Every finding on record at Woodbury Heights Nursing and Rehabilitation Center

Based on observations, record review, and interviews the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, in language that he or she can understand. This was identified for one (1) of one (1) resident (Resident #11) reviewed for communication. Specifically, Resident #11 primary spoken language was other than English. During a medication administration observation on 04/13/2026, Licensed Practical Nurse #8 did not utilize a language interpretation service or communication board and misinterpreted the resident's statements as a refusal of the prescribed eye drops.The findings include: The facility policy for communication last reviewed on 01/2026 documented to accommodate needs when communicating with residents who are deaf, or otherwise Limited English Speaker (LEP) to promote dignity, understanding, and safety. Effective communication ensures that information is provided to the resident in a form and manner that the resident can access and understand. The facility policy for Residents Rights reviewed on 01/2026 documented the facility will inform the resident both orally and in writing, in a language that the resident understands, of their rights, and all rules and regulations governing resident conduct and responsibilities during this stay in the facility. [Residents have] the right to be fully informed in language that he or she can understand their total health status, including but not limited to, their medical condition. Resident #11 was admitted with diagnosis type diabetes mellitus, major depressive disorder, dry eye syndrome of unspecified lacrimal gland. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a brief interview for mental status score of 11, indicating the resident had moderately impaired cognition. The Minimum Data Set assessment documented the resident usually understand others, misses some part/intent of message but comprehends most conversations. The Minimum Datata Set assessment indicated the resident's preferred language was Turkish. The physician's orders last renewed on 03/17/2026 documented carboxymethylcellulose sodium lubricant eye drops 0.5%, instill 1 drop by ophthalmic (eye) route in each eye, two times a day for dry eye syndrome. The care plan titled communication language barrier status initiated on 10/09/2025 documented the resident's native language is Turkish. Interventions included encouraging use of a communication board during activities of daily living and care, meet and anticipate all needs, and obtain an interpreter as needed. During an observation and interview on 04/09/2026 at 10:20 AM, Resident #11 was lying in bed. The resident primarily communicated in Turkish. Resident #11 reported feeling frustrated because they were unable to communicate effectively with staff and did not receive needed care due to the language barrier. Resident #11 stated the facility staff did not utilize a translation service or any other language assistance tools. There was no communication board in the room at the time of the observation. During an interview on 04/09/2026 at 10:40 AM, Resident #11's family member stated the resident did not speak English and had difficulty communicating with staff. The family member expressed concern that the resident may not consistently receive necessary care, including medications, due to the language barrier. The family member stated a communication board, with pictures, was available; however, staff did not consistently utilize it and sometimes the board was not in the resident's room. The family member stated the communication board alone was insufficient to meet the resident's communication needs. During a medication administration observation on 04/13/2026 at 09:07 AM, Licensed Practical Nurse #8 approached Resident #11 with carboxymethylcellulose sodium lubricant eye drops. Resident #11 spoke to Licensed Practical Nurse #8 in Turkish. Licensed Practical Nurse #8 stated they did not understand the resident and interpreted the resident's body language as a refusal and did not administer the medication. Resident #11 continued an attempt to communicate through verbal statements and gestures, including pointing to their eye and gestured [one (1) drop] by lifting one finger. Licensed Practical Nurse #8 did not attempt to utilize the language interpreter services or a communication board. Despite the resident's efforts, Licensed Practical Nurse #8 continued to state that the resident was refusing the medication. Resident #11 stated in Turkish, I will not get my eye drops again, they do not understand me. During an observation on 04/13/2026 at 09:55 AM, Licensed Practical Nurse #8 reapproached Resident #11 to administer prescribed eye drops. Resident #11 raised one finger and used their left hand to open their eyelids, indicating a request for one drop. The resident was speaking in Turkish and stated they want one eye drop into each eye and that the eye drops help with their eye movements. Licensed Practical Nurse #8 stated that Resident #11 was still refusing eye drop medication. Licensed Practical Nurse #8 did not attempt to utilize language interpreter services or a communication board. During an interview on 04/14/2026 at 12:50 PM, Registered Nurse Unit Manager #1 stated they were not aware of Resident #11's language barrier. Registered Nurse Unit Manager #1 stated a communication board was in the resident's room and the language interpreter service was also always available to staff. Registered Nurse Unit Manager #1 stated Licensed Practical Nurse #8 should have utilized the language interpreter service in conjunction with the communication board to effectively communicate with Resident #11 and ensure the residents' needs were met. During an interview on 04/14/2026 at 01:13 PM, the Director of Nursing Services stated that staff are expected to follow the facility policy by utilizing language interpreter services when needed to effectively communicate with the residents and ensure the residents receive necessary care. During an interview on 04/16/2026 at 01:49 PM, the Administrator stated that staff are expected to follow facility's policies and utilize all available resources to ensure residents receive appropriate care. The Administrator stated it was not acceptable for staff to rely solely on their interpretation of body language rather than utilizing available communication resources. 10 New York Code Rules and Regulations 415.3(f)(1)(i)

Based on observations, record review, and interviews during the survey, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical and nursing needs. This was identified for one (Resident #248) of one resident reviewed for respiratory infection and for one (1) (Resident #112) of two (2) residents reviewed for choices. Specifically, 1) Resident #248 complained of cough and sore throat and had a physician's order to administer the nebulizer medication (medication to open airways or reduce inflammation) for five (5) days. There was no documented evidence that a comprehensive care plan was developed to address the newly developed respiratory symptoms. Additionally, licensed nurses continued to administer the nebulizer treatment after the physician's order was completed. 2) Resident #112 had an appointment for radiology services on 04/09/2026 as per the physician's order. The resident was unable to attend the appointment because a certified nursing assistant was not available to accompany the resident required by the radiology facility. This is a repeat deficiency. The findings include: 1) The facility's policy titled, Comprehensive Care Plan, last reviewed in January 2026 documented that the interdisciplinary team will utilize the comprehensive person-centered care planning process to address resident's strengths, needs, and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the physician. The comprehensive person-centered care plan will be reviewed and revised episodically, as plan of care changes. Each discipline will be responsible to keep the comprehensive person-centered care plan current and update the care plan when a new problem/goal/intervention is identified. Resident #248 was admitted with diagnoses including cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture), legal blindness, and major depressive disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated intact cognition. Resident #248 had no active pulmonary diagnosis and did not receive any respiratory treatment. A review of the progress note dated 04/04/2026 documented that resident complaint of cough and sore throat. The Physician was notified and ordered vital signs every shift for five days and Mucinex (an expectorant) 600 milligrams twice a day for four days. A review of Resident #248's Comprehensive Care Plan revealed there were no care plan to address resident's newly developed respiratory concerns including interventions for those concerns. A review of the progress note dated 04/06/2026 documented that Resident #248 was evaluated by the Physician and ordered Duoneb (inhalation medication to relax airway muscles) every morning and at bedtime for congestion. A Physician's Order dated 04/06/2026 documented DuoNeb 0.5 milligrams – 3 milligrams (2.5millligram base)/3 milliliters solution inhale three (3) milliliters every 12 hours for five (5) days for wheezing. The order was to be completed on 04/11/2026. A review of the April 2026 medication administration record documented the nebulizer treatment was administered from evening on 04/06/2026 to evening on 04/13/2026. The order was to be completed on 04/11/2026 during the evening shift (3:00PM – 11:00PM). During an observation on 04/09/2026 at 11:43 AM, Resident #248 was seated in their wheelchair inside their room, and the residents expressed that they were not able to see. A nebulizer kit was observed, in a clear bag, connected to an oxygen tank. During an interview on 04/14/2026 at 09:51 AM, Physician #1 stated that Resident #248 complained of being unable to cough up their sputum and they ordered Duoneb for five days on 04/06/2026. Physician #1 stated they did not extend the medication and the Duoneb should be discontinued after five days. Physician #1 stated that nurses should notify them to re-evaluate if the resident's symptoms persisted and that nurses should administer medications according to physician's order. During an interview on 04/14/2026 at 10:52 AM, Licensed Practical Nurse #3 stated they did not administer nebulizer treatment to Resident #248 on 04/13/2026 and signed the medication administration record in error. During an interview on 04/14/2026 at 02:23 PM, Registered Nurse #2 stated an episodic care plan should have been developed for Resident #248's new onset of respiratory symptoms of coughing and sore throat. Registered Nurse # 2 stated they did not administer the nebulizer treatment to Resident #248 on 04/12/2026 and signed the medication administration record by mistake. Registered Nurse # 2 stated they were aware of their mistake and that they got distracted and forgot to correct their mistake. During an interview on 04/16/2026 at 10:06 AM, the Director of Nursing Services stated that a care plan should have been developed to address the resident's recent respiratory episode. The Director of Nursing Services stated nurses should follow physician's order and should not administer any medication including the nebulizer treatment beyond the indicated timeframe. 2) The facility policy titled, Medical Appointments last reviewed 02/2026 documented if upon review, the interdisciplinary team determines that a resident requires an escort support to ensure their safety, the consultation will indicate an escort is needed. The consultation form will be forwarded to the medical suite to coordinate transportation and an escort. Resident #112 has diagnoses that include prostate cancer and benign prostatic hyperplasia (an enlarged prostate). The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The Minimum Data Set assessment documented the resident was independent in their ability to transfer to and from a bed to a chair (or wheelchair) and required supervision or touching assistance when getting on and off a toilet or commode. The Medical Attending Note dated 03/31/2026, written by Primary Physician #1, documented the resident was seen by an outside Urologist. The outside Urologist requested for the resident to have a Magnetic Resonance Imaging of the pelvis with and without intravenous contrast, due to a palpable penile nodule. The Physician Order dated 04/01/2026 last renewed on 04/11/2026 documented a Magnetic Resonance Imaging(a medical technique used in radiology technique to generate pictures of the anatomy and the physiological processes inside the body)/Magnetic Resonance Angiography (a type of Magnetic Resonance Imaging that focuses on your blood vessels and blood flow) with/without contrast at a radiology facility on 04/09/2026 at 12:40 PM due to benign prostatic hyperplasia with lower urinary tract symptoms. The physician order did not indicate the need for a staff to accompany the resident to the appointment. The undated and unsigned Request for Consultation form documented the resident's Magnetic Resonance Imaging appointment at a radiology facility was scheduled for 04/09/2026 at 12:40 PM. The form also documented that the resident would not need a certified nursing assistant to accompany the resident to their appointment. During an interview on 04/09/2026 at 12:50 PM, Resident #112 stated they had an appointment for a Magnetic Resonance Imaging /Magnetic Resonance Angiography of the pelvis that was scheduled for today at 12:40 PM. The facility was unable to provide a certified nursing assistant to accompany them on the appointment. Licensed Practical Nurse Clinical Staff Coordinator #1 told them there were no staff available due to the facility being short staffed that day. Resident #112 stated they usually go to all of their outside medical doctor appointments independently, but because this appointment was at a radiology facility, they had to be accompanied by a certified nursing assistant to help them get on and off the table used during the testing as the radiology facility was not responsible for providing them with any assistance. During an interview on 04/14/2026 at 10:00 AM, Primary Physician #1 stated they were aware of Resident #112 missing the Magnetic Resonance Imaging/Magnetic Resonance Angiography that was scheduled for 04/09/2026. Primary Physician #1 stated the radiology center expects a certified nursing assistant to be with the resident to assist the resident get up onto the table and for assistance going to the restroom. It is not the radiology facility's responsibility to provide the resident with any assistance. During an interview on 04/14/2026 at 10:25 AM, Medical Office Coordinator #1 stated they received an undated and unsigned Request for Consultation form that documented the resident's Magnetic Resonance Imaging appointment at a radiology facility was scheduled for 04/09/2026 at 12:40 PM. Medical Office Coordinator #1 stated they did not know who had filled out the consultation form. Medical Office Coordinator #1 stated the form documented that the resident would not need a certified nursing assistant to accompany the resident to their appointment. Medical Office Coordinator #1 stated they called the radiology facility and were told Resident #112 needed a certified nursing assistant to accompany them. Medical Office Coordinator #1 stated they sent an email to all department heads, including Licensed Practical Nurse Clinical Staff Coordinator #1 on 04/08/2026 at 3:30 PM to make them aware the resident would need a certified nursing assistant for the radiology appointment that was scheduled for 04/09/2026. During an interview on 04/14/2026 at 10:50 AM, Licensed Practical Nurse Clinical Staff Coordinator #1 stated they did not see the email that was sent by Medical Office Coordinator #1 on 04/08/2026 at 3:30 PM because they had already left for the day. Licensed Practical Nurse Medical Office Coordinator #1 stated the following morning on 04/09/2026, when they returned to work, they worked on the other job duties and never read the email regarding Resident #112 needing a certified nursing assistant for their radiology appointment. Licensed Practical Nurse Medical Office Coordinator #1 stated they did not have an extra certified nursing assistant to send with the resident. During an interview on 04/14/2026 at 10:50 AM, the Director of Nursing Services stated Medical Office Coordinator #1 sent the email too late regarding the need for a certified nursing assistant to accompany Resident #112. The Director of Nursing Services stated the email should have been sent out at least 2-3 days in advance. Less than 12 hours' notice was too late. The Director of Nursing Services stated they would not pull a certified nursing assistant from a unit to accompany the resident because that would leave the other certified nursing assistants working short on their unit. 10 New York Code Rules and Regulations 415.11(c)(1)

Based on record reviews and interviews during the survey, the facility failed to ensure that each resident receives adequate supervision to prevent accidents. This was identified for one (1) (Resident # 252) of eleven (11) residents reviewed for accidents. Specifically, on [DATE] Resident # 252 was able to obtain an unsecured bottle of fungal nail drops from the treatment cart and then self-administer the medication in their eye in the unit dining room. The findings include: The facility policy titled Medication Storage, last updated 01/2026, documented medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. The facility must ensure that only appropriately authorized staff have access to the storage area. Resident #252 was admitted with diagnoses including candidiasis (fungal infection) of skin and nail, dry eye syndrome of bilateral lacrimal glands, and paroxysmal atrial fibrillation (heart disease). The annual Minimum Data Set assessment dated [DATE] documented a brief interview for mental status score of 15, indicating the resident was cognitively intact. Resident #252's care plan for visual deficit, last revised on [DATE] documented the resident complained of burning eyes in a [DATE] note. The care plan notes further documented that the resident was evaluated by their physician and eye irrigation was performed. The physician orders dated [DATE] included orders for azelastine 0.05 % eye drops, to instill 1 drop by ophthalmic route in each eye two (2) times per day, Miebo 100 % eye drops, to instill 1 drop by ophthalmic route in each eye two (2) times per day and clotrimazole 1 % topical solution, apply 2 drops by topical route two (2) times per day for ten (10) days, to apply under all affected nails twice daily. The clotrimazole order was set to expire on [DATE]. A medication error report for Resident #252 dated [DATE] documented Resident #252 approached Licensed Practical Nurse #6 on [DATE] requesting pain medication, eye drops and antifungal nail drops. The pain medication and eye drops were administered; however, the clotrimazole 1% antifungal nail drop solution was placed on top of the treatment cart while Licensed Practical Nurse #6 reviewed the physician's orders on the laptop. Licensed Practical Nurse #6 discovered that there were no active orders for the antifungal nail drops. Licensed Practical Nurse #6 then engaged another resident in conversation, at which time Resident #252 took the antifungal nail drops, went to the unit dining room and self-administered the antifungal nail drops to their eyes. Shortly thereafter, Resident #252 yelled out and the nurse responded to the resident. Eye irrigation was performed by Licensed Practical Nurse #6. The facility's investigative conclusion documented that the Clotrimazole 1% antifungal nail drop solution medication was not secured while on the treatment cart which allowed for unintended access. During an interview on [DATE] at 11:10 AM, Resident #252 stated that their nurse mistakenly administered fungal nail drops to their eyes several days earlier, after requesting pain medication and eye drops. During an interview on [DATE] at 11:52 AM, Primary Physician #4 stated that evening nursing staff made them aware on [DATE] that the resident had self-administered antifungal nail drops to their eyes. Primary Physician #4 could not recall which nurse notified them of the incident. Primary Physician #4 stated Resident #252 should not have been in possession of the medication and should not have self-administered the medication. Primary Physician #4 stated medications should be secured at all times. During an interview on [DATE] at 03:00 PM, Licensed Practical Nurse #6 stated on [DATE], they administered oral medications and azelastine eye drops to Resident #252 at their request. Resident #252 also requested clotrimazole (antifungal) drops; however, the medication was not administered since the previous order for the medication had expired. While verifying the orders for clotrimazole, Licensed Practical Nurse #6 removed the clotrimazole from their treatment cart and placed it on top of the cart. Licensed Practical Nurse #6 stated Resident #252 took the clotrimazole from their cart without their knowledge as they were having a conversation with another resident. Licensed Practical Nurse #6 stated they were unaware that the clotrimazole was missing from the top of the cart until they heard Resident #252 scream for assistance in the unit dining room. Licensed Practical Nurse #6 promptly responded and discovered that the resident had self-administered the antifungal drops to their eyes. Licensed Practical Nurse #6 acknowledged that they should have left the medication in the cart while confirming the physician's order for the resident. During an interview on [DATE] at 10:15 AM, the Director of Nursing Services stated Resident #252 should not have been in possession of the medication and should not have self-administered the medication. The Director of Nursing Services stated that Licensed Practical Nurse #6 should have secured the medication in their locked cart until such time that they were ready to administer the medication. The Director of Nursing Services acknowledged that the unsafe storage of the medication led to the accident hazard. 10 New York Code Rules and Regulations 415.12(h)(2)

Based on observations, interviews, and record review, the facility failed to ensure parental fluids were administered for each resident consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care, and the resident's goals and preferences. This was identified for one (1) (Resident #66) of two (2) residents reviewed for hydration. Specifically, on 04/09/2026 and 04/10/2026, Resident #66 was observed with a peripherally inserted central catheter (a tube inserted into a vein in the upper arm and threaded to a large vein near the heart) to the right upper arm. Review of the electronic medical record revealed there were no physician's orders for the use, monitor, flush, and change the dressing for the peripherally inserted central catheter.The findings include:The facility policy titled Peripherally Inserted Central Catheter Maintenance, Flushing, Removal last reviewed 01/2026 documented peripherally inserted central catheters may be used for short term or long-term intravenous infusion therapy. A peripherally inserted central catheter will be flushed and aspirated for blood return prior to each infusion to assess the catheter functionality and prevent complications. The frequency for flushing central venous access catheter can vary dependent upon the type of the catheter. Removal of a peripherally inserted central catheter will occur at the end of therapy, onset of complications, or when deemed no longer necessary. The dressing, exit site, and the line are to be assessed daily and/or with each administration (if the dressing is clean, dry, intact, and if the line is securely in place without evidence that the line has been dislodged) and evaluate the intravenous line for proper functioning (no difficulties withdrawing blood or flushing the line that might indicate obstruction), and evaluate for signs and symptoms of infection.A facility policy titled Peripherally Inserted Central Catheter /Midline/Central Venous Assess Device Dressing Change last reviewed in 01/2026 documented a dressing for a peripherally inserted central catheter is changed weekly or if soiled. The Physicians order will specify type of dressing and frequency of changes. The policy documented dressing change instructions that included monitoring the catheter site and surrounding area for signs and symptoms of infections and complications and to measure the external length of the catheter to ensure it has not migrated and to document the procedure. Resident #66 was admitted with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), cutaneous abscess (localized collection of pus in the skin caused by bacterial infections) of the buttocks, and pneumonia. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented that the resident did not receive intravenous medications during the assessment period.A Peripherally Inserted Central Catheter, Midline Removal/Reposition form documented the resident had a Peripherally Inserted Central Catheter inserted on 11/13/2025.A nursing progress note dated 12/27/2025 documented the resident had no acute distress three days after completing intravenous antibiotics via the right upper arm peripherally inserted central catheter for a wound infection. The resident's vital signs were stable. There were no progress notes following 12/27/2025 documenting care or monitoring of the peripherally inserted central catheter.A Comprehensive Care Plan titled Intravenous: Peripherally Inserted Central Line/Central Line Care/Management initiated 02/04/2026 and revised on 4/10/2026 documented interventions including to flush the line as pe protocol or physician's order to maintain patency of the line, change the dressing weekly and as needed using aseptic technique and document as per protocol; maintain precautions for the extremity the line is inserted in.During an observation and interview on 04/09/2026 at 10:33 AM, Resident #66 was observed with a peripherally inserted central catheter to the right upper arm. Resident #35 stated used to be on intravenous antibiotic therapy and was no longer on any intravenous therapy and further stated the line was flushed once a week.A review of the electronic medical record revealed no current physician's orders related to the peripherally inserted central catheter, including an order for its use, for monitoring, or for dressing changes.A review of the April 2026 Medication Administration Record and Treatment Administration Record revealed no documentation related to the use, care, or monitoring of the peripherally inserted central catheter.During an observation and interview on 04/10/2026 at 12:11 PM, Resident #66 was observed in their room with a peripherally inserted central catheter to the right upper arm. Registered Nurse #3 was present in the room during the observation. The dressing for the peripherally inserted central catheter was dated 03/30/2026. Registered Nurse #3 stated the resident had slight redness to the catheter site and the resident had no complaint of pain to the area. Registered Nurse #3 stated they were not the regular nurse on the unit and prior to the observation they were not aware the resident had a peripherally inserted catheter in place. Registered Nurse #3 stated they did not flush or assess the catheter prior to the observation. Registered Nurse #3 stated there were no active physician's orders related to the peripherally inserted central catheter. Registered Nurse #3 stated the peripherally inserted central catheter should be flushed every shift and the dressing should be changed every week.During an interview on 04/14/2026 with Registered Nurse #4, the nursing supervisor stated that an order for a peripherally inserted central catheter should include the use of catheter, monitoring, flushing, and dressing change. The catheter line should be flushed every shift and the dressing should be changed weekly unless otherwise specified by the physician's order. The peripherally inserted central catheter line site should be monitored for signs and symptoms of infection and infiltration such as redness, warmth, pain, and swelling. The external catheter length should be measured during dressing change to monitor catheter migration into the body. Registered Nurse #4 stated the nurses do not document the measurement of the external catheter. Registered Nurse #3 stated that even though the resident was no longer receiving intravenous treatment, the physician order should have remained in place for the monitoring and care of the peripherally inserted central catheter line. Registered Nurse #4 stated they did not know there were no current physician's orders in place for the peripherally inserted central catheter for Resident #35 and did not know the reason why. Registered Nurse #3 stated they were not sure why the resident still had a peripherally inserted catheter in place after last antibiotic treatment in December 2026. During an interview on 04/16/2026 at 12:07 PM, Primary Physician #3 stated Resident #35 had a peripherally inserted central catheter to receive antibiotic treatment for the recurrent abscess on the buttocks, and the resident also had pneumonia. Primary Physician #3 stated sometimes the catheter is left in place after treatment for a length of time depending on the resident's condition and stated they wanted the peripherally inserted central catheter to remain in place for long term use for Resident #35 due to the potential of recurrent wound infection of the abscess site and they probably should have documented their rationale in the resident's medical record. During an interview on 04/16/2026 at 1:09 PM, the Director of Nursing Services stated Resident #35 should have had physician orders for use of a peripherally inserted central catheter, monitoring, and flushing the catheter, and for the dressing change. The dressing to the peripherally inserted central catheter site should have been changed a week after the 03/30/2026 and the catheter should have been flushed at least daily. The Director of Nursing Services stated that external catheter measurement should have been documented in the progress notes for monitoring catheter migration. 10 New York Code Rules and Regulations 415.12(k)(2)

Based on observations, interviews and record reviews during the survey, the facility failed to ensure that a resident who needs respiratory care was provided with such care consistent with the comprehensive person-centered care plan. This was identified for one (1) (Resident #1) of three (3) residents reviewed for respiratory care. Specifically, Resident #1 had a physician order to receive supplemental oxygen at two (2) liters per minute via a nasal cannula. On 04/09/2026 Resident #1 was observed receiving oxygen at 10 liters per minute from an oxygen concentrator. The findings include:The facility policy titled Oxygen, last updated 1/2026, documented that the oxygen therapy via nasal cannula is administered as ordered by a Physician and includes correct flow rate, mode of delivery, and frequency. Resident #1 was admitted with diagnoses including chronic obstructive pulmonary disease, extrapyramidal and movement disorder (involuntary movements), and peripheral vascular disease. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 6, indicating the resident had significant cognitive impairment and that the resident received oxygen therapy while a resident of the facility.Resident #1's care plan for use of oxygen due to episodes of shortness of breath., initiated on 12/03/2025 and last revised on 02/25/2026 documented to provide oxygen as ordered by the attending physician.A physician's order dated 03/24/2026 documented to provide oxygen at 2 liters per minute via nasal cannula for diagnosis of chronic obstructive pulmonary disease.During an observation on 04/29/2026 at 10:00 AM, Resident #1 was observed receiving supplemental oxygen via nasal cannula at a rate of 10 liters per minute while connected to an oxygen concentrator. The resident appeared confused and had no knowledge of the correct oxygen setting for the concentrator or had any knowledge of its operation. During an interview on 04/09/2026 at 10:05 AM, Registered Nurse #4 confirmed that the oxygen concentrator flow rate was set to 10 liters per minute and should have been set to 2 liters per minute. Registered Nurse #4 promptly assessed the resident to be stable with an oxygen saturation level of 98% and reapplied the nasal canula at a rate of 2 liters per minute. During an interview on 04/09/2026 at 10:12 AM, Licensed Practical Nurse #7 stated that they were responsible for ensuring the oxygen rate settings were accurate. Licensed Practical Nurse #7 stated they checked Resident #1's oxygen concentrator at the beginning of their shift at 7:00 AM that morning, at which time they recalled the oxygen flow rate was set at 2 liters per minute. Licensed Practical Nurse #7 stated that Resident #1 was unable to change the oxygen flow rate setting themselves. During an interview on 04/15/2026 at 3:10 PM, Primary Physician #4 stated that they were informed on 04/09/2026 by nursing staff of the incorrect oxygen rate being administered to Resident #1. Their expectation was that the oxygen should be delivered as prescribed and that changes should not be made without informing them. During an interview on 04/16/2026 at 10:10 AM, the Director of Nursing stated that Resident #1 should have received oxygen at the rate prescribed by their attending physician and that Licensed Practical Nurse #7 was accountable for checking that the oxygen concentrator was set at appropriate flow rate to deliver oxygen as per the physician's orders.10 New York Code Rules and Regulations 415.12(k)(6)

Based on observations, interviews, and record review, the facility failed to ensure each resident was served food that was palatable, attractive, and at a safe and appetizing temperature. This was identified for five (5) (Resident #19, Resident #41, Resident #88, Resident #181, and Resident #183) of six (6) residents during the Resident Council Meeting. Specifically, during the Resident Council meeting held on 04/10/2026, five (5) of the six (6) residents who attended complained the hot foods and beverages at meals were served cold. On 04/13/2026, during the lunch meal service observations, the lunch meal service temperatures for the hot food and beverage items were observed to be below 135 degrees Fahrenheit for three (3) (Woodcrest 2, Woodcrest 3, and [NAME] 2) of the six (6) units observed.The findings include:The facility's policy titled Food Temperatures last reviewed January 2026 documented foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered with maintained temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods.The Resident Council meeting was conducted on 04/13/2026 at 11:00 AM. Five (5) (Resident #19, Resident #41, Resident #88, Resident #181, and Resident #183) of the six (6) residents in attendance complained they were served cold food and beverages items during meals that should have been served hot. The Food Committee Meeting minutes dated 01/03/2026 documented residents stated, at times, the coffee and hot water were not at the temperature they would like.The Food Committee Meeting minutes dated 02/10/2026 documented a resident stated food was served warm and they would like the food to arrive hotter. On 04/13/2026, during the lunch meal service, six (6) test trays were requested for three (3) of three (3) units in the Woodcrest building and three (3) of three (3) units in the [NAME] building.-The Woodcrest 2 open meal truck with no doors arrived on the unit at 11:57 AM and the rolling open rack of meal trays arrived on the unit at 12:00 PM. The last meal tray on the Woodcrest 2 unit was observed to be served at 12:20 PM at which time the test tray temperatures were taken by Dietary Supervisor #1. The temperature reading for the chicken a-la-king and rice was 125 degrees Fahrenheit and peas and carrots 125 degrees Fahrenheit.The [NAME] 2 open meal truck with no doors arrived on the unit at 12:25 PM. The last meal tray on the [NAME] 2 unit was observed to be served at 12:32 PM at which time the test tray temperatures were taken by Registered Dietitian #1. The temperature reading for the chicken a-la-king and rice was 133.5 degrees Fahrenheit, peas and carrots 125 degrees Fahrenheit, and hot water 126.9 degrees Fahrenheit. The Woodcrest 3 open meal truck with no doors arrived on the unit at 1:07 PM and the rolling open rack of meal trays arrived on the unit at 1:10 PM. The last meal tray on the Woodcrest 3 unit was observed to be served at 1:30 PM at which time the test tray temperature was taken by Registered Dietitian #1. The temperature reading for the chicken a-la-king and rice was 133 degrees Fahrenheit, peas and carrots 130.6 degrees Fahrenheit, and hot water 123.8 degrees Fahrenheit. During an interview on 04/14/2026 at 11:25 AM, the Food Service Director stated they were aware that foods and beverage items intended to be served hot were sometimes being served to residents warm. The Food Service Director stated they were made aware of this by attending Food Committee meetings. The Food Service Director stated meal distribution was sometimes delayed due to the nurses not being present so the Certified Nursing Assistants can start serving the trays or there may be only one Certified Nursing Assistant present in the dining room to hand out trays while the other Certified Nursing Assistants were busy with their assignments caring for other residents. The Food Service Director stated the heat provided by the pellet system only lasts for 45 minutes. The Food Service Director stated having closed food trucks with doors would help the food stay warmer and new food trucks would be arriving at the facility in the first week of May. The Food Service Director stated they had tested the temperature of the hot water and coffee when they arrived at a unit and found them to be between 120 degrees Fahrenheit to 128 degrees Fahrenheit and felt that temperature was hot enough for a hot beverage being served to a resident so they would not burn themselves. The Food Service Director stated the temperature of foods when the residents receive their meals should be at least 135 degrees Fahrenheit. During an interview on 04/14/2026 at 11:55 AM, the Director of Nursing Services stated the facility has identified the issue of the residents not receiving their food hot is due to staff not giving out the meal trays promptly when they arrive at a unit. The Director of Nursing Services stated that Dietitians and Nursing Supervisors are supposed to go to every unit to ensure the process of giving out the meal trays was timely. During an interview on 04/15/2026 at 10:10 AM, the Administrator stated since September of 2025 when they first came to the facility, they were aware of the issue of the residents not receiving their food hot. The Administrator stated the meal trays sit on the unit for a while before being served. The Administrator stated they have tried to have the Dietitians be present at meals to make sure the meal trays are given out timely, but there are not enough Dietitians to be at every meal. The Administrator stated they had focused on the delivery time of the meals to the units but may need to focus more on the meal distribution now. 10 New York Code Rules and Regulations 415.14(d)(1)(2)

Based on observation, interviews, and record review during survey, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. This was identified for one (1) (Resident #35) of five (5) residents reviewed for the Infection Control Task. Specifically, Resident #35 had a physician's order for contact precautions for multidrug resistant infection in the tracheostomy (a surgical opening into the windpipe). On 04/09/2026 two (2) phlebotomists (staff who draw blood) were observed inside Resident #35's room with no protective personal equipment on.The findings include:A facility policy titled Transmission Based Policy last reviewed 01/2026 documented transmission based precautions are designed for residents documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard/universal precautions are needed to interrupt transmission. Precautions are determined based on the mode of transmission of the disease/pathogen involved. Contact Precaution is designed to reduce the risk of transmission of epidemiologically important microorganisms by direct and indirect contact.A facility policy titled Infection Prevention and Control Program last reviewed 03/13/2026 documented the facility will train staff and establish protocols for selecting, donning, and doffing appropriate personal protective equipment and demonstrate competency during resident care. The facility will provide personal protective equipment to support compliance with standard and transmission-based precautions and ensure that it is readily available for staff use.Resident #35 was admitted with diagnoses including tracheostomy status, elevated white blood cell count, and fever. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status was not conducted because the resident was rarely or never understood. The resident had severely impaired cognitive skills for daily decision making.A Comprehensive Care Plan titled Infection dated 03/05/2026 documented the resident was on contact precautions for a multidrug resistant organism known as Pseudomonas in the tracheostomy. Interventions included educating the resident/family, caregivers on methods to limit spread of infection including proper hand hygiene and follow facility policy for Contact Precautions including obtaining and utilizing appropriate personal protective equipment.A current Physician's order documented to follow contact precautions related to multidrug resistant organism, Pseudomonas, of the tracheostomy.During an observation on 04/09/2026 at 2:08 PM, Phlebotomist #1 and Phlebotomist #2 were observed inside Resident #35's room without any personal protective equipment on. A sign was observed posted outside Resident #35's room indicating to stop: contact precautions, everyone must clean their hands, including entering and when leaving the room; providers and staff must also put on gloves and gown before room entry and discard gloves and gown before room exit.During an interview on 04/09/2026 at 2:18 PM, Phlebotomist #1 stated they were in Resident #35's room to perform a blood draw in which they donned (put on) and doffed (take off) personal protective equipment as indicated on the posted sign outside the door. After exiting the resident's room, Phlebotomist #1 stated they forgot some paperwork in the resident's room and asked Phlebotomist #2 to collect the paperwork from the resident's room. Phlebotomist #1 stated they then entered the resident's room to inform Phlebotomist #2 that they must exit the room. Phlebotomist #1 stated they felt they did not need to apply personal protective equipment prior to entering the room because they were just collecting paperwork they had left in the room and had no direct contact with the resident.During an interview on 04/09/2026 at 2:27 PM, Phlebotomist #2 stated they entered Resident #35's room to collect paperwork Phlebotomist #1 had left. Phlebotomist #2 stated they did not notice the sign posted outside the resident's door and did not realize the resident was on contact precautions and, therefore, failed to follow the instructions as indicated on the sign posted outside the resident's door. They stated they entered the room without personal protective equipment to collect the paperwork as requested by Phlebotomist #1.During an interview on 04/10/2026 at 11:49 AM, the Clinical Staff Coordinator stated they were a licensed practical nurse, and they were in the unit hallway speaking with the unit nurse when they turned around and observed Phlebotomist #1 and Phlebotomist #2 in the room without any personal protective equipment on. The Clinical Staff Coordinator stated they instructed the two (2) phlebotomists to step out of room and perform hand hygiene and educated them regarding following the signage posted outside the resident's door.During an interview on 04/10/2026 at 11:56 AM, the Infection Preventionist stated Resident #35 was on contact precautions and the two (2) phlebotomists should have performed hand hygiene and put on personal protective equipment as instructed on the signage that was posted outside the resident's room, no matter the reason for entering the room.During an interview on 04/16/2026 at 1:02 PM, the Director of Nursing Services stated all visitors, staff, and providers should follow transmission-based precautions. The Director of Nursing Services stated Phlebotomist #1 and Phlebotomist #2 should have followed the instructions as indicated on the sign posted outside Resident #35's door for contact precautions each time prior to entering the resident's room.10 NYCRR 415.19(a)(1-3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident was treated with respect and dignity and in a manner that promotes maintenance or enhancement of his or her quality of life. This was identified 1) on nine of nine units during the dining task observations and 2) for seven (Resident #169, Resident #341, Resident #285, Resident #5, Resident #267, Resident #337, and Resident #204) of seven residents interviewed during the resident council meeting. Specifically, 1)during the dining task observations, residents on all nine units were served their breakfast and lunch meals on disposable plates with disposable utensils. 2) On 10/16/2024 at 2:30 PM, all seven residents who attended the resident council meeting verbalized dissatisfaction about meals being served on disposable dishes with disposable utensils because of the broken dishwasher. The finding is: 1) During the dining meal observation of the Breakfast and Lunch meals for all nine resident units on 10/16/2024 and 10/17/2024, the meals were served on disposable Styrofoam plates with disposable utensils. During an interview on 10/16/2024 at 12:45 PM, the Dietary Supervisor stated the residents were receiving their meals on disposable Styrofoam food containers because the dishwashing machine was not working. The Dietary Supervisor did not know how long the dishwashing machine had not been in working condition. During an interview on 10/23/2024 at 3:16 PM, the Administrator stated they were aware of the residents' dissatisfaction with the use of disposable dishes and utensils. The Administrator stated that the dishwashing machine had not been functioning since January of this year (2024). The Administrator stated that the issue has not been addressed since January 2024 due to a combination of failed contractor agreement attempts in January of this year (2024) and the facility's reluctance to provide funds because of a potential facility closure or sale plan earlier this year. 2) During the Resident Council meeting on 10/16/2024 at 2:30 PM, seven of seven residents in attendance verbalized dissatisfaction with utilizing disposable plates and utensils since the beginning of the year due to the facility's broken dishwashing machine. Resident #267 was admitted with diagnoses including Metabolic encephalopathy, Generalized abdominal pain, and Gastric ulcers. The 9/10/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. During an interview on 10/16/2024 at 3:48 PM, Resident #267, the resident council president, stated that all meals are being served on disposable plates with disposable utensils because the dishwashing machine had been broken for several months with no indication of when it would be repaired. Resident #267 stated that the facility is aware of the resident's dissatisfaction with meals served on Styrofoam plates and the use of poor-quality plastic utensils. Resident #267 stated that the resident council members have conveyed their desire for regular plates and utensils to the facility Administrator on multiple occasions. Resident #267 stated that using the Styrofoam disposable plates diminishes the experience of a quality meal. Resident #5 was admitted with diagnoses including Chronic Kidney Disease, Hypertension, and Gastro-Esophageal Reflux Disease. The 9/6/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During an interview on 10/16/2024 at 3:50 PM, Resident #5, a regular attendee of the resident council meetings, stated that Resident Council members have complained to the administrator that the plastic utensils are of poor quality and make it difficult for the residents to enjoy their meals. 10 NYCRR 415.3(d)(1)(i)

Based on observation, interviews, and record review, during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility failed to ensure that food was served in accordance with professional standards for food service safety. This was identified for one unit (Woodcrest one) of nine units observed during the Dining Facility Task. Specifically, the facility did not monitor the temperature of cold food items served to residents in the Woodcrest One Unit during a lunch meal observation on 10/16/2024. The cold food temperature served during the lunch meal measured between 50-60 degrees Fahrenheit (normal range: below 41 degrees Fahrenheit). The finding is: An undated facility policy and procedure titled Food Temperatures documented that the temperatures of the food items will be taken and properly recorded for each meal. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to ensure cold foods stay below 41 degrees Fahrenheit during the portioning, transporting, and delivery process until received by the individual recipient. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. Food sent to the units for distribution (such as meals) is transported and delivered with maintained temperatures at or below 41 degrees Fahrenheit for cold foods. During a lunch meal observation at the Woodcrest One unit on 10/16/2024 at 12:58 PM, the cold food temperature was not documented on the temperature log. Dietary Aide #1 was observed serving the meal without taking the temperature of the cold food items (such as sandwiches, yogurt, and pudding). Dietary Aide #1 was immediately interviewed and stated they do not take cold food temperatures, they only take the temperature of the hot food items on the steam table. The cold food items were already placed on the individual resident trays in the kitchen prior to the trays being delivered to the unit. On 10/16/2024 at 1:06 PM, Registered Dietitian #1 took the temperature of the following cold food items: the cheese sandwich was measured at 60.7 degrees Fahrenheit, and the chocolate pudding was measured at 50 degrees Fahrenheit. Registered Dietitian #1 stated that these temperatures were not in compliance with food safety standards. During an interview on 10/23/2024 at 10:53 AM, the Food Service Director stated that the food temperatures of hot and cold food items should be measured by the dietary staff prior to meal services. The Food Service Director stated it is important to take the temperatures to ensure that the food is not in the danger zone (The temperature danger zone for food is between 40 F and 140 F, where bacteria can grow rapidly) where there is an increased risk of illness. The Food Service Director stated the cold food should have gone to the unit in bulk on a pan of ice rather than pre-plated on the individual trays. 10 NYCRR 415.14(h)

Based on observation, interviews, and record review during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was identified during the Kitchen Task. Specifically, during a kitchen tour with the Food Production Manager on 10/16/2024 the mechanical dishwashing machine was not in working order. Record review and interviews indicated that the dishwashing machine has been out of order since January 2024. The finding is: A facility policy and procedure dated 4/20/2023 titled Dishwashing, documented the Nutritional Services Department shall maintain a file of written procedures for cleaning and maintaining all equipment in the department. The Dietary Aide will report to the Food Production Manager, Supervisor, or Director of Dietary any problems with the dishwashing machine. Upon receipt of the report of problems with the machine, the Plant Operations is called and a routine work request is prepared. The Plant Operations supervisor will determine whether the problem can be handled internally or if an outside company is required. If the machine requires outside service, the Dietary Supervisor, Production Manager, or Director of Dietary will place a service call. An email dated 1/25/2024 from the former Food Service Director to the equipment repair company documented that a quote for the dishwashing machine repair was received in December 2023. The email documented that approval was received from the facility administration. A follow-up email dated 3/25/2024 documented that there was a delay in receiving the necessary parts for repair. During an interview on 10/18/2024 at 9:25 AM, the Food Service Director stated that they started their employment at the facility approximately four months ago. They stated that during that time, they have had various vendors coming to the facility to provide proposals for the new dishwashing equipment. The food service director further stated that they provided the administrator with the proposal. Last week a plumber was in the facility to review the work needed to be done before the purchase and installation of new equipment. A record review revealed a quote for new equipment dated 9/27/2024. During the kitchen tour with the Food Service Director on 10/18/2024 at 9:27 AM, the inoperable dishwashing machine was observed. During a re-interview on 10/23/2024 at 10:53 AM, the Food Service Director stated they are not aware of the details of the previous conversations. They further stated that they had given the administration recommendations for a new dishwashing machine. During an interview on 10/23/2024 at 3:16 PM, the Administrator stated the facility has been looking into repairing or obtaining a new dishwashing machine since January 2024. The Administrator stated that the dishwashing machine has been inoperable since the beginning of the year (January 2024). At that time (January 2024), the facility received a repair quote which was approved; however, there was a delay in receiving the necessary parts. They further stated that sometime in March 2024, the former Food Service Director resigned and the facility's ownership was reluctant to commit the necessary funds to purchase or repair the equipment due to the pending plans for the facility closure or sale earlier in 2024. 10 NYCRR 415.5(e)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024 the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (Resident #79) of six residents reviewed for Accidents. Specifically, Resident #79 was self-administering the Nasal Moisturizing Spray and the facility staff was aware. A review of the resident's medical records indicated no documented assessment to determine if the resident could safely self-administer the medication and there was no physician's order to self-administer the Nasal Moisturizing Spray. The finding is: The facility's policy and procedure titled Self-Administration of Medication, last revised on 6/3/2024 documented to permit each resident to self-administer medications if the interdisciplinary team has determined that the resident can securely store, safely/accurately administer their medications, and maintain a complete and accurate record of such administration. If a resident is deemed capable of self-administering their medication, the physician will write the orders for medication as self-administration. Resident #79 was admitted with Diagnoses including Paraplegia (loss of muscle function in the lower half of the body), Chronic Obstructive Pulmonary Disease (COPD), and Edema. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #79's Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #79 had intact cognition. Resident #79 received respiratory treatment that included oxygen therapy. A Comprehensive Care Plan (CCP) titled Respiratory Disorders: Nasal Congestion, dated 10/5/2018 and last revised on 1/19/2024 documented interventions that included administering medications and assessing for shortness of breath. Oxygen therapy as per physician's order and provide inhalation or nebulizer treatment. A physician's order dated 10/5/2024 documented Nasal Moisturizing 0.65 percent spray. One drop by nasal route twice a day for Nasal Congestion. During an observation and interview on 10/16/2024 at 10:08 AM, Resident #79 was observed with a bottle of Nasal Moisturizing spray on their overbed table. Resident #79 stated the nurse had left the Nasal Moisturizing spray bottle so they (Resident #79) could self-administer the nasal spray. There was no nurse present in Resident #79's room during the observation. The Medical Record lacked documented evidence of a physician's order and assessment for self-administration of medication. A review of the Electronic Medical Administration Record (EMAR) revealed that the nurses had been signing for the Nasal Moisturizing 0.65 spray at 9:00 AM and 5:00 PM every day. During an interview on 10/16/2024 at 10:08 AM, Resident #79 stated they administered the Nasal Moisturizing spray themselves. Resident #79 stated the nurses gave them (Resident #79) the spray bottle to self-administer the medication and they (nurses) took the Nasal Moisturizing spray bottle at the end of the shift to keep it in the medication cart. During an interview on 10/16/2024 at 12:39, Registered Nurse #3, Medication Nurse, stated they had left the nasal spray with Resident #79 to self-administer the medication and then they (Registered Nurse #3) signed the Electronic Medical Administration Record (EMAR). Registered Nurse #3 stated that they typically handed the nasal spray bottle to the resident to self-administer the medication. During an interview on 10/21/2024 at 3:30 PM, Licensed Practical Nurse #6 stated they worked the 3:00 PM-11:00 PM shift, and Resident #79 had always self-administered the nasal saline spray. Licensed Practical Nurse #6 stated they would take the nasal spray from Resident #79 at the end of their shift to store the nasal saline spray in the medication cart. During an interview on 10/22024 at 11:17 AM, the Director of Nursing Services stated the nurses should not have left the saline spray bottle with Resident #79 to self-administer. Resident #79 should have been assessed first for competency in self-administering the medications and the Physician should have been notified to obtain an order to self-administer the nasal saline spray. 10 NYCRR 415.3(f)(1)(vi)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident was provided a safe, clean, comfortable, and homelike environment. This was identified for one (Unit Seacliff 1) of nine units observed during the environmental task. Specifically, Resident #246 's privacy curtain was ripped and had brown stains. The finding is: The facility's policy for Resident Room Cleaning, dated March 2022, documented meaning and sanitizing to improve sanitation and ensure the highest level of cleanliness throughout the facility. To control cross-contamination, and the spread of bacteria and infection to maintain the outward experience of the facility. Complete high and low dusting of all flat surfaces, wall surfaces, corners and edges, windows, drapery, pictures, and ceiling features. The policy did not include when to change or wash the curtains. The Facility's policy for Resident Room-Homelike Environment, dated 6/21/2024 documented the facility is obligated to provide residents with a safe, home-like environment. Resident #246 had diagnoses that included Polyneuropathy (nerve damage), Type 2 Diabetes Mellitus, and Major Depressive disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. During an environmental tour of Unit Seacliff 1 on 10/16/2024 at 10:25 AM PM, Resident #246's privacy curtain was ripped and had brown stains. During an interview on 10/22/2024 at 10:20 AM, Resident #246 stated the privacy curtain had been ripped and was dirty with brown stains and had never been replaced since they were admitted to the facility. They stated it would be wonderful to have a clean and not ripped privacy curtain. Resident #246 stated the facility staff was aware of the ripped privacy curtain. During an environmental tour of Unit Seacliff 1 on 10/22/2024 at 11:00 AM, Resident #246's privacy curtain was ripped and had brown stains. During an interview on 10/22/2024 at 10:23 AM, Certified Nursing Assistant #5 and Certified Nurse's Assistant #6 both stated they were aware the privacy curtain in Resident #246's room was ripped for a while. They had informed the nurse about the ripped curtain; however, could not recall the name of the nurse. They both stated that the Certified Nursing Assistants do not notify the housekeeping staff about the housekeeping issues including the ripped curtains, they only notify the nurses on the unit, verbally. During an interview on 10/22/2024 at 10:30 AM, Registered Nurse #8 stated they were not aware of the ripped and dirty privacy curtain in Resident #246's room. During an interview on 10/22/2024 at 2:21 PM, Housekeeper Supervisor#1 stated the privacy curtains are replaced for each resident room every three to four weeks. Housekeeper Supervisor #1 stated they did not know Resident #246's privacy curtain was ripped and dirty and they were not notified that the curtain needed to be replaced. 10 NYCRR 415.5(h)(2)

Based on record review and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflects the resident's status. This was identified for one (Resident #262) of 38 sampled residents. Specifically, the Minimum Data Set assessment for Resident #262 did not accurately indicate that the resident was receiving comfort care. The finding is: The facility policy and procedure titled Completion of the RAI Process last reviewed 3/16/2023, documented that assessments will be completed within the guidelines outlined in the Resident Assessment Instrument (RAI) manual, including the care planning processes to lead to the development of a plan of care to address and monitor each resident's needs and function, and to track changes in the resident's status. Staff may utilize information in the medical record to assist with the completion of the Minimum Data Set. Resident #262 was admitted with diagnoses including Alzheimer's disease, Bipolar Disorder, and Diabetes Mellitus. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severely impaired cognition. The Minimum Data Set documented comfort care was not provided in the last 14 days. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severely impaired cognition. The Minimum Data Set documented comfort care was not provided in the last 14 days. A physician's order for Comfort Measures Only (CMO), was first ordered on 2/4/2023 and last renewed on 10/19/2024. A comprehensive care plan titled Advance Directives, effective 3/30/2021 and last reviewed on 9/10/2024, documented that Resident #262 received comfort measures only. A comprehensive care plan titled Comfort Care/Palliative Care/Hospice Care Plan, effective 4/8/2022, last reviewed 9/10/2024, documented interventions including comfort care. During an interview on 10/23/2024 at 1:15 PM, the Minimum Data Set Director stated Resident #262 was placed on comfort care since 2/4/2023 as per the physician's orders. The Minimum Data Set was inaccurately coded as not receiving comfort care in the past 14 days. During an interview on 10/23/2024 at 2:37 PM, the Director of Nursing Services stated the Minimum Data Set Coordinators and Minimum Data Set Director were responsible for ensuring the accuracy of the Minimum Data Set assessment. The Director of Nursing Services further stated the provision of comfort care should have been indicated on the Minimum Data Set assessments for Resident #262. 10 NYCRR 415.11(b)

Based on record review and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/24/2024, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed to meet the resident's medical and nursing needs. This was identified for one (Resident #331) of four residents reviewed during the Infection Control Task. Specifically, Resident #331 had a physician's order to place Resident #331 on contact precautions since 5/22/2024. There was no documented evidence that a care plan was developed to reflect Resident #331 was on contact precaution until 10/16/2024. The finding is: The Comprehensive Care Plan Policy dated 2/01/2021 documented that residents of the facility will have a Comprehensive Care Plan completed per Federal and State requirements. An individual Comprehensive Care Plan will be developed for each problem, strength, or need, measurable objectives, and timetables to meet the resident's physical, mental, and psychosocial needs that are identified on the resident's Comprehensive Assessments. The Comprehensive Care Plan is prepared with an interdisciplinary team approach. Resident # 331 had diagnoses including Cerebral Infarction(disrupted blood flow to the brain), Ventilator-dependent, and Tracheostomy Status. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident received Tracheostomy care and Ventilator care. The Minimum Data Set did not indicate the resident had infections in the look-back period. The physician's order dated 5/22/2024 documented Contact Precautions secondary to Pseudomonas {Carbapenem (antibiotic) Resistant} Organisms. A review of the resident's Comprehensive Care Plan from May 2024-10/15/2024 revealed there was no care plan for isolation precautions developed for Resident #331 until 10/16/2024. During an interview on 10/22/2024 at 10:43 AM, Infection Control Nurse#1 stated the resident had been on isolation precautions since May 2024 when they were readmitted to the facility with the drug-resistant Pseudomonas infection. The Infection Control Nurse stated they were responsible for managing the care plans related to infections. The Infection Control Nurse stated they did not develop the care plan for Resident#331's infection and isolation precautions and should have. During an interview on 10/22/2024 at 1:18 PM, the Minimum Data Set Director stated that the unit nurses were responsible for developing and updating the care plans for each resident and it was an oversight that an isolation care plan was not developed for Resident #341. During an interview on 10/22/2024 at 2:34 PM, the Director of Nursing Services stated Resident#331 should have a care plan developed for infection control including contact precautions. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and staff interviews during a recertification survey initiated on 10/16/2024 and completed on 10/24/2024, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. The was identified on one (Woodcrest 2 unit) of nine units observed for medication storage task. Specifically, Licensed Practical Nurse #9 pre-poured medications in a medication cup and stored the medication cup in the medication cart without appropriate labels. Licensed Practical Nurse #9 then attempted to administer the medications to the wrong resident (Resident #100) without properly identifying the resident. The finding is: The Medication administration policy dated 9/07/2023 documented Medication administration will be conducted according to each resident's individualized care plan and physician's orders. Medication administration times will be strictly adhered to, and medications will be administered at the prescribed intervals. Before administering any medication, nursing staff will verify the resident's identity using two patient identifiers (for example name band and date of birth) to ensure the right resident receives the right medication. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. Medications will be prepared in a clean and designated medication preparation area to prevent cross-contamination. Resident #100 had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor. The Minimum Data Set assessment dated [DATE] documented that Resident #100 had a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. Resident #100 had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor. The Minimum Data Set assessment dated [DATE] documented that Resident #100 had a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The physician's order dated 10/5/2024 documented Bupropion (antidepressant) 150 milligrams 24-hour tablet extended release 1 tablet by oral route once daily for nicotine dependence and Depression. Buspirone (anti-anxiety) 5 milligrams 1 tablet by oral route two times per day for anxiety disorder. Furosemide (diuretic) 40 milligrams tablet, give 1 tablet by oral route once daily at 9:00 AM daily, and Miralax (stool softener) polyethylene glycol 3350 17 grams/dose oral powder, give 17 grams mixed with 8 ounces of fluid by oral route once daily. The Woodcrest 2 Unit Medication Cart #1 was observed on 10/17/2024 at 9:24 AM with Licensed Practical Nurse #9. There was a medication cup containing two tablets and three capsules stored in the top drawer of the medication cart. The medication cup had 214 written on the cup. Licensed Practical Nurse #9 stated 214 indicated the resident room number. Licensed Practical Nurse #9 stated the medications in the cup had two capsules of Bacid (probiotic), two tablets of Tylenol (pain medication) 325 milligrams, and one capsule of Neurontin (medication for nerve pain) 100 milligrams. While Licensed Practical Nurse #9 was speaking to the Surveyor, Resident #100 approached Licensed Practical Nurse #9 and requested they get their medication. Licensed Practical Nurse #9 took the souffle cup with the pre-poured Neurontin and Bacid capsules and Tylenol tablets and attempted to administer the medications to Resident #100. Resident #100 stated they already received their morning medications and were only requesting to get the Miralax and that they did not reside in room [ROOM NUMBER]. During an interview on 10/17/2024 at 9:35 AM, Licensed Practical Nurse #9 stated they were a float nurse covering for the medication nurse on the Woodcrest 2 unit. Licensed Practical Nurse #9 stated they offered the wrong medications to the wrong resident and realized that Resident #100 was not the correct resident to receive the medications that were stored in the souffle cup; they thought Resident #100 resided in room [ROOM NUMBER], but later realized that Resident #100 was not from room [ROOM NUMBER]. They should have checked the resident's identification band to make sure the medication was being administered to the right resident. Licensed Practical Nurse #9 stated they usually prepare the medications in front of the resident rooms and then administer the medications soon after they prepare them. Today they pre-poured the medications at the nursing station and identified the medication cups with the residents' room numbers. During an interview on 10/22/2024 at 4:18 PM, the Director of Nursing Services stated Licensed Practical Nurse #9 failed to follow the five rights for medication administration policy which were: the Right resident, the right medication, the right time, the right dose, and the right route. The Director of Nursing Services stated that the medications should never be pre-poured and should never be left in the medication cart without identification labels. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #176) of three residents reviewed for Pressure Ulcers. Specifically, Resident #176 had a physician's order for an alternating air mattress due to multiple pressure ulcers. The resident's most recent weight was 86 pounds. The air mattress weight setting was set to a firm setting which corresponds to a resident who weighs between 360-400 pounds; however, the air mattress was observed to be deflated and was not functioning as intended. The finding is: The facility's policy titled Management of Pressure Ulcers, revised on 2/18/2022, documented that pressure ulcer care requires an interdisciplinary approach that addresses the following areas to promote healing of tissue: reduce or eliminate causative factors such as pressure due to immobility, friction, shear, moisture, and circulatory impairments. Establish an interdisciplinary treatment plan that promotes wound healing and addresses other conditions that may affect wound healing. The alternating air mattress manual, provided by the facility, documented that the soft/firm pressure adjustment knob should be adjusted for a comfortable pressure level customized according to the resident's weight. An illustration in the manual confirms that the soft adjustment corresponds to a resident's weight of 80 pounds and the firm adjustment corresponds to a resident's weight of 400 pounds. Resident #176 was admitted with diagnoses including Non-Alzheimer's Dementia, Malnutrition, and Hip Fracture. The 9/4/2024 Significant Change Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident had seven unstageable (the wound depth is not clear because the wound is covered by a layer of dead tissue) pressure ulcers due to coverage by slough/eschar (dead tissue), and nine unstageable pressure ulcers classified as deep tissue injury (damage to the underlying soft tissues caused by pressure). The resident required substantial/maximal assistance for rolling left to right and was dependent on staff for transfers requiring mechanical lift. The most recent resident weight in the medical record, dated 9/23/2024, was 86.1 pounds. Physician's orders, dated 10/6/2024, documented Comfort Measures Only; Ensure all wound sites are off-loaded every shift; Concave Air Mattress; monitor placement, function, and settings of the concave air mattress every shift. A physician's order dated 10/9/2024 documented treatment orders for the right hip unstageable pressure ulcer and to ensure the site is off-loaded at all times. A physician's order dated 10/22/2024 documented treatment orders for the sacral and left hip wound pressure ulcer and to ensure the site is off-loaded at all times, for diagnosis of pressure ulcer of left hip, unstageable. A wound consult written by Nurse Practitioner #1, dated 10/15/2024 documented to ensure the sacrum and right and left hip wound areas are off-loaded at all times. A review of the October 2024 Medication Administration Record revealed nurses were monitoring the placement, function, and settings of the concave air mattress each shift. A review of the October 2024 Treatment Administration Record revealed nurses documented each shift that all wound sites were off-loaded. On 10/16/2024 at 10:22 AM, Resident #176 was observed in bed. The air mattress weight setting pressure control knob was set to firm at 360 pounds. On 10/22/2024 at 11:10 AM, Resident #176 was observed in bed. The air mattress weight setting pressure control knob was set to firm between the 360-pound and 400-pound settings. The resident was lying on their back. During an interview on 10/22/2024 at 11:27 AM, Licensed Practical Nurse #1 (unit nurse, not assigned to Resident #176 today) stated housekeeping is responsible for adjusting the weight setting on the air mattress pump. Licensed Practical Nurse #1 checked the mattress pump setting and confirmed that the air mattress weight setting was set between 360-400 pounds. Licensed Practical Nurse #1 did not attempt to adjust the setting and stated they were unfamiliar with the air mattress pump and had never touched the setting. A review of the October 2024 Medication Administration Record revealed Licensed Practical Nurse #1 had signed for monitoring, placement, function, and setting of the concave air mattress for Resident #176 during the month on multiple occasions. During an observation and interview on 10/22/2024 at 11:46 AM, Housekeeping Director #1 observed and assessed Resident #176's air mattress with the Surveyor and stated the air mattress was deflated, even though the air mattress weight setting was set at the maximum weight. Housekeeping Director #1 stated the air mattress was malfunctioning and would have to be changed. Housekeeping Director #1 stated the weight setting on the air mattress should be set according to the resident's weight. The nurses on the unit should check the mattress weight setting, as well as the mattress itself, and notify housekeeping if the air mattress is malfunctioning. During an interview on 10/22/2024 at 1:47 PM, Certified Nursing Assistant #1 stated they make sure the air mattress pump light is on and they also check to see if the mattress is firm, but they do not check the weight setting. Certified Nursing Assistant #1 stated the air mattress was firm when they checked right before they went to lunch today. During an interview on 10/22/2024 at 1:52 PM, Licensed Practical Nurse #3 (assigned to Resident #176) stated they do not check the weight setting on the air mattresses. They just check to see if the mattress is firm. Licensed Practical Nurse #3 stated the mattress was fine today when they did the medication pass administration at 9:00 AM. A review of the October 2024 Medication Administration Record revealed Licensed Practical Nurse #3 had documented for monitoring, placement, function, and settings of concave air mattress for Resident #176 during the month on multiple occasions, including for 10/22/2024. During an interview on 10/22/2024 at 2:13 PM, Licensed Practical Nurse #4 (wound care nurse) stated the weight setting on the air mattress should be consistent with the resident's weight, and the nurses on the unit should check the air mattress weight setting during daily care because it is not uncommon for the air mattresses to malfunction. Licensed Practical Nurse #4 stated they did wound rounds today (10/22/2024) with the Nurse Practitioner, but did not check the air mattress setting for Resident #176 today due to an oversight. During an interview on 10/22/2024 at 2:34 PM, Nurse Practitioner #1 stated the weight setting on the air mattress should be consistent with resident weight because that helps with offloading and pressure relief. During an interview on 10/23/2024 at 9:26 AM, the Director of Nursing Services stated the unit nurses are supposed to check that the air mattress is functioning, is inflated properly, and the setting on the pump is appropriate each shift. The unit nurses should immediately report to the unit supervisor or the housekeeping staff if the setting on the pump is not accurate. The unit nurses do not change the setting. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #243) of six residents reviewed for Accident Hazards. Specifically, Resident #243's room was observed with an unsecured, free-standing oxygen E-Cylinder tank (the most common and largest portable oxygen tank) next to the resident's bed. The E-Cylinder tank was not secured in a rolling cylinder stand as per the facility's policy. The finding is: The facility policy and procedure titled Oxygen safety, last revised on 5/4/2024 documented that safety is the responsibility of all staff, residents, visitors, and the public. Hazards or other conditions that could develop into a hazard must be reported to a supervisor or Maintenance Director as soon as practical. Anyone may report a hazard or potential hazard. When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or medical equipment designed to receive and hold compressed gas cylinders. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty. Protect cylinders from damage by not storing them in locations where heavy objects may strike or fall on them, or where they can be tipped over by foot traffic or door movement. Resident #243 was admitted with Diagnoses of Alzheimer's, Diabetes, and Acute Cough. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #243 had severe cognitive impairment. The Minimum Data Set (MDS) documented that Resident #243 did not receive any Respiratory Therapy. Resident #243's Physician's Order dated 5/1/2024 documented DuoNeb 2.5 milligrams-0.5 milligrams per 3 milliliters solution for nebulization. Inhale 3 milliliters by nebulization route 3 times per day for Acute Cough. The order was discontinued on 9/11/2024. There were no documented Physician's Orders for the Oxygen use for Resident #243. A Comprehensive Care Plan (CCP) dated 6/15/2024 titled, Acute Cough, documented interventions that included nebulization treatment, medication as per Physician's Orders, and evaluation for shortness of breath, chest pain, and discomfort with breathing or coughing. During an observation on 10/16/2024 at 1:29 PM, a free-standing, unsecured E-cylinder oxygen tank was observed next to Resident #243's bed. The gauge needle of the E-cylinder oxygen tank was at 1,000 pounds per square inch (PSI, defined as the unit of measurement used to indicate the amount of oxygen in a tank or cylinder), which indicated that the oxygen tank was half full. A nebulizer mask and tubing were attached to the E-cylinder oxygen tank delivery port. During an interview on 10/16/2024 at 1:14 PM, Licensed Practical Nurse #5 stated Resident #243 used the oxygen tank for nebulization. Licensed Practical Nurse #5 stated they did not notice the E-Cylinder oxygen tank was still in Resident #243's room and was not secured in the rolling cylinder stand. Licensed Practical Nurse #5 stated all oxygen tanks must be secured in a rolling cylinder stand. During an interview on 10/21/2024 at 2:31 PM, Certified Nursing Assistant #2 stated they worked on the evening shift and did not notice the free-standing, unsecured E-Cylinder oxygen tank in Resident #243's room. Certified Nursing Assistant #2 stated they would have reported to the Nurse if they had seen the unsecured tank in Resident #243's room. During an interview on 10/21/2024 at 2:44 PM, Registered Nurse #3 stated that Resident #243 had an order for nebulization, and they had used the E-Cylinder oxygen tank for nebulization because they did not have a nebulizer machine at that time. Registered Nurse #3 stated that the physician's order for nebulization had been discontinued in September 2024. Registered Nurse #3 stated the E-Cylinder oxygen tank should have been taken out of Resident #243's room. Registered Nurse #3 stated they did not know the E-Cylinder oxygen tank remained unsecured in Resident #243's room. During an interview on 10/22/2024 at 8:46 AM, the Director of Plant Operation stated that all E-Cylinder oxygen tanks should be secured in a rolling cylinder stand. The Director of Plant Operation stated there should not be any oxygen tanks freely standing and unsecured. The Director of Plant Operation stated that oxygen tanks are combustible (able to catch fire and burn easily) and should not be dragged nor bounced on the floor due to static that can cause combustion. The Director of Plant Operation stated that an unsecured oxygen tank can fall, rupture, and cause physical damage because the tank is highly pressurized. During an interview on 10/22/2024 at 9:44 AM, the Director of Nursing Services stated there should not be any unsecured oxygen tanks in the unit. The nurses should not have used the E-Cylinder oxygen tank for nebulization because the facility had plenty of nebulizer machines. 10 NYCRR 415.12(h)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a system of records and accounts of all controlled drugs were maintained, and the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for three (Resident #207, Resident #301, and Resident #340) of three residents reviewed during the medication storage task and 2) one (Woodcrest 2 Unit) of nine units observed during the medication storage task. Specifically, 1) Resident #207 and Resident #301 Controlled Substance Disposition Record were not accurately reconciled after the medications were administered to the residents. -A Blister Pack containing 12 Marinol 10 milligram capsules (Scheduled III drug) was observed stored in the locked box in the medication refrigerator; however, there was no Controlled Substance Disposition Record maintained for the medication. 2) During an observation on the Woodcrest 2 Unit, pre-poured medications (three capsules and two tablets) were observed in a medication cup stored in the medication cart. Licensed Practical Nurse #9 was observed attempting to administer the pre-poured medications to the wrong resident. The findings are: 1) Resident #207 was admitted with diagnoses that included Multiple Sclerosis and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident received Opioids during the last seven days. Resident #207's physician order dated 9/28/2024 documented Oxycontin 10 milligram crush resistance, extended release, give 1 tablet by oral route every 12 hours for chronic pain. Resident #207's Medication Administration Record documented Oxycontin 10 milligrams was administered at the scheduled time of 9:00 AM on 10/22/2024. During a Medication Storage Task observation on 10/22/2024 at 10:55 AM on the [NAME] 2 Nursing Unit, Resident #207's Controlled Substance Disposition Record for Oxycontin (a narcotic medication) 10 milligrams documented that the last tablet was used on 10/21/2024 at 9:00 PM with 21 remaining tablets; however, the blister pack for the Oxycontin 10 milligram revealed there were only 20 tablets available. The Controlled Substance Disposition Record was not updated after the medication was administered to the resident on 10/22/2024 at 9:00 AM. Resident #301 was admitted with diagnoses that included Parkinson's Disease and Polyneuropathy. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment documented the resident received Opioids during the last 7 days. Resident #301's physician order dated 9/27/2024 documented Tramadol extended-release 100 milligrams, give 1 tablet by oral route once daily for pain. Resident #301's Medication Administration Record dated 10/2024 documented Tramadol extended release 100 milligrams, was administered at the scheduled time of 9:00 AM on 10/22/2024. During a Medication Storage Task observation on 10/22/2024 at 10:51 AM on the [NAME] 2 Nursing Unit, Resident #301's Controlled Substance Disposition Record for Tramadol (pain medication-controlled substance) Extended Release 100 milligrams documented that the last tablet was used on 10/21/2024 at 9:15 AM with eight remaining tablets; however, the blister pack for the Tramadol Extended Release 100 milligram only had seven tablets available. The Controlled Substance Disposition Record was not updated after the medication was administered to the resident on 10/22/2024 at 9:00 AM. -Resident #340 was admitted with diagnoses that included Cachexia (muscle loss) and Dysphagia (difficulty swallowing). The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status was 13, which indicated the resident had intact cognition. The Minimum Data Set documented the resident did not receive scheduled pain medication. Resident #340's physician order dated 6/9/2024 documented to discontinue Dronabinol (Marinol) 10 milligrams by oral route once daily. During a Medication Storage Task observation on 10/22/2024 at 10:58 AM on the [NAME] 2 Nursing Unit, a Blister Pack containing 12 Marinol 10 milligram capsules (Scheduled III drug) was observed stored in the locked box in the medication refrigerator. There was no Controlled Substance Disposition Record to indicate an account of the controlled drug was maintained and periodically reconciled for the past six months. The Controlled Substance Disposition Record provided by the facility documented the last entry on 4/4/2024 indicating 12 capsules were remaining. During an interview on 10/22/2024 at 11:15 AM, Licensed Practical Nurse #8 stated they had administered the Oxycontin and the Tramadol to the residents at 9:00 AM today, but did not sign the Controlled Substance Disposition Record. Licensed Practical Nurse #8 stated they had a bad habit of not signing the Controlled Substance Disposition Record and that it was their mistake that they were rushing. Licensed Practical Nurse #8 stated they should have reconciled and signed the Controlled Substance Disposition Record as soon as they had removed the tablets from the Blister Packs. Licensed Practical Nurse #8 stated they did not count the Marinol because they were not aware the medication was in the locked box stored in the refrigerator. Licensed Practical Nurse #8 stated they did not know the procedure to store the discontinued controlled medication. During an interview on 10/22/2024 at 11:57 AM, Registered Nurse #7 stated that Licensed Practical Nurse #8 should have reconciled the narcotics at the time they removed the tablets from the Blister Packs to ensure the accuracy of the narcotic count. Registered Nurse #7 stated that the nurses were inserviced on the proper process for reconciling controlled drugs. During an interview on 10/22/2024 at 3:47 PM, the Director of Nursing Services stated when the nurses remove the narcotics from the blister pack, they must sign the Controlled Substance Disposition Record immediately, then sign the Medication Administration Record after administration of the medication. The Director of Nursing Services stated that Licensed Practical Nurse #8 should have reconciled and signed the Controlled Substance Disposition Record at the time they removed the Medications (Oxycontin and Tramadol) from the Blister Packs. During a subsequent interview on 10/22/2024 at 4:01 PM, the Director of Nursing Services stated when a narcotic medication is discontinued, the nurses on the unit were responsible for providing the Controlled Substance Disposition Record and the Blister Pack to their Supervisor who would then bring both the Controlled Substance Disposition Record and the Blister Pack to the Director of Nursing Services. The Director of Nursing Services stated they and the Supervisor would reconcile the medication to ensure the accuracy of the medication on the Controlled Substance Disposition Record and the number of medications in the Blister Pack. The Director of Nursing Services stated they were not aware that Marinol was discontinued for Resident #340 as they did not receive the Controlled Substance Disposition Record or the Blister Pack from the unit. 44925 2) The Medication administration policy dated 9/07/2023 documented that medication administration will be conducted according to each resident's individualized care plan and physician's orders. Before administering any medication, nursing staff will verify the resident's identity using two patient identifiers (e.g., name band and date of birth) to ensure the right resident receives the right medication. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. Medications will be prepared in a clean and designated medication preparation area to prevent cross-contamination. Resident #100 had diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus, and Essential Tremor. The Minimum Data Set assessment dated [DATE] documented that Resident #100 had a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The physician's order dated 10/5/2024 documented Bupropion (antidepressant) 150 milligrams 24-hour tablet extended release 1 tablet by oral route once daily for nicotine dependence and Depression. Buspirone (anti-anxiety) 5 milligrams 1 tablet by oral route two times per day for anxiety disorder. Furosemide (diuretic) 40 milligrams tablet, give 1 tablet by oral route once daily at 9:00 AM daily, and Miralax (stool softener) polyethylene glycol 3350 17 grams/dose oral powder, give 17 grams mixed with 8 ounces of fluid by oral route once daily. The Woodcrest 2 Unit Medication Cart #1 was observed on 10/17/2024 at 9:24 AM with Licensed Practical Nurse #9. There was a medication cup containing two tablets and three capsules stored in the top drawer of the medication cart. The medication cup had 214 written on the cup. Licensed Practical Nurse #9 stated 214 indicated the resident room number. Licensed Practical Nurse #9 stated the medications in the cup had two capsules of Bacid (probiotic), two tablets of Tylenol (pain medication) 325 milligrams, and one capsule of Neurontin (medication for nerve pain) 100 milligrams. While Licensed Practical Nurse #9 was speaking to the Surveyor, Resident #100 approached Licensed Practical Nurse #9 and requested they get their medication. Licensed Practical Nurse #9 took the souffle cup with the pre-poured Neurontin and Bacid capsules and Tylenol tablets and attempted to administer the medications to Resident #100. Resident #100 stated they already received their morning medications and were only requesting to get the Miralax and that they did not reside in room [ROOM NUMBER]. During an interview on 10/17/2024 at 9:35 AM, Licensed Practical Nurse #9 stated they were a float nurse covering for the medication nurse on the Woodcrest 2 Unit. Licensed Practical Nurse #9 stated they offered the wrong medications to the wrong resident and realized that Resident #100 was not the correct resident to receive the medications that were stored in the souffle cup; they thought Resident #100 resided in room [ROOM NUMBER], but later realized that Resident #100 was not from room [ROOM NUMBER]. They should have checked the resident's identification band to make sure the medication was being administered to the right resident. Licensed Practical Nurse #9 stated they usually prepare the medications in front of the resident rooms and then administer the medications soon after they prepare them. Today they pre-poured the medications at the nursing station and identified the medication cups with the residents' room numbers. During an interview on 10/17/2024 at 9:43 AM, Registered Nurse Supervisor #9 stated that Licensed Practical Nurses should administer the medications immediately after preparing the medications in the medication cup. Before administering the medications, they must check the resident's name and the medication blister pack to ensure the right medication is being administered to the right resident. During an interview on 10/22/2024 at 4:18 PM, the Director of Nursing Services stated Licensed Practical Nurse #9 failed to follow the five rights for medication administration policy which were: the Right resident, the right medication, the right time, the right dose, and the right route. The Director of Nursing Services stated that the medications should never be pre-poured and should never be left in the medication cart without proper identification labels. 10 NYCRR 415.18(a)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure all drugs and biologicals used in the facility were maintained and stored under proper temperature control. This was identified during a Medication Storage and Labeling Task on one ([NAME] 2 Unit) of nine Nursing Units observed. Specifically, [NAME] 2 Nursing Unit medication refrigerator temperature was observed to be at 60 degrees Fahrenheit. There were two unused/unopened Insulin injection pens and a box of Trulicity (used for Diabetes) injection pens observed stored in the medication refrigerator. Both unopened medications were supposed to be stored in the refrigerator at a temperature between 36 degrees Fahrenheit to 46 degrees Fahrenheit as per the manufacturer's recommendations. The finding is: The facility's Storage of Medication Requiring Refrigeration policy and procedure revised on 7/24/2024 documented that the facility will ensure all medications and biologicals will be stored at proper temperature controls. The refrigerator used for the storage of medications and biologicals includes an accurate functioning thermometer, temperature should be maintained between 36-46 degrees Fahrenheit and the refrigerator temperature is to be monitored every shift to ensure proper temperature control. During a tour of the [NAME] 2 Unit, with Charge Registered Nurse #6 on 10/22/2024 at 11:25 AM, the unit's medication refrigerator was observed with two Insulin injection pens and a box containing Trulicity injection pens. The medication refrigerator temperature was observed to be at 60 degrees Fahrenheit. During an interview on 10/22/2024 at 11:30 AM, Registered Nurse #6 stated they did not know if the temperature for the medication refrigerator was checked on the morning of 10/22/2024. Registered Nurse #6 stated that the temperature of the medication refrigerator is checked daily by the medication nurse and documented on the log sheet. Registered Nurse #6 stated they could not find the daily temperature log sheet for the medication refrigerator. Registered Nurse #6 stated that they did not know the acceptable temperature range for the medication refrigerator or the temperature range for storage of the Insulin and Trulicity pen. During an interview on 10/22/2024 at 3:47 PM, the Director of Nursing Services stated the temperature of the medication refrigerator should be checked daily on every shift by the nurses on the unit. The Director of Nursing Services stated the nurse who counted the narcotics on 10/22/2024, was responsible for checking the temperature of the medication refrigerator. The Director of Nursing Services stated if there was a problem with the thermometer or the refrigerator, the nurses were responsible for reporting to the Maintenance Department for timely follow-up. 10 NYCRR 415.18(e)(1-4)

Based on record review and staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure laboratory services were obtained in a timely fashion to meet the needs of each resident. This was identified for one (Resident #108) of five residents reviewed for Unnecessary Medications. Specifically, a Lipid Profile (a blood test to determine different types of fat in the blood) was ordered for Resident #108 in response to a pharmacist medication regimen review. The blood test was ordered in the electronic medical record on 9/27/2024 and 10/11/2024 but was not communicated to the laboratory and therefore was not done. The finding is: The facility's policy titled Diagnostic Tests and Results, dated 3/22/2022 documented it is the policy of the facility to identify diagnostic tests and results that are needed for the management of resident's care and delineate the timeframe in which the tests and results are expected to be performed or available. Further, the facility will ensure that the results of these tests are communicated to the treating provider in a manner that is timely, accurate, complete, and understood by the recipient. The facility will continuously measure, assess, and, if needed, take action to improve its performance with respect to the above as part of its Quality Assurance and Performance Improvement initiative. Resident #108 was admitted with diagnoses including Non-Alzheimer's Dementia, Diabetes Mellitus, and Depression. The 8/29/2024 Annual Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision making. A physician's order dated 6/26/2024 documented Quetiapine (an antipsychotic medication) 50 milligrams tablet; give 1 tablet by oral route once daily at bedtime for diagnosis of Major Depressive Disorder and Unspecified Psychosis. A Medication Regimen Review dated 9/23/2024 documented the resident is currently receiving Quetiapine (Seroquel). Unable to locate recent hemoglobin A1C (a blood test that measures a person's average blood sugar level over the past 2-3 months) and Lipid Profile in the chart. Recommend three months after the start of medication and then annually thereafter. The Physician/Prescriber responded Agree/Will Do on 9/27/2024. A physician's order dated 10/11/2024 ordered the following blood tests: Complete Blood Count (measures the number of cells in your blood), Comprehensive Metabolic Panel (measures chemical balance and metabolism), hemoglobin A1C, Lipid Profile, and Thyroid Stimulating Hormone (measures level of thyroid-stimulating hormone in your body) to be collected on 10/11/2024. A review of the medical record revealed there were blood test results from blood collected on 10/11/2024 for Complete Blood Count, Comprehensive Metabolic Panel, hemoglobin A1C, and Thyroid Stimulating Hormone. There were no results for the Lipid Profile. During an interview on 10/22/2024 at 8:37 AM, Laboratory Representative #1 stated there were no laboratory work results for a lipid profile and did not even see an order for a lipid profile. During an interview on 10/22/2024 at 8:54 AM, Physician #1 stated they just started working in the facility on 10/10/2024 and could not explain why the Lipid Profile was not done. Physician #1 stated the lipid profile bloodwork should have been done if it was ordered. During an interview on 10/22/2024 at 9:54 AM, Registered Nurse #1 (unit supervisor) stated there is a two-step system when ordering lab work. First, the order has to be entered into the electronic medical record, and then the laboratory has to be notified through a separate ordering system not related to the resident's medical record. Registered Nurse #1 stated usually, if a resident is prescribed an antipsychotic medication, due to the risk of dyslipidemia (abnormal lipid profile), there should be a lipid profile completed within three months from when the medication was started and then annually thereafter. There is no explanation as to why the lipid profile was not done as ordered on 10/11/2024. During an interview on 10/23/2024 at 9:22 AM, the Director of Nursing Services stated the residents' electronic medical record is not interfaced with the laboratory. All of the laboratory work that was ordered on 10/11/2024 should have been done and the facility will have to speak to the laboratory to determine why the lipid profile was not done. During an interview on 10/23/2024 at 11:25 AM, Registered Nurse #4 (overnight supervisor who entered order on 10/11/2024) stated the laboratory work for the lipid profile should have been drawn, but they did not know why the lipid profile was not done. 10 NYCRR 415.20

Based on observation, record review and interviews conducted during an abbreviated survey (NY00322869) initiated on [DATE] the facility failed to ensure that each resident receive treatment and care in accordance with professional standards of practice for 1 out of 5 residents (Resident #1). Specifically, on [DATE] at 6:05 PM Resident #1 experienced respiratory distress. At 7:55 PM Nurse Practitioner #1 assessed the resident and ordered the resident to be transferred to the hospital. Registered Nurse #1 did not follow the order to call for emergency medical transportation, instead Registered Nurse #1 called a non-emergency ambulance service. The company reported that it would take 2 hours for the ambulance to arrive. The resident's family intervened at approximately 9:00 PM and demanded that emergency services (911) be called. The Registered Nurse #1 did not call for emergency transportation via emergency services until 9:20 PM, causing a 1 hour and 33-minute delay in emergency transport treatment. Subsequently, Resident #1 expired while waiting for emergency transportation. This resulted in actual harm to Resident #1 with potential for serious harm for 426 other residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The facility's policy titled Resident Change in condition dated [DATE] documented when a significant change in a resident's condition is identified, the licensed nurse will immediately inform the charge nurse or nursing supervisor. The charge nurse or nursing supervisor will promptly assess the resident and initiate appropriate interventions. The medical provider and the resident's authorized representative will be notified about the change. The policy does not address if or when Emergency Medical Services should be notified. A Comprehensive Care Plan dated [DATE] titled Ventilator Dependent documented resident is on a mechanical ventilator secondary to inability to maintain adequate oxygen saturation. Interventions include evaluate for gurgling respirations, increase secretions and sputum, and inform medical doctor as indicated. The facility Administrator stated that when an emergency requires an ambulance there is no policy that indicates how staff are to determine which ambulance provider to contact. Resident#1 was admitted to the facility [DATE] with diagnoses including Anoxic Encephalopathy (lack of oxygen to the brain causing brain damage), Chronic Embolisms (blood clot), Respiratory Failure/Ventilator Dependent. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) indicating severe impairment. A review of the facility's Transfer Form (form to be sent when a resident is going to the hospital dated [DATE] at 8:03 PM documented that Resident #1 was being transferred to the hospital for Respiratory Distress. A review of the Nurse Practitioner Progress note dated [DATE] at 8:49 PM documented at 7:55 PM Resident #1 was seen for tachycardia (rapid heartbeat), profuse diaphoresis (excessive sweating), and tachypnea (fast breathing). Resident #1 was evaluated with the respiratory team present. Oxygen saturation desaturated to 89% with the ventilator setting set to 60% oxygen, (normal oxygen saturation is 95% or greater), the ventilator oxygen setting was increased to 100% by the respiratory team to maintain residents' oxygen at ,d+[DATE]%, heart rate ,d+[DATE] (normal heart rate ,d+[DATE] beats per minute). Resident was currently on intravenous fluids. Status Post Vancomycin and Zosyn (antibiotics). Resident #1 remains unchanged. Plan of care discussed with Medical Doctor. Transfer Resident #1 to the hospital for further evaluation. Discussed with nursing staff. The Nurse Practitioner #1 note dated [DATE] documented at around 9:00 PM Resident's family showed up and inquired as to why Resident #1 was still in the facility and not at the hospital. Resident's #1 family requested for emergency services to be called. Emergency services were called immediately. Resident #1 was unresponsive when Emergency Medical Services arrived, and they pronounced Resident #1 deceased . A review of Resident #1's Death Certificate dated [DATE] at 9:40 PM, documented the immediate cause of death as cardiorespiratory arrest due to respiratory failure. A review of the Prehospital Care Report filled out by the emergency medical transport technician documented that Emergency Medical Services were notified on [DATE] at 9:20 PM that Resident #1 had breathing problems. Emergency services ambulance staff were at Resident #1's bedside at 9:33 PM. Resident #1 was found in semi-Fowlers position (the head of the bed is elevated ,d+[DATE] degrees) in a hospital bed at the facility and was pulseless. Resident #1 is ventilator dependent, whom according to staff became tachycardic while being evaluated by nurse practitioner at 7:45 PM. Staff increased their ventilator settings, after no improvement called a private ambulance for transport to the hospital. After 1 hour waiting for a private ambulance, the staff decided to call 911. Resident #1 was pronounced deceased after an electrocardiogram (a test that records the hearts electrical activity) was attached to Resident #1 and was found to be in asystole (when the hearts electrical system fails entirely, which causes your heart to stop pumping). During a telephone interview on [DATE] at 4:35 PM, unit Registered Nurse # 1, who worked on the evening shift on [DATE], stated at 8:00 PM, Nurse Practitioner #1 stated to transfer Resident #1 to the hospital. Registered Nurse #1 stated they called the Richmond County Ambulance at 7:50 PM-8:00 PM. Registered Nurse #1 stated they told Nurse Practitioner #1 that there was a 2-hour timeframe for the ambulance. They stated the Nurse Practitioner did not say anything. They stated that at around 9:00 PM the next of kin came and told them to call Emergency Medical Services. Emergency Medical Services came to the facility within 10 minutes. The Emergency Medical Services stated there was no reason to take Resident #1 because the resident had already died . During an interview with Nurse Practitioner #1 on [DATE] at 4:44 PM they stated they assessed Resident #1 and called the Medical Doctor. The Medical Doctor stated to transfer Resident #1 to the hospital. They stated the order was to be carried out right away. Resident #1 was diaphoretic and tachycardic and they wanted Resident #1 to go to the hospital for further evaluation. During a re-interview with Nurse Practitioner #1 on [DATE] at 10:46 AM they stated they expected their order to transfer Resident #1 to the hospital to be carried out immediately. They stated they were not informed that the ambulance would take 2 hours. They stated had they been aware they would have called Emergency Medical Services immediately. During an interview on [DATE] at 12:57 PM with Medical Director, who is also the attending physician for Resident #1, they stated Resident #1 was ventilator dependent and was experiencing respiratory distress and was tachycardic. The Medical Director stated they gave the order for Nurse Practitioner #1 to transfer Resident #1 to the hospital at approximately 7:55 PM. The Medical Director stated that Resident #1's transfer to the hospital was delayed. During an interview with the Director of Nursing on [DATE] at 7:15 PM, they stated on [DATE] in the evening, Resident #1 had a change in condition, but the staff felt Resident #1 was stable. The Director of Nursing stated they reviewed the record on [DATE], after Resident #1 expired and identified no issues. They stated Resident #1 was a chronic tracheostomy resident. When the Nurse Practitioner and Registered Nurse assessed Resident #1 there was no need to call Emergency Medical Services. They stated they would not have called an ambulance because Resident #1 was stable, they would have called the regular Richmond County ambulance ambulette. During an interview with the Administrator on [DATE] at 7:30 PM they stated on [DATE] in the evening, Resident #1 had a change in condition, but the staff felt Resident #1 was stable. The facility will develop a policy related to calling an ambulance for an immediate need for transfer. The facility will train all medical providers and licensed nursing staff related to an emergency transfer policy. 10 NYCRR 483.25

Based on observation, record review and interview during an abbreviated survey (NY00334107), the facility failed to have a system in place to ensure that each resident received adequate supervision to prevent accidents. Specifically, Resident #1 had a history of unsafe smoking and was found by facility staff smoking unsupervised outside of the designated time on four occasions. The facility staff were aware of the resident's noncompliance with smoking; however, there were no interventions put in place to maintain the resident's safety. Resident #1 utilized supplemental oxygen therapy for the diagnosis of Chronic Obstructive Pulmonary Disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Subsequently, on 2/22/2024, Resident #1 sustained a burn to their face (upper lip and on either side of the nose) while smoking unsupervised with oxygen via a nasal cannula. This resulted in actual harm for Resident #1, that is Immediate Jeopardy. The findings are: The facility's Smoking policy dated 02/18/2021 documented, it is the policy of the facility to allow residents who smoke the right to do so in a safe manner that ensures the health and safety of all residents. The policy further documented that if the resident is non-compliant with the smoking policies and rules, staff will take appropriate action. The policy did not document the smoking rules, supervision, or monitoring of residents to prevent smoking related accidents. Resident #1 was admitted with diagnosis including Chronic Obstructive Pulmonary Disease. The Admission Minimum Data Set (MDS) dated [DATE], documented Resident #1 has a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. Resident #1 used a wheelchair for mobility and independently propelled themselves across the facility. Resident #1 was not identified for tobacco use during this assessment. The MDS further documented Resident #1 uses oxygen. A review of Resident #1's physician order revealed the resident received an order dated 12/14/2023 for 4 liters of Oxygen as needed via nasal cannula. A review of the facility's Incident Accident Report dated 02/22/2024 revealed at 8:45 PM the Resident sustained a burn to their bilateral cheeks, nose, and mustache. The Root Cause Analysis portion of the report documented that Resident #1 was smoking while using oxygen. Registered Nurse #1 documented the nasal canula worn by the resident was observed to be blackened and there was an oxygen tank attached to the wheelchair. The final determination was the resident was smoking while the oxygen was in use. A review of Resident #1's smoking care plan initiated on 11/22/2021 revealed Resident #1 had a history of smoking and does not have cigarettes at this time. The care plan further documented that Resident #1 finds cigarettes within facility and is non-compliant with the smoking policy and procedures. Resident had a history of noncompliance with smoking on the following dates: 06/17/2022, 04/06/2023, 07/21/2023 and 10/16/2023. There is no documented evidence the facility increased supervision or monitoring of Resident #1 after the incidents of noncompliance. A review of Resident #1's Nurse Practitioner progress note dated 02/22/2024 at 10:47 PM documented under the Head, Eyes, Ears, Nose and Throat portion of the Nurse Practitioner's physical examination of Resident #1 that the resident sustained burns to bilateral nasal labial folds which extended to the resident's cheeks. The physical examination report also documented that Resident #1's nostrils were black, and that Resident #1 complained of blurry vision. The Nurse Practitioner's progress note concluded that Resident #1 was sent to the emergency room for further evaluation. Furthermore, a review of Resident #1's wound consult progress note dated 02/27/2024 at 12:31 PM documented under the History of present illness and significant events portion of the wound consult note that Resident #1 suffered burns to their face while smoking cigarette while on oxygen therapy. The wound consult progress note documented that Resident #1 sustained wound to their face measuring 5.0 x 9.0 centimeters. The wound consult note recommended the necessary course of treatment to Resident #1's wound which were being administered to the resident's facial wound. During an observation conducted on 2/27/2024 at 11:16 AM, Resident #1 was observed with a surgical mask, areas of redness and blisters were noted on both cheeks. During an interview conducted on 02/27/2024 at 2:58 PM, Certified Nursing Assistant #1 stated that Resident #1 wheeled themselves independently around the facility. Certified Nursing Assistant #1 further stated they were aware the resident smoked but did not know how they obtained smoking materials. During an interview with Social Worker #1 on 02/27/2024 at 12:40 PM they stated the resident has a smoking contract on file but does not have cigarettes. Social Worker #1 stated the facility does not know how Resident #1 obtained cigarettes or lighters. Social Worker #1 stated the facility had designated smoking times and designated staff who assist residents with smoking. Residents are to be supervised during smoking sessions. During an interview on 02/27/2024 at 4:05 PM the Director of Nursing stated that the resident had violated the smoking policy by smoking outside of the designated smoking times on more than one occasion. The Director of Nursing stated that smoking outside the designated smoking time poses fire safety and burn threats to the entire residents and staff of the facility. The Director of Nursing stated that no resident was supposed to be in possession of any smoking paraphernalia (cigarette and lighter). The Director of Nursing stated that the facility was aware that Resident #1 was on oxygen, however, the facility did not reassess nor educate the resident for safe smoking while oxygen was in use because the resident's previous smoking violations did not involve oxygen. The Director of Nursing stated Resident #1's behavior of smoking without supervision and the facility's inability to account for how the resident got the cigarette and lighter poses safety risks to Resident #1, and all other residents and staff of the facility. During an interview with the Administrator on 02/27/2024 at 5:05 PM they stated the incident with Resident #1 smoking which resulted in injury was an isolated incident. The Administrator reiterated that the facility was aware that Resident #1 was on oxygen, however, the facility did not reassess nor educate the resident for safe smoking while oxygen was in use because the resident's previous smoking violations did not involve oxygen. The Administrator stated, Resident #1 was assessed as having a BIMS (Brief Interview of Mental Status, an assessment to determine level of cognition) score of 15 indicating intact cognition. This should guide Resident #1's decision to smoke safely. The Administrator stated that the facility needed to revise their policy addressing situations such as the safety concern identified with Resident #1. The Administrator stated that a root cause analysis needed to be done to establish the source of the cigarettes and lighter in Resident #1's possession. The Administrator stated the current investigation and Resident #1's revised care plan did not monitor for effectiveness of the care plan. During an interview with the Medical Director on 02/28/2024 at 10:40 AM, they stated they were not Resident #1's attending physician, however, they were aware of the incidents that involved Resident #1s' violation of the facility's smoking policy. The Medical Director stated the facility intervention for Resident #1's smoking violations should have been reviewed and amended following the first, second, and third identified violations. The Medical Director stated the incidents of smoking while using oxygen created a safety risk to Resident #1 and other residents throughout the facility. During an interview with Resident #1 on 2/28/2023 at 2:47 PM they stated the cigarette blew up in their face while smoking in the courtyard. The resident would not provide any additional information. 10 NYCRR 415.12(h)(1)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00310476) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #738) of four residents reviewed for Pressure Ulcers. Specifically, Resident #738 was admitted to the facility with an unstageable pressure ulcer to the sacral region which deteriorated to a Stage 4 pressure ulcer. The resident was identified as a high risk for pressure ulcer development. On 8/1/2022 Resident #738 was identified with a new Stage 3 pressure ulcer (pressure injuries that extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) to the left shoulder and on 8/29/2022 with a new Stage 4 pressure ulcer (pressure injuries that extend to muscle, tendon, or bone) to the right shoulder with no prior documented evidence of the resident's skin being compromised in these areas. This resulted in actual harm to Resident #738 that is not Immediate Jeopardy. The finding is: The facility's policy titled, Wound Interventions - Interdisciplinary dated 12/16/2020 and last revised 2/18/2022 documented that to provide interdisciplinary wound interventions to assist in the development of a care plan. These interventions will be selected based on the individual needs of the resident. Procedures included but were not limited to avoid repositioning resident on pressure ulcers; Establish a written repositioning/turning schedule using a turning clock; When the side-lying position is used, a 30-degree turning position should be used; Use devices such as pillows or foam wedges to prevent direct contact between bony prominences; Use a lifting sheet; Select appropriate support surface for the resident in bed and/or in a chair; and Use a dynamic surface such as air-loss mattresses, if indicated. The facility's policy titled, Turning and Positioning dated 5/23/2023 documented regular turning and repositioning of residents is essential to prevent the development of pressure ulcers. The residents who are immobile or have a higher risk of pressure ulcers may require more frequent turns. Nursing home staff will document the turning and positioning schedule, interventions performed, and the resident's responses in the resident's record. Documentation should include the date, time, and staff member responsible for each turn. Any changes in the resident's skin condition or the development of a pressure ulcers will be addressed promptly. The facility's policy titled, Pressure Ulcer Notification/Investigation Form dated 6/2014 documented that upon identification or decline of a pressure ulcer, the clinical Nurse Manager/Licensed Nurse will conduct an investigation and complete the pressure ulcer notification/investigation form. The pressure ulcer investigation form must be initiated by the end of the shift in which the new pressure ulcer was identified. The Nurse Manager/Licensed Nurse will complete all information on the form pertinent to the identification of a new pressure injury; Conduct an investigation to determine causative factors and document findings on the form; Once completed the form is to be placed in the Wound Care Nurse's mailbox; Inform the Nursing Supervisor/Assistant Director of Nursing (ADNS); Document (the pressure ulcer) in the Progress Notes and place the resident on the 24 hour report; Notify the Medical Doctor (MD)/Nurse Practitioner (NP) of the findings and obtain a treatment order and initiate the treatment as ordered. Nurse at time of the finding is to inform the resident's contact; Wound care will notify the interdisciplinary team; A separate care plan will be initiated upon discovery of the pressure injury; Plan of care to be reviewed and new interventions to be placed as needed. Resident #738 had diagnoses which included Respiratory Failure, Anoxic (lack of oxygen) Brain Injury, and was Ventilator dependent. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making and a Brief Interview for Mental Status (BIMS) could not be completed. The resident was totally dependent on the assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one Stage 4 pressure ulcer upon admission to the facility. The resident utilized pressure-reducing devices while in a chair and bed and was on a turning and repositioning program. The Comprehensive Care Plan (CCP) for Skin Integrity: At Risk for Skin Breakdown dated 1/9/2022 documented no reasons as to why the resident was at risk for skin breakdown. The interventions included for the Certified Nursing Assistant (CNA) to evaluate the resident's skin condition daily during care and report any skin abnormalities to the Nurse; Provide incontinent care; and to maintain turning and positioning schedule as recommended. The CCP for Skin Integrity: Sacrum dated 1/11/2022 documented that the resident had an Unstageable pressure ulcer upon admission which progressed to a Stage 4. The interventions included to monitor the ulcer site and dressing placement every shift; Maintain turning and positioning schedule every 2 hours as recommended; Monitor and report changes in ulcer's size, drainage, and color; Provide treatments as ordered by the Medical Doctor (MD); and monitor effectiveness of treatment(s) ordered. The CCP was updated on 1/12/2022 indicating the sacral pressure ulcer was now a Stage 3 measuring 3 centimeters (cm) x 2 cm x 0.1 cm. The CCP was updated on 3/24/2022 indicating the pressure ulcer to the sacrum was now assessed as a Stage 4 measuring 9 cm x 6 cm x 0.2 cm. The Wound Care Progress Note dated 1/11/2022 written by the former Registered Nurse (RN) Wound Care Nurse (RN #15) documented that the resident was seen status post (s/p) new admission and was identified with a left plantar foot blister, a left heel Deep Tissue Injury (DTI), and a Sacral unstageable pressure ulcer measuring 2 cm x 2 cm x 0 cm. The plan of care (POC) included to continue with turning and repositioning every 2 hours and as needed and to continue to be seen and followed by the wound care team on a weekly basis. The Physician Order's dated 5/4/2022 documented Comfort Measures Only (CMO), Do Not Hospitalize (DNH), Do Not Resuscitate (DNR), No Antibiotics, No intravenous (IV) Fluids, No laboratory work-up, and No weights. A Nursing Assessment created on 7/23/2022 and completed on 8/1/2022 documented that the resident's Braden Scale (a tool used to identify the risk for developing pressure ulcer) score was 12 indicating that the resident was at high risk for developing pressure ulcers. The Wound Care assessment dated [DATE] written by the Wound Care Physician (WCP) documented that the resident had a Stage 4 pressure injury to the sacrum measuring 17.0 cm in length, 19 cm in width, and 0.5 cm in depth. The wound bed had 95% pink granulation (healthy tissue), 5% yellow slough (dead tissue), and 0% black eschar (dead tissue). The recommendations included to adhere to the facility repositioning and decubitus prevention protocol. The Wound Care Progress Note dated 7/25/2022 written by the former RN Wound Care Nurse (RN #15) documented that the resident was seen by the wound care team on 7/25/2022. The Stage 4 sacral wound measured 17 cm x 19 cm x 0.5 cm. Continue Santyl (enzymatic debridement agent)/Alginate (wound dressing). The CNA Documentation Record dated July 2022 documented that the resident's skin was checked every day once on the 7:00 AM-3:00 PM shift, once on the 3:00 PM-11:00 PM shift, and once on the 11:00 PM-7:00 AM shift. The CNAs documented either an a which meant performed or a g which meant issue reported and documented under the Skin Check/Care task. The CNA Documentation Record dated July 2022 also documented that the resident was turned and positioned every two hours under the Turn and Position task. The Wound Care assessment dated [DATE] written by the WCP documented that the resident's Stage 4 pressure injury to the sacrum now measured 19.0 centimeters (cm) in length, 20 cm in width, and 0.5 cm in depth. The Wound Care Assessment also documented for the first time that the resident now had a Stage 3 pressure injury to the left shoulder measuring 3.5 cm in length, 3.5 cm in width, and 0.2 cm in depth. The wound bed had 80% pink granulation and 20% yellow slough. The Physician's Order dated 8/1/2022 documented to apply Santyl 250 unit/gram topical ointment - Cleanse the left shoulder with normal saline (NS). Apply Santyl followed by Calcium Alginate. Cover with a dry protective dressing (DPD) daily and as needed. The Wound Care Progress Note dated 8/1/2022 written by the former RN Wound Care Nurse (RN #15) documented that the resident was seen by the wound care team on 8/1/2022. The Stage 3 left shoulder pressure ulcer measured 3.5 cm x 3.5 cm x 0.2 cm with moderate odorless drainage. Review of Nursing Progress Notes revealed no documentation related to a change in skin condition to the resident's left shoulder prior to 8/1/2022. The Comprehensive Care Plan (CCP) for Skin Integrity: Stage 3 Left Shoulder dated 8/2/2022 documented that the resident was seen by the wound care team on 8/1/2022. The wound was stable and to continue with the current plan of care (POC). The Wound Care assessment dated [DATE] written by the WCP documented that the resident had a Stage 4 pressure injury to the sacrum measuring 17.0 centimeters (cm) in length, 20 cm in width, and 0.5 cm in depth. The Wound Care Assessment also documented that the resident had a Stage 3 pressure injury to the left shoulder measuring 2.5 cm in length, 3.5 cm in width, and 0.3 cm in depth. The CNA Documentation Record dated August 2022 documented that the resident's skin was checked every day, once on the 7:00 AM-3:00 PM shift, once on the 3:00 PM-11:00 PM shift, and once on the 11:00 PM-7:00 AM shift. The CNAs documented either an a which meant performed or a g which meant issue reported and documented under the Skin Check/Care task. The CNA Documentation Record dated August 2022 also documented that the resident was turned and positioned every two hours under the Turn and Position task. The Wound Care assessment dated [DATE] written by the WCP documented that the resident had a Stage 4 pressure injury to the sacrum measured 18.0 centimeters (cm) in length, 20 cm in width, and 0.5 cm. The Stage 3 pressure injury to the left shoulder measured 2.0 cm in length, 3.0 cm in width, and 0.2 cm in depth. The Wound Care Assessment also documented for the first time that the resident now had a Stage 4 pressure injury to the right shoulder measuring 3.5 cm in length, 14.0 cm in width, and 0.2 cm in depth (Many measured as one). The wound bed had 90% pink granulation, 10% yellow slough. The Physician's Order dated 8/29/2022 documented to apply Santyl 250 unit/gram topical ointment, cleanse the right shoulder wound with NS, apply Santyl and Calcium Alginate, and cover with DPD. Review of Nursing Progress Notes revealed no documentation related to a change in skin condition to the resident's right shoulder prior to 8/29/2022. The CCP effective for Skin Integrity: Stage 4 Right Shoulder dated 8/29/2022 documented that the resident was seen by the wound care team on 8/29/2022. Right shoulder Stage 4 scattered (areas) measured 3.5 cm x 14.0 cm x 0.3 cm with 90% pink and 10% yellow wound bed. Moderate amount of drainage. Treatment continues with Santyl and Alginate. The Treatment Administration Record (TAR) for the month of July 2022 and August 2022 to monitor skin Integrity daily. The TAR was signed by nursing staff to indicate the skin was monitored daily as documented. The current RN Wound Care Nurse (RN #9) was interviewed on 8/8/2023 at 12:30 PM and stated that when they do weekly wound rounds with the WCP, they (RN #9 and WCP) do not have the time to do a full body check of the resident because there are a lot of residents to be seen. RN #9 stated that sometimes during weekly wound rounds, they (RN #9 and WCP) may spot something else, but most times they (RN #9 and the WCP) go straight to the wound that they (RN #9 and WCP) are there to evaluate. RN #9 could not explain how the right shoulder pressure ulcer was initially identified as a Stage 4 on 8/29/2022. The former RN Wound Care Nurse (RN #15) was interviewed on 8/08/2023 at 1:50 PM and stated that the first time they (RN #15) are made aware of a pressure ulcer, they (RN #15) write a Progress Note. RN #15 stated that they (RN #15) could not recall what happened and why the first time the resident's left shoulder was seen on wound rounds on 8/1/2023, it was already a Stage 3. RN #15 stated that when a pressure ulcer is first identified, an RN or a Licensed Practical Nurse (LPN) has to fill out a pressure ulcer communication form and send it to the Wound Care Office. RN #15 stated that then an investigation would be conducted to try and determine how the pressure ulcer occurred and these investigations were kept in a binder in the Wound Care Office. The Wound Investigation Reports for Resident #738's the left and right shoulder pressure ulcers were requested on 8/8/2023 from the Director of Nursing Services (DNS) and from the Administrator; however, the facility was not able to provide the Wound Investigation Reports related to the resident's left shoulder pressure ulcer identified on 8/1/2022 and the right shoulder pressure ulcers identified on 8/29/2022. On 8/9/2023, the DNS provided an Investigative Report Injury of Unknown Origin Skin dated 8/1/2022 for the resident's left shoulder wound and 8/29/2022 for the resident's right shoulder wound. Staff assigned to the resident on the preceding shifts for 48 hours, including RNs, Licensed Practical Nurses (LPNs), and CNAs were interviewed and all stated that they had no knowledge of either wound prior to wound care rounds. The root cause analysis of the pressure ulcer development was the resident had impaired mobility, incontinent of bowel and bladder, totally dependent for mobility for turning and positioning, with respiratory failure on a ventilator and receiving Tube feedings (fed by a tube into the stomach), had a history of (h/o) Cardiac Arrest, h/o Drug Abuse, diagnosis of Seizures, h/o Osteomyelitis (bone infection), and Skin Impairment admitted with a large sacral Stage 4 pressure ulcer. The resident's primary 3:00 PM-11:00 PM Certified Nursing Assistant (CNA) #11 was interviewed on 8/8/2023 at 2:45 PM and stated they were not the person who found either of the resident's shoulder pressure ulcers. CNA #11 stated that the resident was a two person assist for bathing, brief changing, and for turning and positioning. CNA #11 stated that the only time the resident came out of bed was when they were showered. CNA #11 stated that the resident was only able to be turned from side to side because the wound on the resident's sacrum was so big. CNA #11 stated that when they positioned the resident, they would put two pillows along the resident's front, one pillow between their knees, and two pillows along their back. CNA #11 stated that the procedure is to turn and position a resident every two hours, but they have other residents that also need to be dealt with so there really is no set time for turning and positioning and that the resident would be turned 2 to 3 times on their shift. CNA #11 stated that the resident would also sweat a lot and they would change Resident #738's gown when they repositioned the resident. The resident's primary 3:00 PM-11:00 PM LPN #7 was interviewed on 8/9/2023 at 10:00 AM and stated that they remembered the resident well due to the resident's large sacral wound. LPN #7 stated that the resident was laying on their back for most of the time with a pillow on each side of them underneath their hips to take pressure off the sacral area. LPN #7 stated that if a resident was comfortable and asleep, it was their right to not be disturbed and not turned and positioned during the night. LPN #7 stated that they never had a treatment to do for Resident #738 and therefore would never have a reason to turn them (Resident #738) over. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 10:45 AM and stated that Wound Investigation Reports are completed for nosocomial pressure ulcers (developed at the facility); however, the Wound Investigation Reports could not be found for the left and right shoulder wounds that the resident developed in the facility. The DNS stated that a Progress Note should have been written when each wound was first identified and by whom. The resident's primary 7:00 AM-3:00 PM CNA #12 was interviewed on 8/09/2023 at 11:50 AM and stated that if they see any redness on a resident, they would notify a Nurse and they did not notice any changes in the resident's skin. CNA #12 stated that they could not remember who first discovered the resident's shoulder wounds. CNA #12 stated that they try their best to turn and position a resident every 2 hours, especially a resident with wounds, but sometimes it is difficult when there are only 4 or 5 CNAs working a shift instead of the usual 6 CNAs. CNA #12 stated that the resident was never on their back due to the large sacral wound. CNA #12 stated that they would position the resident on their side with one pillow behind the back from the shoulder to their waist and one pillow between their legs. CNA #12 stated that the resident was showered on their shift twice a week and if it was not a shower day, they would clean the resident in bed and change the resident's gown because the resident would sweat a lot. The resident's primary 11:00 PM-7:00 AM shift CNA (CNA #13) was contacted on 8/9/2023 at 2:05 PM and was unavailable for interview. The Wound Care Physician (WCP) was interviewed on 8/9/2023 at 2:15 PM and stated that by definition a wound is a Stage 3 when it has slough at the base. The WCP stated residents on ventilators, such as Resident #738, are compromised patients with multiple issues and a wound could develop fairly quickly due to lack of mobility, nutritional factors, and overall multiple comorbidities. The WCP stated that despite seeing the resident on a weekly basis, a wound could have developed at any time during that week. The WCP stated that someone must have told them that the resident had something on their (Resident #738) shoulders for them to assess the resident's shoulders during wound rounds. The WCP stated that they would think that the resident's skin had to be compromised in some way before it developed to a Stage 3 or Stage 4. The WCP stated that they would assume that the resident's skin would have shown some redness first because the skin cannot go from nothing to something. The WCP stated that neither the CNAs nor the Nurses brought a change in the resident's skin condition to their attention. The WCP stated the first time they saw the resident's left shoulder pressure ulcer the wound was already a Stage 3 and the first time they saw the right shoulder pressure ulcer the wound was assessed as a Stage 4. The DNS was re-interviewed on 8/9/2023 at 3:50 PM and stated that the resident's skin could not have been intact and then gone to a Stage 3 or a Stage 4 pressure ulcer. The DNS stated that there had to have been some change in the resident's skin that should have been seen when showering the resident, turning and positioning the resident, and when changing the resident's clothes. The DNS stated that there was no documentation of the resident's left and right shoulder pressure ulcers prior to being seen on wound rounds and there should have been. The DNS also stated they would not expect a resident to be left on their back to sleep on during the 11:00 PM - 7:00 AM shift if the resident was on turning and positioning program. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that pain management was provided to each resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #116) of two residents reviewed for Pain Management. Specifically, Resident #116 with diagnosis of Multiple Sclerosis (MS-a chronic disease of the central nervous system) had a Physician's order to receive Baclofen (a muscle relaxant) 10 milligrams (mg), give two tablets 20 mg every 12 hours at 6:00 AM and 6:00 PM for muscle spasms. Resident #116 did not receive the 6:00 PM dose of Baclofen on 7/22/2023. The resident reported their pain level was 9 out of 10 because the Baclofen was not administered. Additionally, the facility staff did not monitor or assess resident's pain level on 7/22/2023 during the 3:00 PM-11:00 PM shift. This resulted in actual harm to Resident #116 that is not Immediate Jeopardy. The finding is: The facility's policy, titled Pain Management, dated 8/26/2022, documented to ensure that residents receive appropriate pain management interventions, promoting their comfort, well-being, and overall quality of life. Medications will be prescribed and administered based on the resident's pain assessment and care plan. Accurate documentation of pain assessment, interventions, and resident responses will be maintained in the resident's record. Resident #116 was admitted with diagnoses including Multiple Sclerosis, Diabetes Mellitus, and Pain. The 6/15/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident was receiving the pain medication regimen and had no pain in the last 5 days. During the Resident Council Meeting held on 8/2/2023 at 12:52 PM, Resident #116 stated that on 7/22/2023 they did not receive their pain medication, Baclofen, during the evening shift and they were in a lot of pain. The Comprehensive Care Plan (CCP) for Pain: Alteration in Comfort related to MS dated 8/3/2017 and last reviewed on 6/29/2023 documented interventions including ongoing assessment of pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors; administer medications as ordered by the physician, encourage to report pain and discomfort as soon as possible, monitor for effectiveness of pain medication and revise pain management as needed; and obtain a pain scale before and after administration of pain medications. Physician's orders dated 6/24/2023 documented: -Baclofen 10 mg tablet, give two tablets (20 mg) by oral route every 12 hours (6:00 AM and 6:00 PM) for a diagnosis of Muscle Spasms. -Baclofen 10 milligram (mg) tablet, give one tablet by oral route once daily at 1:00 PM for a diagnosis of Muscle Spasms. -Monitor and record pain every shift. Review of the July 2023 Medication Administration Record (MAR) revealed that the resident did not receive the 6:00 PM dose of Baclofen on 7/22/2023 and the resident's pain was not monitored during the 3:00 PM-11:00 PM shift on 7/22/2023. There were no comments on the MAR indicating why the pain medication was not administered and why the pain was not monitored. The medical record including the nursing progress notes did not indicate why the Baclofen was not administered and why the pain assessment was not completed on 7/22/2023 during the 3:00 PM-11:00 PM shift Registered Nurse (RN) #5 was interviewed on 8/10/2023 at 9:29 AM and stated they (RN #5) were the only assigned medication nurse for Resident #116's unit on the 3:00 PM-11:00 PM shift on 7/22/2023. RN #5 stated they (RN #5) were responsible to administer medication to the entire unit; however, they were not able to complete the medication pass for the side of the unit that Resident #116 resides on. RN #5 stated they were not able to administer the evening medications for Resident #116 because they (RN #5) were working alone that night and they were just learning the medication pass process at the facility. Review of Resident #116's medical record revealed no documented evidence that RN #5 contacted the physician or a supervisor about not being able to administer the resident's evening medications as per the physician's orders on 7/22/2023. Physician #1, who was Resident #116's Physician, was interviewed on 8/10/2023 at 9:35 AM and stated they were not aware that Resident #116 missed their evening medications on 7/22/2023. Physician #1 further stated that Baclofen helps with muscle spasms. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 10:44 AM and stated for missed medications, the doctors and the family member have to be informed. The DNS stated any negative outcomes should be determined; medication error investigations should be completed, and education is needed. The DNS stated RN #5 should have reached out for help from a supervisor if there was a staffing problem. Resident #116 was interviewed on 8/10/2023 at 11:33 AM and stated they have multiple sclerosis and get muscle spasms. Resident #116 stated they were in a lot of pain and had a terrible night on 7/22/2023 because they missed the muscle relaxant. Resident #116 stated they have been on Baclofen for a long time and the pain is mainly in their legs and right arm. Resident #116 stated on the night of 7/22/2023 their pain level was 9 on a scale of 0-10 (zero being the least pain and 10 being the highest pain level). Resident #116 stated the Baclofen helps and most of the time the pain is tolerable, but if they miss the Baclofen, the pain gets very uncomfortable. Resident #116 was re-interviewed on 8/10/2023 at 4:20 PM. Resident #116 stated they (Resident #116) told the 11:00 PM-7:00 AM Licensed Practical Nurse (LPN) #2 about their pain level on 7/22/2023. Resident #116 stated LPN #2 told the resident that they (Resident #116) had to wait until the next dose of the Baclofen was due at 6:00 AM on 7/23/2023. Physician #1 was re-interviewed on 8/10/2023 at 4:34 PM. Physician #1 stated if the resident reports they have pain level of 9 out of 10 you have to take their statement as valid. Physician #1 stated missing the Baclofen dose may have caused Resident #116 discomfort. The resident was not happy, and the resident wants to make sure that does not happen again. Physician #1 stated they were surprised that no one called them to let them know the resident was in pain. Physician #1 stated they would have told the nurse to administer the Baclofen, even though the dose was missed at 6:00 PM. Physician #1 stated the nurse should have called them. 10 NYCRR 415.12

Based on observation, staff interviews and record review during an abbreviated survey (NY 474), the facility failed to accurately identify the resident's advance directive status and did not initiate Cardiopulmonary Resuscitation (CPR) when a resident was found unresponsive and with no pulse. This was evident for 1 (Resident #1) of 4 residents reviewed for Advance Directives. Specifically, Resident #1 who had a Full Code status as documented in the Social Work notes, Physician notes and the Comprehensive Care Plan was not provided with life- saving CPR when found unresponsive and with no pulse. Licensed Practical Nurse (LPN) #1 and Registered Nurse Supervisor (RNS) #1 did not verify the resident's code status after noting a discrepancy and did not initiate CPR. This resulted in actual harm to Resident #1 with the potential for serious harm for 291 Residents with full code status that is immediate jeopardy and substandard quality of care. The findings are: The facility's policy titled Do Not Resuscitate (DNR) dated [DATE] documented all residents admitted to the facility shall be presumed to consent to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest unless there is a consent for issuance of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physicians will document the DNR order in the medical record. DNR orders must be reviewed and renewed by the attending physician each time the resident is required to be seen, but not less than once every 30 days and must indicate that the order was reviewed in the resident's chart. Residents with DNR orders will be identified in the following ways: 1) an alert will be initiated in sigma (symbol of orange circle); 2) an orange label on the spine of the resident's medical record; 3) an orange identification on the resident's bracelet indicating DNR. The armband shall be worn always. A list of DNR's will be distributed by the social worker department to each unit as they are updated as needed. The facility's policy titled Cardiopulmonary resuscitation (CPR) dated [DATE] documented it is the policy of the facility that when cardiac/respiratory arrest occurs, prior to arrival of EMS, at a minimum basic life support must be provided via chest compression, artificial ventilation and use of AED as indicated. The initiation of CPR to a resident who experiences cardiac/respiratory arrest will be in accordance with the resident's advance directive. CPR-certified staff will be available at all times to provide CPR when needed. Brain death begins ,d+[DATE] minutes following a cardiac arrest if CPR is not initiated. CPR will be immediately initiated in the case of cardiac arrest unless: resident has an advanced directive declining CPR with a valid DNR order by the physician in place; there are obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, decomposition). Resident's code status of DNR order will be in the Electronic Medical Record (EMR) on the horizontal tab next to the patient's name. The facility's policy titled Resident identification bracelets revised on [DATE] documented all residents will always have an identifying wristband in place to allow for proper resident identification. The admitting nurse or unit clerk will verify if any additional tabs need to be placed on the resident's ID wristband, including but not limited to allergy (red), aspiration precaution (blue), elopement risk (green), or DNR (orange), and place them on ID wristband. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS-an assessment tool) dated [DATE] documented the resident with Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. The Advance Directives documented resident had no advance directives. The Comprehensive Care Plan (CCP) dated [DATE] documented the Resident had advance directives of healthcare proxy. The CCP lacked documented evidence of resuscitation instructions. Interventions included assist Resident responsible party to enact advanced directives and review advanced directives quarterly and as needed with resident and responsible party. On [DATE], the Social Worker (SW #1) documented the Resident did not wish to initiate MOLST at this time. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An advance directive order for HCP was written on [DATE] and [DATE]. The Nurse Practitioner's (NP#1 and NP #2) notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] documented Resident was a full code. The Nurse's Progress notes (NPN) dated [DATE] at 7:30 AM by Registered Nurse Supervisor (RNS #1) documented a pronouncement of death note at 6:55 AM. Clinical signs and symptoms of death: unconscious and unarousable (yes), absence of respiration (yes), palpable pulse (no), absence of heartbeat (yes), no audible or palpable blood pressure (yes), pupils fixed and dilated-non-reactive (yes), body shows signs of rigidity (rigor mortis) (no), signs of lividity (cyanosis/blood pooling) (yes). An additional note documented Writer was called to the unit to see the resident who was reported to be unresponsive. When seen Resident presented with no signs of life. Resident is DNR. This was respected and resident was determined expired at 6:55 AM. The NPN dated [DATE] at 10:34 AM by Licensed Practical Nurse (LPN#1) documented at 6:55AM during morning meds, I was called by the CNA that the resident is not responsive. I observed resident lying in bed with no pulse, full vitals taken immediately. RNS#1 notified; MD made aware. The NP #2 note dated [DATE] at 1:41 PM documented time of death 6:55 AM, cause of death cardiac arrest, cardiac arrhythmia and [CONDITION(S)] ([CONDITION(S)]). Resident#1's identification (ID) wrist band given to the surveyor by the Director of Nursing (DON) had a DNR orange tab alert and hemodialysis purple tab alert. Review of Resident #1's Electronic Medical Record (EMR) under alerts lacked an alert for DNR, a symbol of orange circle. The facility's investigative summary completed on [DATE] documented on [DATE] a discrepancy was identified regarding Resident's expiration which facilitated an immediate investigation. Interviews were performed and statements obtained. On [DATE] at 6:45 AM CNA #1 and CNA #2 reported they observed Resident#1 looked dead and RNS #1 came to the room. LPN#1 stated at 6:55 AM they were alerted by CNA#1 that the Resident is unresponsive with no pulse, no respiration and could not obtain vital signs LPN#1 notified RNS #1. LPN#1 noted Resident#1 had ID band on with orange tab indicating resident is a DNR. The Resident's EMR lacked the orange symbol indicating DNR. LPN#1 alerted RNS #1 about the band and EMR discrepancy and LPN#1 stated they were instructed by RNS #1 to follow the wishes of Resident#1 as DNR. RNS #1 statement documented they responded to the Resident's room at approximately 6:55 AM and the Resident showed no signs of life. RNS #1 reported they checked the Resident's ID band and observed an orange dot listing patient as DNR and respected their wishes and did not initiate CPR. RNS #1 stated that on review of the Resident data on the unit they were unable to locate any advance directive information and utilized the Resident clinical presentation and ID band to make their decision. The facility's investigative summary also documented that based on information, the facility reviewed the incident as part of their Quality Assurance Program Initiative (QAPI). A review of policy and procedure and appropriate actions were not taken by staff and additional measures could have been utilized to identify patient advance directives. The findings revealed RNS #1 relied on Resident's clinical presentation and overt signs of death as well as the orange tab ID band indicating resident was a DNR. RNS #1 did not follow policy and procedures or adhere to professional standards of practice of verifying the resident's advance directives and code status after noting a discrepancy as the patient EMR. During an interview on [DATE] at 10:55 AM the night shift CNA#1 stated on [DATE] at approximately 6:45 AM, while doing rounds they noted Resident#1 did not respond to their name. CNA #1 turned on the light and the resident appeared unresponsive. Resident was pale, mouth was open, and resident was not breathing. CNA #1 called LPN #1; LPN #1 checked the resident's ID band which had a DNR alert. LPN #1 called RNS #1, they came and observed the resident is DNR, as per the wristband. During an interview on [DATE] at 12:31 PM the night shift LPN #1 they stated on [DATE] while they were giving medications, CNA #1 told them that Resident#1 was unresponsive. They went to the room and took the vital signs and noted an absence of pulse. The Resident's body was warm, not breathing and not responding to sternal rub. LPN #1 checked the armband and found the armband indicated DNR. They told CNA #1 to stay with the resident and they went to check the EMR. The EMR indicated Resident had no DNR order. They informed RNS #1 regarding the discrepancy and waited for further instructions. LPN #1 stated if the Resident was not a DNR the protocol was to call a code blue and start CPR. LPN #1 told RNS #1 they would get the crash cart and RNS #1 stated no. LPN #1 stated they told RNS #1 several times that the Resident #1 was a full code. RNS #1 instructed them to do their work and notify the family and doctor of Resident's expiration. During a phone interview on [DATE] at 2:37 PM the night shift RNS #1 stated on [DATE] they received a call from LPN #1 at approximately 6 or 7AM that they found the resident dead. RNS #1 stated they took their penlight and checked the Resident's pupils and noted pupils were fixed and dilated. They checked the carotid pulse and noted an absence of pulse, resident's skin was cold, and mottling started to take place. RNS #1 stated the Resident had an armband that indicated DNR status. RNS #1 stated they checked the Medical Doctor (MD) orders and did not find any documentation regarding advance directives. There was no documentation of DNR in the EMR. RNS #1 stated they followed Resident's ID band and clinical presentation of the Resident not to do CPR. RNS #1 stated if Resident did not have ID band, they would have called a Code Blue. RNS #1 stated usually there is a list at the nursing station on a green paper from SW with all Residents on floor and their DNR status. During an interview on [DATE] at 5:30 PM with the Director of Nursing (DON) they stated they were made aware of the incident during morning meeting on [DATE]. The DON stated the RN Risk Manager (RNRM) initiated the investigation and identified an issue that the EMR had no orange alert and CPR was not performed for Resident #1, who was a full code. Both nurses were removed from the schedule the morning of incident. They were both terminated as of [DATE] and they were reported to the Office of Professions. The facility immediately in-serviced all licensed staff on [DATE] on emergency response, CPR, documentation on codes and ID band accuracy. The DON stated as of [DATE] they have in-serviced 221 staff out of 350 staff and as of [DATE] 299 staff received in-service which is about 85% of the total licensed staff. The 15% of staff who did not receive in-service were not scheduled to work and will be given in-service before returning to work. The facility changed the ID band policy that the admission nurse will apply Resident's arm band and the SW will double check to make sure the armbands are appropriate. The DON stated an audit was conducted by unit clerks to ensure ID band alerts were correct. The facility did an audit of all MD orders to ensure accuracy. Human Resources identified 40% of staff were not up to date with their CPR certification. DON stated they have arranged for CPR classes to have the 40% get their updated CPR certification. DON stated they have staff on all shifts that are CPR certified. The SW did an audit and updated the care plan to ensure resident's wishes were communicated to licensed staff. There is an orange binder on each unit which list all residents with DNR. There was a new admission audit form to ensure all information is on the form and uploaded to the EMR. During a phone interview on [DATE] at 7:34 PM with the Administrator they stated they were informed during morning report on [DATE] at 9:30 AM that Resident expired and there is an issue with expiration. They immediately initiated the investigation and investigation revealed Resident #1 was wearing ID band with Hemodialysis and DNR tab/alert on the band and based on documentation on the Resident's chart in multiple places it says the Resident is a full code. RNS #1 relied on the ID band and did not perform CPR. LPN #1 acknowledged there was discrepancy on chart on multiple documentation and ID band. LPN #1 spoke to RNS #1 and did not perform CPR or call code blue. Based on findings the facility tried to implement changes to make sure this will not occur again. RNS #1 and LPN #1 were suspended pending investigation and were terminated and reported to The Office of Professions. In the investigation, the facility did note there were areas they can put measures in place to help the staff. The SW conducted audits on all care plans to ensure advance directives were current and updated. The Unit Clerk conducted an audit of resident armbands. An emergency Quality Assurance Performance Improvement (QAPI) was held today all residents who are a full code will have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All audits were started on [DATE]. Staff were in serviced on emergency codes, ID bands and CPR. The IJ began on [DATE]. The Administrator was informed of the Immediate Jeopardy and provided with the Immediate Jeopardy template on [DATE]. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey: The facility On [DATE] the facility conducted a facility wide audit of residents' armbands to ensure placement, alert accuracy, EMR match and DNR status. Mandatory Inservice-Emergency Response was started on [DATE] for all licensed staff. As of [DATE] they have 299 out 350 which is 85% of licensed staff received in-service. The remaining 15% percent are not on the schedule to work and will be in-serviced prior to commencing work. Interviews conducted on [DATE] at [DATE] with all staff (4 CNAs, 1 LPN, 2 RNs, and 2 RNS), RN Risk Manager, DON and Administrator to ascertain the post incident in-service training/education regarding facility's procedures on identifying resident's code status. Termination of RN Supervisor & LPN on [DATE]. Reported both nurses to The Office of Professions on [DATE]. Facility Wide Care Plan Audit-of all advanced directive care plans. Reviewed polices on advanced directives, facility codes and identifiers with revision to ID band policy to include licensed personnel to check for accuracy. Facility Wide EMR Audit-checked all residents for CPR and DNR orders for accuracy. The facility checked all the residents' physicians' orders for CPR and DNR. CPR certification- all licensed staff will have updated certification by [DATE]. 483.24(a)(3)

Based on record review and interviews during an abbreviated survey (Complaint # NY 859), the facility did not ensure one (Resident #1) of three residents reviewed for pressure ulcers received necessary treatment and services including a comprehensive assessment to address development, evaluation and follow up of the resident's skin impairment. Specifically, Resident #1 had a pressure ulcer to the right lower buttocks/ischium that was identified by the resident on 09/20/2018 which was not assessed until 09/23/2018 by a Registered Nurse (RN). The same RN (RN#2) initiated treatment without a physician's orders [REDACTED]. Upon return to the facility on [DATE], there was no pressure ulcer assessment nor revision to the treatment plan. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings are: The facility's policy titled Management/treatment of [REDACTED]. -When a pressure ulcer is identified, the nurse will notify the attending physician and document findings in the progress notes. -The nurse who identifies the ulcer must initiate treatment immediately and proceed with appropriate notification and documentation of same. The licensed nurse will complete and forward the Nursing/Wound Care Communication Form to the Wound RN/Designee. - The physician/Medical Provider will document a medical note and order an appropriate treatment when the pressure ulcer is identified and will continue to document the status of the pressure ulcer in monthly progress notes or when medically necessary until the area is healed. The physician's orders [REDACTED]. -Pressure ulcer will have a care plan implemented that documents an interdisciplinary approach to the healing of the pressure ulcer which reflects the guidelines for the treatment of [REDACTED]. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 09/05/2018 documented the resident with severely impaired cognition. He required extensive assistance with Activities of Daily Living. The resident was occasionally incontinent of urine and always incontinent of bowel. The resident was at risk for developing pressure ulcers with pressure reducing device for the bed and chair. The Braden Scale (pressure ulcer risk assessment tool) dated 03/10/2018 documented that the resident was at moderate risk for developing pressure ulcers. The Comprehensive Care Plan (CCP) for at Risk for Pressure Ulcer/Injury effective 07/17/2017 updated on 06/26/2018 documented interventions to include check and change incontinent briefs every 2-4 hours and as needed, the CNA evaluation of skin condition daily during care and report any skin abnormalities to nurse. Monitor the resident for signs of circulatory problems i.e. discoloration, [MEDICAL CONDITION], changes in the skin temperatures, swelling, c/o pain, monitor/report skin for redness, [MEDICAL CONDITION], openings, rashes, bruising, blisters, excoriation, etc. The medical record dated 08/01/2018 to 09/22/2018 lacked documented evidence of a skin impairment to the resident's buttock or the ischium. A nursing progress note by the RN #2 dated 09/23/2018 at 1:18 AM, documented that the resident was alert and oriented times three. The RN documented Right lower buttocks/ischium skin noted dark purple with serosanguineous drainage. Need MD evaluation. Communicated via the book. (Telephone order) for (normal saline cleanse), pat dry, apply [MEDICATION NAME] (cover dressing) once daily and as needed till healed. A late entry note by Physician #1 on 09/23/2018 for 09/20/2018 documented that the resident stated he had a wound on his backside, and it looked purplish in color. The medical record lacked documented evidence of a physical examination by Physician #1 of the resident's buttock/ischium on 9/20/18 or order for treatment to the affected area. The telephone physician's orders [REDACTED]. The order was not signed by the physician until 10/06/2018, after the resident was discharged from the facility. The Treatment Administration Record (TAR) for 09/2018 documented: to right lower buttock/Ischium, normal saline cleanse (NSC), pat dry and apply [MEDICATION NAME] every day and as needed. The TAR was signed by the staff indicating treatment administration from 09/23/18 through 10/05/2019. The Nursing notes by RN #1 dated 09/24/2018 and 09/25/2018 documented (treatment) completed and ischium and right buttocks improving. Physician's #1 note dated 09/25/2018 documented the resident was concerned about a purplish lesion on his right buttock/hip. The physician documented that she did not examine the resident's buttock/hip wound. The physician further documented that she would examine the resident when the wound care nurse was available to minimize moving the resident in order to minimize the resident's discomfort. The nursing progress notes by RN #1 dated 09/26/2018 and 09/27/2018 documented that the ischium and right buttocks were improving, and the treatment was completed. The medical record lacked documented evidence that a CCP was initiated or updated for the resident's impaired skin condition to the right buttock/ischium from 09/23/2018 through his discharge from the facility. The nursing progress note dated 09/29/2018 documented the resident was transferred to the hospital at 10:10 PM for complaints of chest pain and blood in the sputum. The emergency room Initial Triage/Intake assessment dated [DATE] at 10:35 PM documented, the resident had an unstageable pressure ulcer to the right buttock that was beefy red and a black/eschar measuring 30 centimeters (cm) x 15 cm. An unstageable pressure ulcer to the left buttock, beefy red, black eschar 10 cm x 10 cm. The resident was diagnosed with [REDACTED]. The nursing progress note dated 09/30/2018 documented, the resident returned from the hospital on [DATE] at 4:30 AM. The medical record lacked documented evidence of a skin assessment or treatment evaluation for the right and left buttock upon the resident's return from the hospital on [DATE]. The Certified Nursing Accountability Records for 09/2018 and 10/2018 documented the skin checks were completed for the resident with no skin impairment. The interdisciplinary notes from 09/28/2018 through 10/05/2018 lacked documented evidence of any notations regarding the buttocks and ischium skin impairment including a wound care consult for Resident #1. The RN#1 note dated 10/05/2019 at 12:49 PM documented, the resident was transferred to the hospital for Altered Mental Status at 11:45 AM. The Emergency Department Adult Triage Note dated 10/05/2018 at 1:10 PM, documented that the resident had multiple pressure ulcers in various stages of healing around the sacrum, genital area, and bilateral thighs. The RN #1 was interviewed on 08/13/2019 at 1:36 PM and stated that RN#2 had brought to her attention that the resident had a stage II ulcer on his hip or buttock (date not recalled). She could not recall the exact location. She became aware of the ulcer the following day and that there was a treatment in place. The RN stated that the Physician #1 was made aware of the resident's left hip or buttock wounds by RN #2. Resident #1 did not allow Physician #1 and the wound care nurse to assess the wound on a few occasions (dates not recalled). RN #1 stated that there was documentation of the resident's refusal however, she could not find it in the resident's medical record. In a follow-up interview on 08/13/2019 at 2:43 PM, RN #1 could not recall the characteristics of the resident's wound. The regular day shift Certified Nursing Assistant was interviewed on 08/13/2019 at 2:51 PM and stated that she could not recall that the resident had any skin impairment on his right buttock/ischium while she was taking care of the resident. RN #2 was interviewed on 08/13/2019 at 3:23 PM and stated that according to her documentation on 09/23/2018, the resident was noted with a purplish wound with serosanguineous drainage to the right buttock. The physician was not notified of the wound because it was 1:00 AM at night. She wrote a telephone order for the treatment by herself without notifying the physician and documented her findings in the communication book for the physician. The Director of Nursing (DON) was interviewed on 08/13/2019 at 4:17 PM and stated that when the resident's skin impairment was observed by RN #2 on 09/23/2018, there should have been documentation in the medical record of a detailed description of the resident's wound to ascertain the staging of the wound, a wound consult should have been initiated to address the wound treatment. The primary care physician (#1) did not assess the wound either and should have. A CCP should have been developed and updated with new interventions. There was no change in the wound treatment as the resident was not assessed and followed by the wound care physician and wound care nurse. When the resident was readmitted to the facility on [DATE], a prudent nurse should have reassessed the resident's skin condition, however, no skin assessment as the resident returned back from the hospital with 12 hours. The Registered Dietitian (RD) was interviewed on 08/16/2019 at 10:53 AM and stated that she was not aware that the resident had wounds to his buttock/ischium. She stated that the nursing staff will report to her if a resident developed a wound and that assessment and interventions would be put in place however, this was not done for Resident #1. The Medical Director (MD) was interviewed on 08/16/2019 at 1:22 PM and stated that Physician #1 was seeing the resident almost on a daily basis. The MD stated that according to the late entry note on 09/23/2018, the resident had complaints of wound to his buttock area and that a physical examination was not conducted by Physician #1. The MD expected the physician to examine the resident on 09/20/2018. Some physicians may not want to get involved with a resident's wounds and would obtain a wound consult. There was no order for a wound consult for the resident. There was also no documentation in the medical record of an assessment related to the resident's wounds. A follow-up interview was conducted with the MD on 08/16/2019 at 2:10 PM and he stated that Physician #1 documented in her progress notes that she was aware of the wounds and not the treatment. The wound care nurse (WCN) was interviewed on 09/17/2019 at 12:27 PM, she stated that she was the wound care nurse at the facility in (MONTH) and (MONTH) (YEAR). She did not recall the resident. She further stated that if she did not write a wound care note, completed a wound care assessment or update care plan it meant that she was not notified of the resident's skin impairment. Multiple attempts were made to contact Physician #1. The physician was not reachable. 415.12 (c) (2)

Based on record review and staff interview during an abbreviated survey, the facility did not ensure that each resident remained free from mistreatment, neglect and misappropriation of property. Specifically 1) one (Resident #1) of 3 residents admitted with a [DIAGNOSES REDACTED]. The physician was not notified until 8/26/15 at which time lab work was ordered. The hemoglobin level of 4.3 (critical) and Hematocrit level of 13.9 (critical) indicated a loss of blood. The resident was transferred to the hospital and received blood [MEDICAL CONDITION] and 2) one (Resident #2) of three sampled residents reviewed for misappropriation of property, had three of his Workmen's Compensation checks cashed by the facility without his consent/permission. This resulted in actual harm that is not Immediate Jeopardy for Resident #1. Complaint ID Number: NY 185, NY 639, Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) dated 06/19/2015 for Actual [MEDICAL CONDITION] Reflux documented interventions including monitor for active GI Bleed. The Minimum Data Set 3.0 (MDS- clinical assessment tool) dated 07/24/2015 documented Resident #1's cognitive status as intact. The Nursing Progress Notes (NPN) dated 08/19/2015 at 12:27 AM documented the resident complained at 5:00 PM of not feeling well, vital signs taken T (Temperature) 98.6, heart rate 66, respiration 18, blood pressure 83/38. The resident's daughter called and was notified of the resident's status. The resident was to be monitored for black colored stool and report to the medical Doctor. The 11 PM - 7 AM shift was made aware. Resident #1's medical record lacked documented evidence of physician notification or any clinical follow up related to the black colored stool from 08/19/15-08/25/15. The Certified Nursing Assistant (CNA) Accountability Record dated 08/19/2015 on the evening shift documented a large, pasty bowel movement. The NPN dated 08/24/2015 at 2:00 PM documented T97.6, BP126/65, P 56, oxygen saturation 98% R18. The resident is alert, responds to verbal and tactile stimuli, out of bed to wheelchair with assist x1. The resident transferred to another building this shift. All belongings given to the floor, all medications including narcotics given to the nurse. The Interim physician order [REDACTED]. The NPN dated 08/27/2015 at 2:30 PM documented the resident labs returned with HGB 4.3 (critical), HCT 13.9 (critical), the Medical Doctor made aware and gave an order to transfer to emergency room for possible blood transfusion. The daughter, who was visiting, was made aware. The Interim Physician order [REDACTED]. During an interview with the Director of Nursing (DON), on 09/02/2015 at 11:29 AM she stated that on 08/26/2015 the resident's daughter reported that the resident appeared pale, and that she had a history of [REDACTED]. The DON followed up with the family concerns, and no specimen was found or ordered in the other building. The physician was called (by the DON) and ordered a CBC, a BMP, and stools for occult blood x2. Folic Acid and an iron supplement were added to the resident's medication regimen. The laboratory report was received on 08/27/2015, the physician was notified and the resident was transferred to the hospital. The DON also stated that when a resident presents with dark stools and the nurse is notified, the physician should be made aware so that the resident can have a follow up of labs and stools specimen. An interview with the 3 PM-11 PM Registered Nurse (RN) #1 was conducted on 09/02/2015 at 3:25 PM, she stated that on 08/19/2015 Resident #1 complained that she was not feeling well. She checked on the resident and checked her vital signs, blood pressure 83/38. The Attending Physician was called and made aware of the blood pressure and gave orders to hold the blood pressure medications x72 hours. She called Resident #1's daughter to notify her of the resident's status and was told by the daughter that the resident had a dark colored, tarry stool. RN #1 gave report to the 11 PM-7 AM nurse and placed the resident on the 24 hour report. She did not notify the Physician or the Registered Nurse supervisor about the stools. It was late, and she didn't know why the doctor was not notified. She also stated she was not aware that the resident had a [DIAGNOSES REDACTED].#1 stated she checked the nursing admission assessment for the [DIAGNOSES REDACTED]. During an interview with 7:00 AM-3:00 PM shift Certified Nursing Assistant (CNA) #1, on 09/03/2015 at 9:47 AM she stated that she was the primary caregiver for Resident #1. She assisted with bathing, dressing, hygiene and toileting. The resident was alert and oriented x3, and communicated her needs. Resident #1 reported, unable to recall the date, that the nurse told her she needed to give a stool sample, a specimen hat was placed on the toilet to collect the stool. The resident did not have a bowel movement that day. The primary nurse was made aware and stated that there was no order for a stool specimen, CNA #1 also stated she later received report (from the Registered Nurse) to monitor the resident for black stool. During an interview with the 7:00 AM-3:00 PM shift Licensed Practical Nurse medication nurse (LPN) #1 on 09/03/2015 at 10:15 AM, she stated that the resident was alert and oriented x3 and communicated her needs. LPN #1 stated that the resident did complain of having dark and bloody stools, (when she was in the first building, did not recall the date) and she told the resident that the staff was aware. LPN#1 stated she did not report this to the Registered Nurse, or the Physician she assumed that the nurse who placed the resident on the report communicated with the Physician. During a telephone interview with the Attending Physician on 09/03/2015 at 11:50 AM, he stated that when a resident is admitted from the hospital with a GI Bleed it is usually resolved before discharge. He did not recall being notified of the resident having black tarry stools. He stated if a resident has a low blood pressure, and dark colored or black tarry stools he should be notified. The Attending Physician also stated if he was notified, an order would have been given for blood work, and with a low blood pressure the resident's blood pressure should have been monitored every 4-6 hours. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-clinical assessment tool) dated 04/20/2015 documented Resident #2's cognitive status as being intact. Review of an email received by the Facility's Administrator on 06/26/2015 (a complaint) documented that the Finance Department had been taking checks mailed and addressed to (Resident #2), opening and depositing them. Four Checks dated 03/09/2015, 04/20/2015, 05/04/2015, and 06/15/2015 payable to Resident #2, in the amount of $840.00 were signed and countersign by the facility staff. The Facility lacked documented evidence of a policy and procedure related to Mail Delivery prior to this incident. During an interview on 07/13/2015 at 11:13 AM with the Office Manager, she stated that when a resident received mail, including checks it is given to the social worker, if it is to be placed in the resident's account. Resident #2's mail came in and was forwarded to the finance office, (reason unknown) the checks were deposited to his account and applied to his bills. The checks should have been delivered to his room. The Medicaid coordinator spoke to Resident #2's family after concerns were voiced. The mail goes to the mail room then it gets dispatched to the unit where it is delivered to the resident. During an interview on 07/13/2015 at 3:21 PM with the Bookkeeper, she stated usually mail is forwarded from the mail room to the business office. She also stated that if the mail is addressed to a resident it should be delivered to the resident. She stated that the business office received mail that was forwarded from the Post Office for Resident #2. She stated that it should have been sent back to the resident. She added that the resident did not sign his checks, the facility stamped the checks to the bank with the facility's deposit stamp, and it went into our operating account. 415.4(b)

Based on staff interviews, and record review during an abbreviated survey, the facility did not ensure that each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically one (Resident #1) of 3 residents,' admitted with a [DIAGNOSES REDACTED]. Resident #1's medical record lacked documented evidence of a clinical workup from 8/19/15-8/25/15. On 8/26/15, Resident #1's Physician was notified of the black colored stools, blood work was ordered and revealed that Resident #1 had a Hemoglobin level of 4.3 (critical), and a Hematocrit level of 13.9 (critical). Both lab results indicate a loss of blood. Resident #1 was transferred to the hospital where she received blood [MEDICAL CONDITION]. This resulted in actual harm to Resident #1 which is not Immediate Jeopardy. Complaint ID number: NY 185 Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) dated 06/19/2015 for Actual [MEDICAL CONDITION] Reflux documented interventions including monitor for active GI Bleed. The Minimum Data Set 3.0(MDS- clinical assessment tool) dated 07/24/2015 documented Resident #1's cognitive status as intact. The Nursing Progress Notes (NPN) dated 08/19/2015 at 12:27 AM documented the resident complained at 5:00 PM of not feeling well, vital signs taken T (Temperature) 98.6, heart rate 66, respiration 18, blood pressure 83/38. The resident's daughter called and was notified of the resident's status. The resident was to be monitored for black colored stool and report to the medical Doctor. The 11 PM - 7 AM shift was made aware. Resident #1's medical record lacked documented evidence of any clinical follow up related to the black colored stool from 08/19/15-08/25/15. The Certified Nursing Assistant (CNA) Accountability Record dated 08/19/2015 on the evening shift documented a large, pasty bowel movement signed by the CNA. The NPN dated 08/24/2015 at 2:00 PM documented T97.6, BP126/65, P 56, oxygen saturation 98% R18. The resident is alert, responds to verbal and tactile stimuli, out of bed to wheelchair with assist x1. The resident transferred to another building this shift. All belongings given to the floor, all medications including narcotics given to the nurse. The Social Worker Progress Note dated 08/26/2015 documented this writer spoke with the resident and her daughter regarding issues with unit and long term placement. The nursing issues were referred to the Director of Nursing. The Interim physician order [REDACTED]. The NPN dated 08/27/2015 at 2:30 PM documented the resident labs returned with HGB 4.3 (critical), HCT 13.9 (critical), the Medical Doctor made aware and gave an order to transfer to emergency room for possible blood transfusion. The daughter, who was visiting, was made aware. The Interim Physician order [REDACTED]. During an interview with the Director of Nursing (DON), on 09/02/2015 at 11:29 AM she stated that on 08/26/2015 the resident's daughter reported that the resident appeared pale, and that she had a history of [REDACTED]. The DON followed up with the family concerns, and no specimen was found or ordered in the other building. The physician was called (by the DON) and ordered a CBC, a BMP, and stools for occult blood x2. Folic Acid and an iron supplement were added to the resident's medication regimen. The laboratory report was received on 08/27/2015, the physician was notified and the resident was transferred to the hospital. The DON also stated that when a resident presents with dark stools and the nurse is notified, the physician should be made aware so that the resident can have a follow up of labs and stools specimen. An interview with the 3 PM-11 PM Registered Nurse (RN) #1 was conducted on 09/02/2015 at 3:25 PM, she stated that on 08/19/2015 Resident #1 complained that she was not feeling well. She checked on the resident and checked her vital signs, blood pressure 83/38. The Attending Physician was called and made aware of the blood pressure and gave orders to hold the blood pressure medications x72 hours. She called Resident #1's daughter to notify her of the resident's status and was told by the daughter that the resident had a dark colored, tarry stool. RN #1 gave report to the 11 PM-7 AM nurse and placed the resident on the 24 hour report. She did not notify the Physician or the Registered Nurse supervisor about the stools. It was late, and she didn't know why the doctor was not notified. She also stated she was not aware that the resident had a [DIAGNOSES REDACTED].#1 stated she checked the nursing admission assessment for the [DIAGNOSES REDACTED]. During an interview with 7:00 AM-3:00 PM shift Certified Nursing Assistant (CNA) #1, on 09/03/2015 at 9:47 AM she stated that she was the primary caregiver for Resident #1. She assisted with bathing, dressing, hygiene and toileting. The resident was alert and oriented x3, and communicated her needs. Resident #1 reported, unable to recall the date, that the nurse told her she needed to give a stool sample, a specimen hat was placed on the toilet to collect the stool. The resident did not have a bowel movement that day. The primary nurse was made aware and stated that there was no order for a stool specimen, CNA #1 also stated she later received report (from the Registered Nurse) to monitor the resident for black stool. During an interview with the 7:00 AM-3:00 PM shift Licensed Practical Nurse medication nurse (LPN) #1 on 09/03/2015 at 10:15 AM, she stated that the resident was alert and oriented x3 and communicated her needs. LPN #1 stated that the resident did complain of having dark and bloody stools, (when she was in the first building, did not recall the date) and she told the resident that the staff was aware. LPN#1 stated she did not report this to the Registered Nurse, or the Physician she assumed that the nurse who placed the resident on the report communicated with the Physician. During a telephone interview with the Attending Physician on 09/03/2015 at 11:50 AM, he stated that when a resident is admitted from the hospital with a GI Bleed it is usually resolved before discharge. He did not recall being notified of the resident having black tarry stools. He stated if a resident has a low blood pressure, and dark colored or black tarry stools he should be notified. The Attending Physician also stated if he was notified, an order would have been given for blood work, and with a low blood pressure the resident's blood pressure should have been monitored every 4-6 hours. 415.12

Based on observation, staff interviews and record review during an abbreviated survey, the facility did not ensure that each resident assessed at risk for falls was provided adequate supervision and interventions to protect the health and safety of the residents. Specifically one (Resident #1) of three residents reviewed for risk for falls was assessed as cognitively impaired with a history of falls; however, Resident #1 was not accurately identified as a fall risk. On 4/12/15 Resident #1 was left on the toilet unsupervised and found on the floor with a laceration to her head, transferred to the hospital, and returned to the facility with a [DIAGNOSES REDACTED].#1. Additionally, Resident #2 and Resident #3 identified as high risk for falls were not accurately identified as at risk for falls. Resident #2 and Resident #3 did not sustain injury. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. Complaint ID: NY 278 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 4/1/15 documented Resident #1 with severely impaired cognitive skills for daily decision making; Functional status requiring extensive assistance of one person with toileting, transfer and personal hygiene. The facility policy dated 2/2015 titled Fall Prevention Program documented that resident will be assessed for falling star program by nurse based on assessment. Resident on falling star program will have a yellow star placed over their bed, on the back of their wheel chair over their bed and on their name plate outside the door to alert staff and visitors of the resident's risk for falls. A yellow star will also be placed on the resident care profile/Certified Nursing Assistant Accountability Record (CNAAR). The policy lacked documented evidence that a resident should be constantly supervised in the bathroom. Implementation of Fall Prevention Intervention: Include fall prevention intervention measures in CNAAR. Monitor staff compliance with fall prevention measures including the following general measures: resident transfer assist, ambulation and other activities as necessary. CNAs to follow directions for fall preventions and measures as per care plan indicated on resident's CNAAR. The admission physician's orders [REDACTED]. The fall risk assessment dated [DATE] documented score of 16 indicating high risk for falls. The Comprehensive care plan (CCP) dated 3/25/15 documented self-care deficit as evidenced by require extensive assist of one person with personal hygiene, dressing, toileting and transfer. Interventions included anticipate needs, assist with morning and evening care, and assist with toileting and toilet upon request. The CCP dated 3/25/15 documented incontinent of bladder and bowel. Interventions including provide toileting every 2 to four hours, provide assistance with toileting and incontinent care as needed. The CCP dated 3/25/15 documented at risk for falls related to psychotropic drug use, sepsis and unsteady gait. Interventions included monitor activities, educate resident to seek assistance, bed in low position, nonskid socks, bed alarm, chair alarm. CCP outcomes on 4/9/15 documented found on floor, resident unaware why she got up. No injury noted. Updated on 4/13/15 to add toileting schedule. The Occupational therapy assessment dated [DATE] documented precautions: fall safety. The CCP dated 4/12/15 documented at risk for fall related to fell in past 30 days, unsteady gait, use of psychotropic medication and sepsis. Interventions included monitor activities, bed in low position, monitor for changes in condition, transfer to hospital for laceration to head. Return from hospital continue with safety measures and medicate for pain. The CCP lacked documented evidence of resident being placed on falling star program or providing constant supervision or assistance in bathroom. The nursing progress note dated 4/12/15 documented resident was found on floor in the dining room bathroom. On assessment resident incoherent due to dementia, noted bleeding from back of head. Ice pack applied to head and the resident was transferred to hospital as per physician order. Resident returned to the unit on 4/12/15 during 3:00 PM-11:00 PM shift with [DIAGNOSES REDACTED]. The Certified Nursing Aid Accountability Record (CNAAR) dated April 2015 documented resident at risk for fall with bed alarm, chair alarm, nonskid socks, on 4/9/15 updated to add concave mattress. The CNAAR lacked documented evidence of supervision needs during toilet use. The facility occurrence investigation report dated 4/17/15 documented moments after being assisted to the toilet, this resident stood up pulled up her pants and fell on the floor. While it is believed that the alarm would not have prevented the fall, assigned CNA failed to follow plan of care and disciplinary action has been taken. Resident was transferred to hospital with [DIAGNOSES REDACTED]. Upon return from the hospital resident was moved closer to nursing station, neuro checks were initiated. The Resident was subsequently transferred to the hospital unrelated to this fall and admitted with CHF/Pneumonia. In conclusion there is no evidence of neglect, abuse, or mistreatment. During an interview with the 7:00 AM-3:00 PM Certified Nursing Assistant (CNA #2) on 5/4/15 at 12:04 PM, CNA #2 stated that on 4/12/15 she was covering the dining room when the charge nurse (CN) asked her to toilet Resident #1. She took Resident #1 to the bathroom and the assigned CNA (CNA #1) helped her transfer Resident #1 from her wheel chair to the toilet and also reported that Resident #1 can be left alone as she is able to sit by herself on the toilet and would call when she is finished. CNA #2 stated that CNA #1 left the dining room after transferring Resident #1 to the toilet. CNA#2 stated that she left Resident #1 on the toilet as she was covering the dining room and had no coverage to monitor residents in the dining room. CNA#2 stated that she assumed that the nurse would cover the dining room for her when she toileted the resident as it is the normal practice on the unit. After approximately five to seven minutes CNA #2 did not hear the call bell from the dining room bathroom, she went to check on Resident #1 and found her on the floor with her pants pulled up and blood under her head. CNA #2 stated that Resident #1 did not have a chair alarm if resident had a chair alarm I would have known that the resident was a fall risk, because she was not on my assignment I did not have any idea of her being a fall risk. The resident did not have a yellow band or a star on her chair to identify her as a fall risk. CNA#2 further could not recall Resident #1 being discussed during report for monitoring while being toileted. During an interview with the 7:00 AM-3:00 PM Registered Nurse (RN #1) on 5/4/15 at 12:20 PM, RN#1 stated that Resident #1 was alert and oriented x one to two and required one person assist for transfer. RN #1 did not think Resident #1 was at high risk for falls. RN#1 stated that residents who are high risk for falls are identified by a yellow star on the chart and a yellow star on the room door. RN#2 stated she could not recall if Resident #1 had a chair alarm or a yellow star on her chair or needed monitoring. During an interview with the Occupational Therapist (OT) on 5/4/15 at 1:45 PM, the OT stated that Resident #1 required contact guard (limited assistance) for transfer. Resident #1 had good sitting balance but unsteady gait. Safety was the biggest issue due to resident's impaired cognitive status. The staff needed to be by the bathroom door during toilet training in the gym as Resident #1 may ring the call bell and get up at the same time. The OT stated that he did not think he needed to relay information related to supervising Resident #1 during toileting to nursing staff since Resident #1 stayed on the unit with nursing 23 hours a day. During an interview with the Registered Nurse Charge Nurse (CN) on 5/4/15 at 2:00 PM, the CN stated that Resident #1 was alert and oriented x1 and required extensive assistance of one person with activities of daily living. Resident was incontinent of bowel and bladder and needed to be watched during toileting as she was high risk for fall due to history of falls, unsteady gait and impaired cognition. Resident #1 was on falling star program; she needed to be in line of sight during toileting because she did not know enough to call for help, she would just get up on her own. The high risk for fall information is conveyed to CNAs by placing a yellow star sticker on the CNAAR, wheel chair, room door and on the spine of the chart. The CN stated that she did not recall fall risk identification (yellow star) on Resident #1's chair. A lot of times the stickers fall off from the chair. The CN stated that nursing is responsible for replacing and monitoring the fall risk identifiers' (yellow stars) presence on the designated areas. The CN stated that Resident #1 had a chair alarm on the chair but was not sounding at the time of the fall. The CN stated that she had instructed CNA #1 to toilet Resident #1; CNA #2 was watching the dining room, she was not supposed to toilet residents unless she had asked someone to stay to cover the dining room. The CN stated that she instructed the dining room aid (CNA #2) to watch the dining room and let CNA #1 take care of Resident #1's toileting needs. The CN walked out of the dining room after instructing the CNAs. After approximately five to seven minutes later the CN was called in to the dining room because resident had fallen from the toilet. The CN stated that Resident #1 should not have been left alone as she was high risk for falls and is not alert enough to call for help when finished. The CN stated that the CNAAR did not have written instructions to not leave resident alone on the toilet that's why the identifiers such as chair alarms and yellow stars are in place. During a subsequent telephone interview with the CN on 5/15/15 at 12:10 PM, the CN stated that the yellow star on the wheel chair and on the room door and CNAAR indicate not to leave residents' alone while on toilet. The CNA covering the dining room would know high risk for fall residents by presence of the yellow star on the wheel chair. The CNA covering the dining room is not to toilet residents, he/she has to call the assigned CNA. The CNA who toileted Resident #1 was expected to keep her in line of sight while she was on the toilet. During a subsequent interview with the CN on 6/8/15 at 1:30PM, the CN stated that the residents who are not able to call for help and won't wait for the staff to respond to the call bell are more at risk and are placed on the falling star program. The falling star is part of the fall risk care plan and an intervention but not necessarily written out as an intervention on the care plan maybe we should write it as an intervention. The residents with a yellow star on the CNAAR, wheel chair and door should not be left alone in the bathroom. During an interview with the In-service Coordinator (IC) on 5/4/15 at 2:35 PM, the IC stated that residents who are considered high risk for falls based on their fall risk assessment are identified by placing a yellow star on the CNAAR, spine of the chart, on the room door and on the residents' wheel chair. During a subsequent interview with the IC on 6/8/15 at 1:50PM, the IC stated that not all high risk residents are placed on falling star program, it is decided by the CN and the interdisciplinary team (IDCP). The IC further stated that the falling star is not an intervention, it's an alert system which is indicated by placing the yellow stars on the wheel chair, spine of the chart and the room door. After each incident the plan of care is revised and the interventions are placed based on the occurrence. The need for assistance and monitoring during toileting is an individualized intervention and should be placed on the plan of care and on the CNAAR for staff to be knowledgeable about the amount of monitoring needs. The CNAs are made aware of residents monitoring needs during toileting by the CNAAR, indicators such as yellow stars and chair alarms. If the CNAs who are not assigned to resident and are toileting the resident, they should ask the assigned CNA and the nurses on the unit for guidance related to amount of monitoring needed for toileting for a particular resident and if needed they can grab the CNAAR to review the residents' risk status. During an interview with the assigned 7:00AM-3:00PM Certified Nursing Assistant (CNA #1) on 5/4/15 at 2:44PM, CNA#1 stated that Resident #1 was provided total care, she was not aware that Resident #1 could not communicate when she was finished using the bathroom. CNA#1 usually placed resident on the toilet and stayed in the bathroom or in resident's room to keep Resident #1 in line of sight because when she finished she would get up of the toilet on her own if the staff didn't get to her on time. CNA #1 stated that she helped Resident #1 stand from her wheel chair and CNA#2 placed her on the toilet. The CN instructed CNA #1 to continue her other assignments and CNA #2 would take care of Resident #1. CNA #1 left the dining room to take care of other residents I told the dining room aid (CNA #2) that resident can stand. CNA#1 did not recall a chair alarm or a yellow star on the wheel chair for Resident #1. CNA#1 could not recall Resident #1 being discussed during the reports to monitor her during toileting. During an interview with the Director of nursing (DON) on 5/4/15 at 3:10PM, the DNS stated that residents who are assessed to be high risk for falls are placed on falling star program. The assigned staff identifies residents as fall risk by the yellow stars placed on their wheel chair, on the door and on the CNAAR. The DON stated that Resident #2 should have had the yellow star placed on his wheel chair to identify him as high risk for falls. The DON further stated that Resident #3 should have had her wheel chair identified with her name and room number and a yellow star to identify her as a fall risk. The DON also stated that nursing is responsible for making sure that the yellow stars are in place for residents who are assessed to be as high risk for falls. During a subsequent telephone interview with the DON on 6/5/15 at 3:36PM, the DON stated that Resident #1 was high risk for falls and should have had a yellow star on the wheel chair to alert all staff of her high risk status. The DON stated that the CNAAR did not have written directives for CNAs to be present when Resident #1 was using the toilet but the CNAs should have an idea to watch her closely during toileting as she required extensive assistance of one person for toileting needs. The CNAs should have some capacity of understanding that residents should be monitored in the toilet as she is alert and oriented x1 and required extensive assistance of one person. The DON further stated that the CNAs are made aware of fall risk status during morning report and during huddle (meeting held for specific issues with residents). The DON was unable to provide any documentation of Resident #1 being discussed during huddle. During an interview with the 3:00 PM-11:00 PM Certified Nursing Assistant (CNA#3) on 5/4/15 at 3:30PM, CNA#3 stated that the resident is a high risk for falls and the staff has to monitor her closely when she is on the toilet as she tends to stand up and don't know what she is doing her cognition is impaired. CNA#3 stated that she was not aware of resident having a yellow star on the chair. During an interview with the Attending Physician(MD) on 6/16/15 at 10:15AM, the MD stated that Resident #1 had dementia and was at risk for falls. The standard protocol is to monitor the residents when they are at risk for falls especially with cognition deficit. The MD stated that Resident #1 should have been monitored when using toilet due to risk for falls and injury. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 4/2/15 documented BIMS score of 13 indicating cognitively intact. The facility policy dated 2/2015 titled Fall Prevention Program documented that resident will be assessed for falling star program by nurse based on assessment. Resident on falling star program will have a yellow star placed over their bed, on the back of their wheel chair over their bed and on their name plate outside the door to alert staff and visitors of the resident's risk for falls. A yellow star will also be placed on the resident care profile/Certified Nursing Assistant Accountability Record (CNAAR). The policy lacked documented evidence that a resident should be constantly supervised in the bathroom. Implementation of Fall Prevention Intervention: Include fall prevention intervention measures in CNAAR. Monitor staff compliance with fall prevention measures including the following general measures: resident transfer assist, ambulation and other activities as necessary. CNAs to follow directions for fall preventions and measures as per care plan indicated on resident's CNAAR. The Comprehensive care plan (CCP) dated 3/27/15 documented at risk for falls secondary to unsteady gait. Interventions including bed and chair alarm and nonskid socks. The CCP lacked documented evidence of resident being placed on falling star program. The Fall Risk assessment dated [DATE] documented score of 14 indicated high risk for fall. During an observation on 5/4/15 at 1:25PM Resident # 2 was observed in his room on his bed. There were no yellow star observed over his bed or on his wheel chair and on the CNAAR. During a subsequent observation on 5/4/15 at 3:05PM, Resident #2 was observed sitting in his wheel chair in his room, the wheel chair was observed with no yellow star. During an interview with the Director of nursing (DON) on 5/4/15 at 3:10PM, the DNS stated that residents who are assessed to be high risk for falls are placed on falling star program. The assigned staff identifies residents as fall risk by the yellow stars placed on their wheel chair, on the door and on the CNAAR. The DON stated that Resident #2 was on falling star program and should have had the yellow star placed on his wheel chair to identify him as high risk for falls. During a subsequent interview with the CN on 6/8/15 at 1:30PM, the CN stated that Resident #2 was on falling star program as he was high risk for falls and was trying to get out of bed and wheel chair on his own without assistance and should have had the yellow star placed on the wheel chair and the room door as an identifier for fall risk. 3) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 4/15/15 documented BIMS score of 15 indicated cognitively intact. The facility policy dated 2/2015 titled Fall Prevention Program documented that resident will be assessed for falling star program by nurse based on assessment. Resident on falling star program will have a yellow star placed over their bed, on the back of their wheel chair over their bed and on their name plate outside the door to alert staff and visitors of the resident's risk for falls. A yellow star will also be placed on the resident care profile/Certified Nursing Assistant Accountability Record (CNAAR). The policy lacked documented evidence that a resident should be constantly supervised in the bathroom. Implementation of Fall Prevention Intervention: Include fall prevention intervention measures in CNAAR. Monitor staff compliance with fall prevention measures including the following general measures: resident transfer assist, ambulation and other activities as necessary. CNAs to follow directions for fall preventions and measures as per care plan indicated on resident's CNAAR. The Comprehensive care plan (CCP) dated 4/8/15 documented at risk for falls related to fell in past 30 days, unsteady gait and use of psychotropic medications. Interventions included nonskid socks, monitor activities, educate to use call bell and orient resident to new surrounding and safety devices. The CCP lacked documented evidence of resident being placed on falling star program. The Fall Risk assessment dated [DATE] documented score of 12 indicating high risk for falls. During an observation at 3:10PM Resident #3 was observed in her bed, the wheel chair assigned to Resident #3 lacked evidence of any identification (resident's name or room number) or a yellow star. During an interview with the Director of nursing (DON) on 5/4/15 at 3:10PM, the DNS stated that residents who are assessed to be high risk for falls are placed on falling star program. The assigned staff identifies residents as fall risk by the yellow stars placed on their wheel chair, on the door and on the CNAAR. The DON further stated that Resident #3 was on falling star program and should have had her wheel chair identified with her name and room number and a yellow star to identify her as a fall risk. The DON also stated that nursing is responsible for making sure that the yellow stars are in place for residents who are assessed to be as high risk for falls. During a subsequent interview with the CN on 6/8/15 at 1:30PM, the CN stated that Resident #3 was on falling star program as he was high risk for falls and was trying to get out of bed and wheel chair on his own without assistance and should have had the yellow star placed on the wheel chair and the room door as an identifier for fall risk. The CN stated that Resident #3 had gotten up out of bed without calling or waiting for staff, she was alert but forgetful that is why she was placed on falling star program. The NC stated that Resident #3 should have had a yellow star on her room door and wheel chair as an identifier for the fall risk. 415.12(h)(1)(2)