walker. The PT stated the resident required a geri chair for comfort and a soft belt restraint was not an "ideal restraint." The PT said a soft belt should not be used when a resident was seated in a geri chair as it had the potential for "excursion" up to the resident's neck. He stated a soft belt restraint had the potential to ride up the back of the chair to the level of the resident's chest. The PT stated he had observed the soft belt at the resident's chest level, retied it, and did not necessarily inform the nursing staff. He stated the Inservice Department was responsible for training the staff on the appropriate way to apply restraints. The therapist stated it was "dangerous" to put the soft belt restraint under the resident's clothing. The Clinical Care Coordinator (CCC), who was a registered nurse (RN), was interviewed on May 17, 2012 at 1 PM and stated the soft belt restraints were to be tied at the resident's waist level. She said the In service Coordinator trained the staff on how restraints were to be applied. She said the resident's restraint should be around the bottom back of the chair, "crisscrossed around her, around the bars and then tied." She stated placing the soft belt under the resident's clothing "worked best" for the resident, depending on the resident's mood. The direct care staff (CNAs) made the decision when to be place the soft belt under the resident's clothing. The Acting Director of Social Services was interviewed on May 17, 2012 at 2 PM and stated the social workers were involved upon implementation of a restraint, and contacted the family for their consent. In summary, the facility failed to ensure the resident's safety related to the use of the soft belt restraint as they: - failed to apply the soft belt restraint correctly, increasing the risk of strangulation; - failed to ensure staff had knowledge of the correct application requirements for the use of the soft belt restraint; - failed to monitor the use of the soft belt restrain to assure it was applied correctly; and - failed to assess restraints by the interdisciplinary team to determine the least restrictive restraint to meet the resident's needs. 2) Resident #16 had [DIAGNOSES REDACTED]. The January 25, 2012 social work progress note documented the resident continued using a geri chair (a chair that prevented self rising) and a soft belt restraint when out of bed for safety. Review of the interdisciplinary progress notes from January 25 -April 11, 2012 contained no documented evidence the resident had unsafe movements or had attempted to stand independently. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. He required total assistance of 2 persons and a Hoyer lift for transferring to chair and bed. The MDS documented the resident was non-ambulatory, required total assistance with all activities of daily living (ADL's) and used a trunk restraint daily. The monthly restraint reassessment dated [DATE] documented the resident was to continue with a soft belt restraint. The April 19, 2012 nursing progress note documented the resident's daughter continued to give consent for a soft belt restraint. The comprehensive care plan (CCP) dated April 19, 2012 documented the resident needed total assistance with bed mobility and had a history of [REDACTED]. The May 1, 2012 nursing progress note documented the resident's condition continued to decline, and a physician order [REDACTED]. The physician orders, dated May 3, 2012, documented the resident was to be in a geri chair when out of bed for comfort and positioning and was to use a soft belt restraint for safety. The soft belt restraint was to be released per policy. The May 10, 2012 speech pathologist progress note documented the resident had periods of extreme lethargy and was difficult to arouse. The current undated certified nurses aide (CNA) kardex documented the resident required the assistance of 1 person; had a chair alarm; was to sit in a geri chair; and use a soft belt restraint when out of bed. On May 15, 2012 at 10 AM and 12:05 PM the resident was observed sleeping in the hallway in his reclined geri chair with a soft belt restraint tied across his waist and around the middle of the geri chair and not secured to the chair to prevent it from moving up the back of the chair. The resident was observed on May 15, 2012 at 5:15 PM in the hallway in a geri chair with a soft belt restraint tied around the middle of the geri chair and not secured to the geri chair to prevent it from moving up the back of the chair. On May 16, 2012 at 8:45 AM the surveyor interviewed CNA #10. The CNA stated the resident was total care and his condition had declined recently. She stated he was to wear a soft belt restraint when in the geri chair and it took 2 staff to apply it. She stated that she learned how to use restraints in CNA training class. She said residents' primary CNAs kept track of the restraint and when it was released. On May 16, 2012 at 9:10 AM, the surveyor interviewed the registered nurse (RN) Clinical Care Coordinator (CCC). She stated the interdisciplinary team decided when a restraint was to be used and physical therapy decided what type of restraint to use. She stated reassessment of the restraint was done every quarter and if there had been no attempts by the resident to self transfer, they would try the resident without the restraint. The RN said the geri chair for this resident was not a restraint that it was for comfort and mobility. She stated there was a basic way to tie the soft belt restraint and it was the responsibility of all manager's to ensure they were tied correctly. The RN said if she found a restraint that was not tied correctly she would have the CNA inserviced. She stated she expected the soft belt to be tied at waist level. On May 16, 2012 at 5:55 PM, the resident was observed seated in the geri chair with the soft belt tied around the back of the chair at waist level, not secured to the chair. In summary the facility: - failed to ensure the safety of the resident as the soft belt restraint was not applied correctly, increasing the risk for strangulation. - failed to ensure assessment and care planning was completed for the use of a trunk restraint in conjunction with a chair that prevented self rising; and - failed to ensure a reassessment was done following a decline in resident's condition. 3) Resident #2 had [DIAGNOSES REDACTED]. The current facility policy "[MEDICAL CONDITION] Precautions" updated August 2005 documented a "rail pad" was to be placed "inside of side rails" for residents at risk for [MEDICAL CONDITION]. The resident's latest Monthly Restraint Re-Assessment, dated January 4, 2012, did not document the use of side rail restraints. The annual Minimum Data Set (MDS) assessment, dated March 14, 2012, documented the resident had severe cognitive impairment; required extensive assistance for all activities of daily living; was non-ambulatory; and had no physical restraints. The comprehensive care plan, updated March 28, 2012, documented the resident had 4 half padded side rail restraints due to a history of [MEDICAL CONDITION] "per family request." physician's orders [REDACTED]." During the initial unit tour at 10:30 AM on May 14, 2012, the registered nurse (RN) Unit Manager stated there were no residents on the unit who had side rail restraints. At 12:10 PM on May 14, 2012, a surveyor observed the resident sitting in a geri chair in her room. Attached to her bed were 4 half side rails covered by green pads measuring 15 inches in height x 34 inches in length. At 3:25 PM on May 14, 2012, a surveyor observed the resident lying in bed with 4 elevated, padded side rails and 3 large pillows in the bed. CNAs #1 and 2 were in the room, and stated the resident had 4 padded side rails because she used to try to climb out of bed when she resided on another unit. They said the resident no longer moved in bed, and the padded side rails were used per a family member's wishes. During an interview with the RN Unit manager at 3:30 PM on May 15, 2012, she stated that she found no documented evidence that the resident had [MEDICAL CONDITION] activity within the past year. She stated the facility did not use solid pads on the side rails of residents with [MEDICAL CONDITION] precautions, and instead applied foam covering to individual rails. The Care Tracker resident profile, dated May 15, 2012, used by certified nurse aides (CNAs) to provide care, documented the resident was to have 4 elevated side rails covered with green pads whenever she was in bed. At 11:15 AM on May 17, 2012, a surveyor interviewed the Administrator and RN Unit Manager. The administrator stated that approximately 2 years ago, the facility removed the solid pads from side rails and replaced them with high density foam insulation. This was installed by maintenance on individual rails to protect residents from injury during [MEDICAL CONDITION]. He stated the facility no longer used the solid padding because it reduced residents' vision when in bed. The RN stated the facility policy should be changed to reflect the facility's current practice. She stated she had not discussed with the resident's family the use of individual rail padding rather than solid padding. During an interview with the physician at 3:45 PM on May 16, 2012, she stated the resident should have minimal restrictions rather than fully padded side rails. In summary, the facility did not ensure the resident was free from an unnecessary physical restraint, as: - the interdisciplinary team did not re-assess the resident for the continued need for the restraint, and provide restraint reduction; and - there was no evidence the resident's family was counseled regarding the potential side effects of the fully padded side rails. 10 NYCRR 415.4 (a)(2)(iv),(3)(i-iii) .

Based on record reviews, staff interviews, and observations conducted during the extended standard survey, it was determined for 3 of 5 residents (Residents #11, 16, and 27) reviewed for restraints, for 1 of 2 residents in the expanded sample (Resident #33) and for 1 resident out side of the sample (Resident #53), the facility failed to ensure the safety of the residents when they: - failed to identify staff lacked knowledge of the correct application requirements for soft belt restraints; - failed to educate staff in a timely manner on the correct application of soft belt restraints, after the restraint was applied incorrectly; and - failed to provide supervision to the residents who were restrained with a soft belt. Additionally the facility did not ensure 1 of 1 resident (Resident #1) reviewed for unsafe wandering received adequate supervision to prevent accidents. Specifically, For Resident #11, staff were not inserviced in a timely manner on correct application of soft belt restraints. Residents #11, 16, 33 and 53 were observed with the soft belt restraints applied incorrectly while seated in chairs not recommended for use with soft belt restraints. Resident # 27 had a soft belt applied incorrectly without proper staff training in the application of the restraint to prevent injury. For Resident #1, the facility did not develop and implement interventions in a timely manner to monitor the resident whereabouts. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for the health and safety of Residents #11, 16, 27, 33, and 53, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #1. Findings include: 1) Resident #11 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) documented on January 19, 2012, the resident had a history of [REDACTED]. Nursing progress notes dated January 20, 2012 through February 20, 2012 documented the resident frequently attempted to get up and attempted to remove the soft belt restraint. Some examples included: - on January 23, 2012 the resident was observed "slipping from under her waist restraint"; - on February 3, 2012 the resident successfully removed the soft belt restraint and it was reapplied; and - on February 4, 2012, the resident "undid" the soft belt restraint numerous times. On February 21, 2012, nursing documented the resident was "found on floor in front of" her wheelchair. The chair alarm did not sound at the time and the soft belt restraint was in place. A Quality Assurance Accident/Incident Report was initiated on February 21, 2012 and documented the resident was found on the floor leaning against the wheelchair. The softbelt restraint was tied and intact. The chair alarm was in place and did not sound. The battery was changed in the chair alarm and the resident was placed in a high back chair with a soft belt restraint. On February 22, 2012 nursing documented in a progress note, the resident pulled the soft belt restraint up to her shoulder. Nursing progress notes dated February 23, 2012 through April 10, 2012 documented the resident's frequent attempts to remove the soft belt restraint. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and exhibited behavioral symptoms not directed toward others 1 to 3 days of 7 days. The resident required extensive assistance with activities of daily living and used a trunk restraint daily. On April 24, 2012 nursing documented in a progress note the resident was observed on "hall floor leaning against chair." The soft belt restraint was described as on the resident and the chair. A Quality Assurance Accident/Incident Report was initiated on April 24, 2012 and documented the resident was found sitting upright on the floor in front of the chair with the softbelt "still attached" and the alarm sounding. The report concluded there was no evidence of abuse, neglect or mistreatment as the resident had a history of [REDACTED]. The resulting intervention included having "all staff on the unit in-serviced on proper placement and securing of soft belt restraints." The report documented this was to be done through the inservice department. On April 26, 2012, the registered nurse (RN) Clinical Care Coordinator (CCC) completed an "Inservice Referral Form" requesting an inservice for the South 3 unit staff on all 3 shifts, including nurses. The reason documented for the referral was "due to resident's sliding out of chair- inservice is needed on how to correctly apply and tie a soft belt restraint." Nursing progress notes dated April 29, 2012 through May 5, 2012 documented the resident continued to attempt to remove the soft belt and tried to get up out of the chair. On May 15, 2012 at 2:50 PM certified nurse aide (CNA) #5 was interviewed as she was familiar with the incident from April 24, 2012. She stated at the time of the incident, the softbelt was on the resident and remained tied to the chair. Her understanding was the belt was not tied "good enough." She stated she was trained how to apply the restraint when she was first trained as a CNA and had not had any recent training. On May 17, 2012 at 2:10 PM the Infection Control RN who assisted the Staff Educator was interviewed with the Director of Nursing (DON) as the Inservice Coordinator was unavailable. The Infection control RN stated she was aware a recent inservice was done with the South 3 unit staff because of a resident incident and she was not sure if staff attendance was documented. The DON stated in an interview on May 17, 2012 at 3:50 PM, she was not aware the inservicing of South 3 unit staff had been done and she "oversees" the inservices. She stated the inservice for the incident on April 26, 2012 should have been done as it involved resident safety. CNA #9 was interviewed on May 17, 2012 at 5 PM and stated she had worked in the facility for less than 1 year and had no recollection of being inserviced on restraint application. She stated the Staff Educator was going to show her how to apply a soft belt restraint and did not, so the other CNAs and a nurse showed her how to apply it. Although she was not working on South 3 at the time of the interview, she stated she was generally assigned to that unit and soft belt restraints were used regularly. When CNA #5 was interviewed on May 17, 2012 at 5:05 PM, she stated she had worked at the facility for 2 to 3 years, received the annual mandatory training at the facility which did not include application of restraints. On May 17, 2012 at 7:30 PM, the DON stated in an interview, she was aware of Resident #11's incident in April (April 24, 2012) and could not recall any other fall involving a restraint, prior to that one. She stated she would have to look into it. The resident was observed during survey from May 14, 2012 through May 17, 2012 out of bed, with the soft belt restraint in place, seated in the geri chair. The soft belt was observed tied around the resident's chest area, either over her clothing or under her clothing, and was tied around the chair in various ways. For example; - May 14, 2012 at 12:30 PM in the dining room in the ger-chair with the softbelt around the resident's chest. The resident was rocking back and forth and pulling herself forward, tightening the belt on her chest; - May 15, 2012 at 8:15 AM in the dining room in the geri chair with the softbelt around her chest; - May 15, 2012 at 12:25 PM in the dining room in the geri chair with the soft belt under her clothing and around her chest; - May 15, 2012 from 3:30 PM to 3:40 PM reclined in the geri chair with the soft belt in place over her shirt and around her chest; - May 15, 2012 at 3:50 PM, the resident's restraint was removed and at 3:55 PM it was reapplied under her clothes and around her chest; and - May 17, 2012 at 1 PM and again from 5:10 PM to 6:00 PM with the soft belt under her shirt and the belt tied around the back of the ger chair not secured to the chair in any way to keep it from sliding up the back of the chair. At 4:05 PM on May 18, 2012, the Staff Educator was interviewed regarding the restraint inservice. She stated she was not aware of the incident that occurred with Resident #11 on April 24, 2012 and did not know why she received the referral to do training. She stated she planned on doing it "next week" (week of May 21, 2012). She stated the CCC asked her why it had not been done and she stated she "had not gotten to it yet" as her orientation schedule was every other week and she had to do it when she could schedule it. She stated the CCC told her she needed to do it, however did not explain the reason. The manufacturers specifications for the soft belt restraint (Posey Soft Belt) were provided during survey and included the following information: - improper application, or use, of any restraint may result in serious injury or death; - staff must have ongoing training to be able to demonstrate competency in the device; - there was a risk of chest compression, or suffocation, if the resident's body was suspended off the chair; and - monitor "per facility policy" to ensure the resident cannot slide down or fall off the chair and become suspended or trapped. In summary the facility: - failed to ensure the safety of the resident as staff lacked knowledge of the correct application requirements for the soft belt restraint; - failed to educate staff in a timely manner on the correct application when the restraint was not applied correctly; and - failed to provide supervision to the resident when restrained with the soft belt. 2) Resident #53 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) documented on September 22, 2011, a softbelt restraint was used when the resident was out of bed related to unsafe, unassisted transfers and gait. The CCP documented the soft belt restraint was to be released per policy. The social services progress note dated February 21, 2012 documented the social worker contacted the residents family member for approval of the soft belt restraint in the chair. On February 22, 2012, physical therapy documented the resident "is in a wheelchair with a restraint in place." A monthly restraint note dated February 23, 2012 documented "continues to utilize a softbelt out of bed for unsafe unassisted transfers, softbelt is released per policy." The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired, the resident used a wheelchair for mobility and a trunk restraint daily. The physician's orders [REDACTED]. May rest up to two hours with restraint on." The interdisciplinary progress notes from February 24 through May 14, 2012 did not document the soft belt was used when the resident was in a glider chair or that the resident used a glider chair. In an interview on May 17, 2012 at 4:45 PM the registered nurse (RN) Clinical Care Coordinator (CCC) stated the resident used a soft belt restraint in a glider chair. At that time, the certified nurse aide (CNA) #8, assigned to care for the resident that evening, showed the surveyor the resident, who was sitting in a glider chair near nurses station with a soft belt restraint in place. CNA #8 demonstrated for the surveyor how the soft belt was placed on the resident while in a glider chair. CNA #8 placed the soft belt across the front of the resident, under her shirt and over her under shirt. CNA #8 crossed the straps behind the resident's back, brought the straps around the cushion of the glider above the arm rests and stated that was done so the straps were between the crease of the cushion and the arms rests. She stated this was to prevent the straps from sliding up. CNA #8 tied the straps in a knot in back of the chair, and said the soft belt restraint was tied correctly. CNA #8 said she received training in another state, but while at this facility, she received inservice and was provided with a work sheet and a picture. The resident was observed on May 17, 2012 at 6:20 PM sitting in a glider chair with the soft belt restraint tied around the back of the chair at the level of the resident's abdomen. The restraint was not tied to the frame of the glider chair, and at this time CNA #8 stated the soft belt was tied correctly. CNA #8 stated the resident did not "really move" unless she was "antsy," and the chair alarm would sound. The manufacturers specifications for the soft belt (Posey Soft Belt) were provided during survey and included the following information: - improper application, or use, of any restraint may result in serious injury or death; - staff must have ongoing training to be able to demonstrate competency in the device; - there was a risk of chest compression, or suffocation, if the resident's body was suspended off the chair; and - monitor "per facility policy" to ensure the resident cannot slide down or fall off the chair and become suspended or trapped. There was no documented support for use of a soft belt in a glider chair by the resident's physician or in the resident's medical record. In summary, the facility: - failed to effectively assess the risk related to the use of the soft belt restraint in a glider chair, - failed to evaluate and implement interventions appropriate to prevent future hazards, - failed to educate and train staff in a timely manner on the correct use of restraint when restraint was not used effectively. 3) Resident #1 had [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented wandering behavior occurred daily. The elopement/wandering risk assessment dated [DATE] documented the resident was at risk for wandering. The social services progress note dated January 3, 2012 documented "she spends time ambulating the merry walker around halls and common areas (has no sense of safety or awareness of direction)." The accident and incident report dated March 22, 2012 at 4:15 PM, documented the resident was observed exiting the elevator on the South 1 Unit. The report documented the licensed practical nurse (LPN) was at her medication cart and looked down the hall towards the lobby, the elevator doors opened and "out came this resident." The report documented the resident was last toileted by staff at 4 PM and was last seen by staff at that time in the lobby area. The report documented staff were instructed to do 15 minute checks on the resident. The LPNs' statements dated March 21 and 23, 2012 documented staff were not aware of how the resident got on the elevator, the elevator door opened on the first floor and the resident was there in her merry walker. There was no documentation of how the resident got on the elevator or when she left the floor. The certified nurse aide's (CNA) statement dated March 22, 2012 documented the CNA was on break and did not see anything. The comprehensive care plan (CCP) dated March 23, 2012 documented the resident wandered in a merry walker. Approaches included 15 minute checks and try to keep the resident in eye sight when she was in the Merry Walker. The CCP did not specify whether the 15 minute checks were to be done for that evening only or on an ongoing basis. No additional interventions or approaches were documented. A copy of the 15 minute check flow sheet dated March 22, 2012 from 4:30 PM to 11:15 PM showed no documented evidence 15 minute checks of the resident were completed after 11:15 PM on March 22, 2012. On March 23, 2012 a new Elopement/Wandering Risk Assessment was completed and documented the resident was at risk for wandering. This was unchanged from the Elopement/Wandering Risk Assessment done in December 2011. The quarterly MDS assessment dated , March 28, 2012 documented the resident's wandering behavior occurred daily and the resident's cognitive status was severely impaired. During an interview with surveyor on May 15, 2012 at 10 AM, the RN CCC stated she placed a wanderguard on the resident's Merry Walker that morning. At that time, the surveyor observed a wanderguard on back left post of the resident's Merry Walker. Review of the medical record revealed no documented evidence the Elopement/Wandering Assessment was updated regarding the placement of a wanderguard on the resident. There was no documentation in nursing progress notes that the wanderguard was applied. The CCP, updated on May 15, 2012, documented "Wanderguard bracelet on merry walker to lock elevator when resident is near - no need for 1/2 hour checks d/t resident able to safely wander." No additional approaches were documented. The CCP did not have a Wander Risk Sticker on May 15, 2012. The facility's wandering/elopement policy revised in October of 2011 defines safe wandering as a "Resident has capacity and cognitive ability to recognize hazards or danger." An interview was conducted with CNA #4 on May 16, 2012 at 1:20 PM. She stated "if she leaves the unit we have an alarm now. That's our clue to go and get her." The CNA stated 15/30 minute checks were recorded on sheets that were kept in a folder on the nursing unit. During an interview with the RN CCC on May 16, 2012 at 1:25 PM, she stated "it would be very hard to elope with a Merry Walker," "Her risk was relatively low." The RN stated the resident was on "15 minute checks for that night" in regards to resident's incident of unsafe wandering. During an interview with the RN CCC on May 16, 2012 at 1:25 PM, she stated she placed the resident on half hour checks, while in the Merry Walker, on May 15, 2012. On May 17, 2012 at 10 AM a surveyor asked CNA #7 for a copy of the half hour check flow sheet. A copy was provided documenting checks at 7:15 AM, 8:45 AM and 9:15 AM. The CNA stated he completed the checks every half hour and he would be completing one in about 10 - 15 minutes. There was not a documented check for 9:45 AM time. On May 17, 2012 at 10:00 AM CNA #4 who provided the resident's care on May 16, 2012, gave a copy of the half hour checks to the surveyor upon request. The check list was from the 7:30 AM - 3 PM shift. A folder was set up on May 17, 2012 by CNA to hold check flow sheets as the A side unit did not have one prior to this date. On May 17, 2012, the surveyor requested copies of all CNA check flow sheets that were completed for the resident from the RN CCC. The RN stated to the surveyor on May 17, 2012 at 10:31 AM she did not have any other check flow sheets for the resident and "It is possible a staff member brought it home with them in their pocket." The RN stated the checks were only when the resident was in the Merry Walker not when she was in bed. There were no documented checks sheets provided for the date the wanderguard was placed May 15, 2012 for any shift and there was not a documented check flow sheet provided for 3-11 shift on May 16, 2012. The facility's Wandering/Elopement Evaluation Protocol revised in October 2011 documented: - The CCP is individualized with specific interventions; - The CCP contains wander risk sticker; - The resident is placed on wander list at nurses station; - If a resident receives a wanderguard: Residents location will be checked every 1/2 hour, staff will check for wanderguard one time each shift. Document in Care Tracker. In summary the facility: - did not effectively assess the resident's elopement risk; - did not evaluate and implement interventions in a timely manner to prevent future unsafe wandering events; and - did not monitor the effectiveness and modify interventions as necessary. 10 NYCRR 415.12 (h)(2)

Based on observation, staff interview, and record review conducted during the extended recertification survey, it was determined for 3 of 5 sampled residents (Residents #11, 16 and 27) who utilized soft belt restraints, 1 of 2 residents (Resident #33) in the extended survey utilizing soft belt restraints, and 1 resident out side of the sample (Resident #53), the facility's administration failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards. Specifically, the facility failed to have a system in place to: - ensure staff had the knowledge of the correct application requirements for the use of soft belt restraints; and - ensure staff monitored the use of the soft belt restraints to assure they were applied correctly and did not pose a significant risk for strangulation. This resulted in no actual harm with potential for serious harm to resident health and safety that was Immediate Jeopardy and Substandard Quality of Care for Residents #11, 16, 27, 33 and 53. Findings include: The Director of Nursing (DON) was interviewed on May 17, 2012 at 3:50 PM and stated: - she was aware of the incident that occurred in April, 2012 with Resident #11 and did not think the inservice training had occurred as there was no documented evidence of the training and the certified nurse aides (CNAs) did not recall being trained; - the inservices were not completed in a timely manner as the incident involved resident safety; - she oversees the in-services and it previously had been the Assistant Director of Nursing's (ADON) responsibility; - she did not recall a second incident with this resident related to the use of the restraint; and - she did not know if all CNAs provided a repeat demonstration of restraint application when inserviced annually on restraints. There had been a change in the in-service department within the past year. The Administrator was interviewed at 5:50 PM on May 17, 2012. He stated: - he was aware of one incident with the use of a restraint in April, 2012 and that staff were to be inserviced; - he was not aware of any other incidents with the resident involved in the April 2012 incident; - he was not aware of any ongoing problem with the use of the soft belt restraints; - he was aware of other concerns with restraint use and stated the problems were addressed by the interdisciplinary team; and - he was aware of problems as he signed the incident/accident reports and did quarterly restraint rounds. In summary, the administration failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards, as they failed to have a system in place to thoroughly monitor and supervise the residents utilizing physical restraints and failed to educate staff on the appropriate use and application of restraints. For further details refer to tags: F 221 Residents have the right to be free from physical restraints; F 323 Residents have the right to be free from accident hazards and receive adequate supervision to prevent accidents. 10NYCRR 415.26(a)