Every finding on record at Bedford Center for Nursing and Rehabilitation

Based on observation, record review, and interviews conducted during the Recertification Survey from 03/12/2025 to 03/19/2025, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #40) of 1 resident reviewed for Dignity out of 39 total sampled residents. Specifically, the Licensed Practical Nurse administered insulin to Resident #40 while they were seated in the hallway without providing any form of privacy. The findings are: The facility's policy titled Quality of Life- Dignity, implemented 07/2017 and last reviewed 01/12/24, stated that staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Resident #40 had diagnoses that included Diabetes Mellitus and Hypertension. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #40 had moderately impaired cognition and received insulin injections on 7 of 7 days. The Physician's Orders dated 2/17/25 documented Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro): Inject 5 unit subcutaneously before meals: give if blood sugar (BS) is greater than 150. The Physician's Order dated 02/28/2025 documented fingerstick monitoring before meals and at bedtime. On 03/18/25 at 09:21 AM, during the Medication Administration task Licensed Practical Nurse #3 was observed administering medications to Resident #40 who was sitting on their rollator, in the hallway. Licensed Practical Nurse #3 asked Resident #40 if they checked their blood sugar and Resident #40 replied that they had. Licensed Practical Nurse #3 then reviewed the Electronic Medical Record and informed Resident #40 that they will get insulin coverage, and asked which area of their body they would like to receive it. Licensed Practical Nurse #3 then proceeded to give the insulin to the right side of Resident #40's abdomen while they sat in the hallway, where other residents were walking, without providing any form of privacy. On 03/14/25 11:58 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #40 does not stay in their room and does not stay still to get the insulin administered. Licensed Practical Nurse #3 also stated that they try to ensure Resident #40's privacy, but Resident #40 does not listen and gets impatient. On 03/14/25 at 12:20 PM, Resident Nurse Manager #3 was interviewed and stated that sometimes Resident #40 gets impatient and would refuse to go to their room to receive insulin. Resident Nurse Manager #3 also stated that they usually give insulin injections to Resident #40 while they are in their room, and the Licensed Practical Nurses know they are supposed to ensure privacy. On 03/14/25 at 12:32 PM, the Director of Nursing was interviewed and stated that the Licensed Practical Nurses are supposed to provide privacy for the residents, even if the resident refuses and if the insulin is administered in the hallway. The Director of Nursing also stated that there are screens that are available for use to ensure privacy. 10 NYCRR 415.5(a)

Based on observations, staff interviews and record review conducted during the Recertification Survey from 03/12/2025 to 03/19/2025, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 (Resident #40) of 6 residents observed for Medication Administration task. Specifically, Resident #40, admitted with a diagnosis of Diabetes Mellitus, was administered Lantus Insulin by the Licensed Practical Nurse, without confirmation of the blood sugar results received from the Freestyle Libre (a blood sugar monitoring device attached to the skin). Further, there was no documentation of a Physician's Order for the Freestyle Libre device for blood sugar monitoring. The findings are: The facility's policy titled Medication Order Reconciliation created July 2017, last reviewed March 2025, stated the facility is to ensure that all medications orders are reconciled to prevent errors, maintain resident safety, and comply with applicable regulations. The policy also stated that reconciliation will occur during admissions, discharges, transfers, order changes, and routine reviews. The facility's policy titled Medication Orders created 03/2016, last revised 07/22 stated that the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders, and that a current list of orders must be maintained in the clinical record of each resident. Resident #40 had diagnoses that included Diabetes Mellitus and Hypertension. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #40 had moderately impaired cognition and received insulin injections on 7 of 7 days. The Physician's Orders dated 2/17/25 documented Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro): Inject 5 unit subcutaneously before meals: give if blood sugar (BS) is greater than 150. The Physician's Order dated 02/28/2025 documented fingerstick monitoring before meals and at bedtime. The Comprehensive Care Plan focus documented Resident #40 has type 2 Diabetes Mellitus, created 2/18/25 documented a goal of Resident #40 will have no complications related to diabetes through the review date. Interventions included Diabetes medication as ordered by doctor, and to monitor/document for side effects and effectiveness. The Nursing Admission Summary note dated 2/17/25 documented Resident #40 was admitted from the hospital with diagnoses that included Pre-Syncope, impaired mobility and a secondary diagnosis of Type 2 Diabetes Mellitus. The hospital's After Visit Summary and Medication List dated 2/17/25 documented Flash glucose scanning reader, use medications as directed by provider. A nursing note dated 3/5/25 documented Resident #40 is alert and responsive, self-checked their blood glucose via the Freestyle Libre 3 Plus Sensor and the result is 324 mg/dl. On 03/14/25 at 09:21 AM, during the Medication Administration task, Licensed Practical Nurse #3 was observed administering medications to Resident #40 in the hallway. Licensed Practical Nurse #3 asked Resident #40 if they checked their blood sugar and Resident #40 replied that they had, and that it was 269. Licensed Practical Nurse #3 then checked the Electronic Medical Record and informed Resident #40 that they will get the coverage. Licensed Practical Nurse #3 then proceeded to instill 5 units of Insulin Lispro to Resident #40 without first verifying Resident #40's blood sugar level. On 03/14/25 11:58 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #40 has had the Freestyle Libre device since admission and is able to read their own blood sugars. Licensed Practical Nurse #3 also stated that they did not know if there was an order for the Freestyle Libre in the Electronic Medical Record. On 03/14/25 at 12:20 PM, Registered Nurse #3 was interviewed and stated that they were aware that Resident #40 had the Freestyle libre device and they had it when they were admitted from the hospital. Registered #3 also stated that Resident #40 reads the blood sugar results, and the Licensed Practical Nurse is supposed to verify the reading on the device. Registered Nurse #3 further stated that any type of device that a resident has been provided with is documented in the Electronic Medical Record. Registered Nurse #3 stated that the order for the device must have been missed for Resident #40. On 03/14/25 at 12:32 PM, the Director of Nursing was interviewed and stated that the Licensed Practical Nurses are supposed to actually see the blood sugars readings before administering any insulin, and that the Freestyle Libre device should be included in the Physician's orders. The Director of Nursing verified that there was no order for the device. On 03/19/25 at 01:29 PM, Physician #1 was interviewed and stated that they are the Primary Physician for Resident #40. Physician #1 also stated that they did not realize that an order had not been placed for the Freestyle Libre device initially, but they had an order placed after 03/14/2025, once they were made aware. Physician #1 further stated that there should have been an order in place for the device when Resident #40 was admitted . 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification and survey from 03/12/2025 to 03/19/2025, the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (Unit 2) of 5 medication storage areas reviewed. Specifically, controlled medications were not properly stored in a double cabinet in the Unit 2 medication room. This was observed during the Medication Storage task. The findings are: The facility policy titled Controlled substances revised 12/15/2024 stated the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. The policy also stated that controlled substances must be stored in the medication room in a locked container, separate from containers from any non-controlled medication. This container must remain locked at all times, except when it is accessed to obtain medications for residents. On 03/14/2025 at 12:51 PM to 1:24 PM, the Unit 2 medication room was observed with Registered Nurse #1. Registered Nurse #1 unlocked the first door for the cabinet. The second door of the cabinet was observed to be ajar and when Registered Nurse #1 inserted the key into the second door, they were unable to turn the lock. Multiple controlled medications were observed in the unlocked cabinet including Morphine sulfate 100mg per 5 ml 3 boxes, Hydromorphone hydrochloride 4mg tab -90 tablets, Oxycodone immediate release 5mg-30 tablets, Clonazepam 2mg -24 tablets, Oxycodone 5mg - 21 tablets, Tramadol hydrochloride - 25 mg-30 tablets, Clonazepam 0.5mg -31 tablets, and Lorazepam 1mg-30 tablets. On 03/14/25 at 01:21 PM, the maintenance book was observed with entries from 02/13/2025-03/14/2025 and there were no entries related to the narcotic box lock. On 03/14/2025 at 02:08 PM, Licensed Practical Nurse #2 was interviewed and stated they noticed two days ago that the narcotic cabinet lock was not closing, and when they tried the narcotic lock yesterday evening the key was not turning so they called maintenance and the Assistant Director of Nursing. Licensed Practical Nurse #2 also stated that maintenance attempted to fix the lock and were unsuccessful and stated they would return but they did not. On 03/17/2025 at 03:21 PM, Registered Nurse #1 was interviewed and stated last Thursday (03/13/2025) they were informed by Licensed Practical Nurse #3 that the narcotic lock was not working. Registered Nurse #1 also stated the following day (03/14/2025) they were informed that the lock was still sticking but they were not aware that it had not been fixed. Registered Nurse #1 further stated that medication should not be kept in the cabinet if both locks are not working, and the medication should have been moved and stored properly. On 03/19/2025 at 1:18 PM, the Assistant Director of Nursing was interviewed and stated that the narcotic lock box needs to be secure and if the lock is not functional the narcotics should be removed from the area and placed in locked area until the issue with the lock is resolved. The Assistant Director of Nursing also stated that the nurses should communicate with the unit directors and nursing administration when they have concerns with the narcotic storage. The Assistant Director of Nursing further stated that they were not informed that the narcotic box was not functional, and that staff were not able to secure the medication. On 03/19/2025 01:33 PM, the Director of Nursing was interviewed and stated that the last time they looked at the narcotic boxes was 2 weeks ago, and they did not observe, and were not informed of, any issues at that time. The Director of Nursing also stated that they should be notified if the key is broken, maintenance should be informed, and if the issue is not fixed during the shift they should be informed of that. The Director of Nursing further stated that they were informed of the issue about medication narcotic box on the 2nd floor last week. 10 NYCRR 415.18(e)(1-4)

Based on interviews and record review conducted during an abbreviated survey (NY00294793), the facility did not ensure each resident received adequate supervision to prevent elopement. This was evident in 1 out of 4 residents sampled for wandering and elopement (Resident #1). Specifically, Resident #1 who had a history of attempted elopement, was identified at high risk for elopement and was assigned a wander alert device (a device that alerts staff when the resident is exiting the building), exited the facility without staff knowledge on 04/22/2022 at 7:39am. Resident #1 was located by the New York Police Department (NYPD) on 04/23/2023. The findings are: The undated Policy and Procedure on Wandering, Unsafe Residents documented that staff would identify residents who are at risk for harm because of unsafe wandering including elopement. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk for elopement or other unsafe behavior. Resident #1 was admitted to the facility with diagnoses including Schizophrenia, Unspecified Psychosis, and Major Depressive Disorder. The Minimum Data Set (MDS, resident assessment tool) dated 04/17/2022 documented that Resident #1 had severely impaired cognition, Section E of the MDS documented that Resident #1 had wandering behavior. Resident #1's Kardex (for Certified Nursing Assistant) dated 04/01/2022 documented instructions for frequent monitoring while in bed. A care plan for high risk for elopement related to dementia and disorientation was initiated for Resident #1 on 04/12/2022. The interventions include assess for fall risk, distract resident from wandering by offering pleasant diversions-structured activities, food, and conversation, television, book, monitor location and document wandering behavior. A Nursing Progress Note dated 04/12/2022 at 04:30 am documented that Resident #1 pushed the staff to board the elevator after being redirected several times in the hallway. Resident #1 carried around their belongings tied up in a plastic bag. A nursing note dated 04/13/2022 at 11:27 pm documented that Resident #1 began walking around the unit and stood in front of the elevator and refused to move. Resident got on the elevator but eventually got off. An Elopement Risk Assessment form dated 04/14/2022, documented that Resident #1 was at risk for elopement. The form documented that Resident #1 had a history of or attempted elopement at home or in the facility, verbally expressed the desire to go home, packed their belongings, or stayed near an exit door, and had a wandering behavior. A care plan for high risk for elopement related to dementia and disorientation updated on 04/14/2022 documented that a wander alert device was applied to Resident #1's right ankle. A CNA Documentation Survey Report for 04/2022 documented that Resident #1 had wandering behavior on 04/12/2022 and 04/21/2022 on the 7:00 am - 3:00 pm shift. A Nursing Progress Note dated 04/14/2022 at 6:26 pm documented that Resident #1 was wandering aimlessly and attempting to go into the elevator. A Wander guard bracelet was placed, but the Resident managed to tear off the bracelet and dispose of it in the trash can. A Nursing Progress Note dated 04/20/2022 at 4:43 am documented that Resident #1 wanders frequently in the hallway during the night and resisted redirections to their room. The updated elopement care plan dated 04/20/2022 documented that Resident #1 wanders in the hallway during the night and resisted redirections. Additional interventions were implemented on 04/20/2022 to include frequent and close monitoring. There was no documented evidence that Resident #1 was being monitored frequently. There was no documented evidence that Resident #1's wander alert device was being monitored for placement and functionality. A Nursing Progress Note dated 04/22/2022 at 05:07 pm documented that at approximately 08:45 am, it was noticed that Resident #1 did not come to the food cart for their breakfast as they always do, the Resident was not in their room. The CNAs on the unit began to search all rooms, bathrooms, and staircases to no avail. Code Grey was called. An hourly monitoring form dated 04/21/2022 to 04/22/2022 documented that Resident #1 was being observed hourly from 04/21/2022 at 11:00 pm to 04/22/2022 at 7:00 am. A Resident Incident/Accident Report dated 04/22/2022 documented that at approximately 8:45 am, the nurse went to Resident #1's room to find them missing. Code Gray was called. Building was searched entirely to no avail. The facility Investigation Summary dated 04/22/2022 documented that on 04/22/2022 at about 08:45 am, the unit nurse observed that Resident #1 was not on the unit. Resident #1 was seen at 07:00 am in their room and was served breakfast at 07:30 am. Resident was noted missing at 8:30 am and initial unit search was done. Code Gray was called at 9:00 am. Family and 911 was notified at 9:30 am. The Director of Nursing (DON) and an NYPD Detective reviewed the outdoor security camera footage and it indicated that Resident #1 walked out of the building at 7:39 am. Resident #1 returned to the facility on [DATE] with the wander alert still in place. During an interview on 03/21/2023 at 09:32 am, CNA #1 stated that they out 07:45 am but did not make rounds since they arrived late. The CNA said that they made rounds at 08:30 am and noticed that Resident #1 was not in their room. CNA #1 stated that they immediately told Licensed Practical Nurse (LPN) #1 that Resident #1 was not in their room. They searched the entire unit and went to the staircases and when Resident #1 was not located, LPN #1 announced Code Gray. CNA #1 stated that it was the first time they were assigned to Resident #1 and honestly cannot remember if Resident #1 was an elopement risk. CNA #1 stated that Resident #1 is on hourly monitoring just like the other residents. The CNA stated that they did not hear any alarm going off on the unit. CNA #1 stated that Resident #1's room is located across the floor from an exit door leading to a staircase. During an interview on 03/06/2023 at 12:15 pm, CNA #3 stated that they did not hear any alarm on the day that Resident #1 eloped. The CNA stated that they heard Code Gray called at about 08:30 am. During an interview on 03/06/2023 at 10:33 am, LPN #1 stated that they were assigned to Resident #1's unit and was on duty on the day that Resident #1 eloped from the facility. LPN #1 said that they arrived on the first-floor unit (Resident #1's unit) between 7:30am and 7:45am and did not hear any alarms going off at that time. LPN #1 stated that CNA #1 notified them between 08:00 am - 08:30 am that Resident #1 was not in their room, and they started to look for Resident #1. LPN #1 said that while they were looking for Resident #1, they heard an exit door alarm (located across the hall from Resident #1's room) going off. LPN #1 said that they instructed CNA #1 to check the stairs and Resident #1 was not in the stairwell. LPN #1 stated that they checked the entire unit but did not find Resident #1 and that they announced Code Gray (for missing person) between 8:30 am and 9:00 am. LPN #1 stated that they were not sure if the Resident was wearing a wander alert when the Resident eloped. LPN #1 stated that they do not know how frequently Resident #1 was being monitored. During an interview on 03/06/2023 at 12:32 pm, the ADON (Assistant Director of Nursing) stated that Resident #1 was observed missing on 04/22/2022 at approximately 8:30 am. The ADON stated that Resident #1 was always standing by their door, so they assumed that Resident #1 went through the door that was across from their room. During an interview on 03/21/2023 at 11:22 am, RNS #1 (Registered Nurse Supervisor) stated that Resident #1 is at high risk for elopement and that they initiated the wander alert device for Resident #1 on 04/14/2022. RNS #1 stated that they recalled Resident #1 removed the wander alert and threw it in the trash can, but the wander alert was replaced. During a follow-up interview with RNS #1 on 06/13/2023 at 2:50 pm, RNS #1 stated that prior to 04/22/2022, Resident #1 was on hourly monitoring which is the same monitoring for all the residents on the unit. RNS #1 said that Resident #1 was wearing a Wander alert device. They stated that frequent monitoring means either a resident is on every 15 minutes or every 30 minutes visual monitoring. During an interview on 03/30/2023 at 1:30 pm, the Maintenance Staff (MS) stated that they were not at the facility on the day of the incident and was made aware of the elopement the next day when they came back to work. MS stated that they checked all exit doors in the building and the Wander alert sensors, and the alarms were all functioning and audible. MS stated that the exit doors on the units are alarmed and are equipped with a Wander alert sensor. A code must be entered on the keypad to exit the unit to the stairwell. The MS said that you must push the button on the keypad to enter the unit from the stairwell. MS explained that if a code is entered on the unit exit doors, the alarm will not activate, but if the code is not entered and someone tried to exit just by pushing the door, there is a 15-second delay before the door opens and then the alarm will start ringing. The MS said that if a resident is wearing a Wander alert gets close to the door, the door will beep and locked. The MS stated that prior to the elopement, they tested all the exit door alarms once a week and Wander alert alarms/sensors monthly. The MS said that vendor came in and checked all the exit doors and they were fully functional. The MS stated that the elevators are also equipped with a Wander alert sensor. The MS stated that the elevator will start beeping and will shut down if a resident who is wearing a Wander alert enters the elevator. The MS stated that the exit door alarms were last checked on 04/04/2022 and documented on the inspection log. During an interview on 03/22/2023 at 2:00 pm, the Director of Nursing (DON) stated that their investigation revealed that Resident #1 was last seen and served breakfast at about 7:30 am. The DON stated that Resident #1 eloped by going through the exit door located across the hallway from their room, took the stairwell to the ground floor, and walked out of the building through a gate that leads to the sidewalk. The DON stated that the exit door across from Resident #1's room has an alarm and a wander alert sensor that was working. The DON said that they tested the exit door alarms and sensors on the day of the elopement. The DON stated that the gate that Resident #1 went through is an emergency exit and that it was not locked. The DON said that people can exit through the gate, but they cannot enter from the outside. The DON said that they reviewed the camera facing the street with the NYPD and it showed Resident #1 exiting the building through the emergency exit gate at 7:39 am on 04/22/2022. The DON further stated that they did not review the camera on the unit because they were focused on finding out where Resident #1 went. The DON stated that Resident #1 was wearing their wander alert bracelet when they return to the facility on [DATE] and that the alarm was triggered when Resident #1 was entering the lobby. During a follow-up interview on 05/26/2023 at 11:12 am, the DON stated that Resident #1 should have been on frequent monitoring not just hourly. The DON said that the nurses and the CNAs are responsible for checking the wander alert placement every shift and that it should have been documented on the CNA instructions. The DON also stated that the wander alert placement check should have been signed for by the nurses on the Treatment Administration Record (TAR). The DON stated that Resident #1 had an elopement care plan for wander alert, but the information was not carried over to the CNA Instructions and the TAR. The DON voiced that the nursing supervisor is responsible for ensuring that the accountability record has instructions for frequency of monitoring of residents at risk for elopement and wander alert check. 10 NYCCRR 415.12 (h)(2)

Based on observation, interview and record review conducted during an abbreviated survey (NY00294793), the facility did not ensure that an elopement incident was thoroughly investigated. This was evident in 1 out of 4 residents sampled for wandering and elopement (Resident #1). Specifically, Resident #1 eloped from the facility on 04/22/2022. The facility investigation documented that they reviewed the outdoor security camera footage and it indicated that Resident #1 walked out of the building at 7:39 am. The facility investigation did not determine how Resident #1 exited the unit. The findings are: The undated Policy and Procedure on Elopement documented that staff shall investigate all cases of missing residents. Resident #1 was admitted to the facility with diagnoses including Schizophrenia, Unspecified Psychosis, and Major Depressive Disorder. The Minimum Data Set (MDS, resident assessment tool) dated 04/17/2022 documented that Resident #1 had severely impaired cognition, Section E of the MDS documented that Resident #1 had wandering behavior. A Resident Incident/Accident Report dated 04/22/2022 documented that at approximately 8:45 am, the nurse went to Resident #1's room to find them missing. Code Grey was called. Building was searched entirely to no avail. The facility Investigation Summary dated 04/22/2022 documented that on 04/22/2022 at about 08:45 am, the unit nurse observed that Resident #1 was not on the unit. Resident #1 was seen at 07:00 am in their room and was served breakfast at 07:30 am. Resident #1 was observed missing at 8:30 am and initial unit search was done. Code Gray was called at 9:00 am. Family and 911 was notified at 9:30 am. The Director of Nursing (DON) and a New York Police Department (NYPD) Detective reviewed the outdoor security camera footage and it indicated that Resident #1 walked out of the building at 7:39 am. Resident #1 was returned to the facility on [DATE] with the Wander alert still in place. The facility's investigation did not address how Resident #1 exited the unit undetected by staff. During an interview on 03/21/2023 at 09:32 am, Certified Nursing Assistant (CNA) #1 stated that they were assigned to Resident #1 on the day of the incident. CNA #1 stated that they made rounds at 08:30 am and noticed that Resident #1 was not in their room and immediately told Licensed Practical Nurse (LPN) #1. They searched the entire unit and went to the staircases and when Resident #1 was not located, and LPN #1 announced Code Gray. CNA #1 stated that they did not hear any alarm going off on the unit. During an interview on 03/06/2023 at 12:15 pm, CNA #3 stated that they did not hear any alarms going off on the day that Resident #1 eloped. During an interview on 03/06/2023 at 10:33 am, LPN #1 stated that they arrived on the first-floor unit (Resident #1's unit) between 7:30am and 7:45am and did not hear any alarms going off at that time. LPN #1 stated that CNA #1 notified them between 08:00 am - 08:30 am that Resident #1 was not in their room, and they started to look for Resident #1. LPN #1 said that while they were looking for Resident #1, they heard an exit door alarm (located across the hall from Resident #1's room) going off. LPN #1 said that they instructed CNA #1 to check the stairs and Resident #1 was not in the stairwell. During an interview on 03/06/2023 at 12:32 pm, the ADON (Assistant Director of Nursing) stated that Resident #1 was always standing by their door, so they assumed that Resident #1 exited the unit through the exit door that was across from their room. The ADON stated that they initiated the elopement investigation and that they did not review any surveillance camera because the Director of Nursing (DON) took over the investigation. During an interview on 03/22/2023 at 2:00 pm, the DON stated that they viewed the surveillance camera that was facing the street and it showed Resident #1 walking out the building on 04/22/2022 at 7:39 am. The DON stated that they did not review the surveillance camera on the unit because they were focused on finding out where Resident #1 went. 10NYCRR 415.4(b)(ii)

Based on observation, interview, and record review conducted during the Recertification Survey from 3/21/23 to 3/28/23, the facility did not ensure a comprehensive person-centered care plan (CCP) was reviewed and revised to address a resident's needs. This was evident for 1 (Resident # 157) of 3 residents reviewed for Dignity out of 37 total sampled residents. Specifically, Resident #157's CCP was not reviewed and revised to reflect Resident #157's preference to lie in bed exposed The findings are: The facility policy titled Care Planning - Interdisciplinary Team created 2/2018 documented the care plan is based on the resident's comprehensive assessment. Resident # 157 had diagnoses of unspecified dementia and repeated falls. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 157 had severely impaired cognition, no behavior problem, and required extensive assistance of 2 people for dressing. On 03/21/23 at 12:04 AM, Resident # 157 was interviewed and stated they did not like to wear clothes or gown or be covered by sheet while staying in bed. On 03/21/23 at 12:04 AM and 03/27/23 at 09:14 AM, Resident # 157's lower half was observed from the hallway and Resident #157's bare legs and incontinent brief were visible. Resident #157 was not covered by a sheet. The privacy curtain was partially drawn and blocking the view of Resident # 157's upper body from the hallway. Psychiatry consult dated 2/10/23 documented Resident # 157 was calm, cooperative, able to make needs known, and there was no evidence of psychosis. The behavior note dated 2/21/23 documented the CNA entered room and saw Resident # 157 taking off their gown and put it on the floor. There was no documented evidence Resident #157's CCP was reviewed and revised to reflect the resident's preference to lie in bed unclothed and uncovered. On 03/24/23 at 03:07 PM, the Certified Nursing Assistant (CNA) # 1 was interviewed and stated Resident # 157 was alert, confused, and required extensive assistance of 2 people for dressing. CNA #1 stated Resident # 157 does not like to wear gown or clothes, takes off their gown themselves, and only wears an incontinent brief when in bed. Resident #157 had no problem wearing clothes when out of bed. CNA #1 covers Resident # 157's body with the sheet as needed and notified the nurse that Resident #157 had a behavior problem of refusing to wear their gown while in bed. On 03/24/23 at 03:41 PM, the Registered Nurse (RN) #1 was interviewed and stated Resident # 157 had a behavior problem of only wearing an incontinent brief while in bed and often refused to be covered by sheet. RN # 1 stated the RNs were responsible for creating and updating CCPs for residents and Resident #157's behavior should have been care planned. RN #1 was unable to explain the reason there was no CCP for Resident #157. On 03/24/23 at 04:01 PM, the Director of Nursing (DON) was interviewed and stated residents wearing only incontinent brief and being naked to other people on any occasion is a behavior problem. There should be a care plan to address the behavior problem for the residents. The DON also stated they were not aware that Resident # 157 did not like to be dressed and only wore an incontinent brief while in bed. Resident # 157 did not have a care plan to address the behavior problem of wearing incontinent brief only and being naked in bed. The DON stated they would reinforce with the unit manager to develop the care plan to address behavior problem. 415.11(c)(2)(i-iii)

Based on observation, interviews, and record review conducted during the recertification and complaint (NY00308940) survey from 3/ 21/23 to 3/28/23, the facility did not ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This was evident for 1 (Resident #165) of 5 resident reviewed for Urinary Incontinence. Specifically, Resident #165 did not have a urology consultation scheduled in accordance with Medical Doctor Orders (MDO) to address recurrent urinary tract infections (UTI). The findings are: The facility policy titled Physician Consultations dated 2/2016 documented the attending physicians will place orders for needed specialists. The nursing secretary contacts consultants to schedule a date for evaluation. Resident #165 had diagnoses of urine retention and acute embolism thrombosis. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #165 had moderately impaired cognition, did not display inappropriate behaviors, and was frequently incontinent. On 03/23/23 at 11:46 AM, a telephone interview was conducted with Resident #165 who stated they had episodes of incontinence, had a urinary tract infection, and was supposed to see the urologist during their stay at the facility. Resident #165 was not evaluated by the urologist and left the faciity on [DATE]. A Lab Report dated 11/16/22 documented Resident #165 had a urine culture on 11/14/22 and klebsiella pneumoniae was present. The MDO dated 11/16/22 documented Resident #165 was ordered Bactrim DS 800-160mg for 7 days for cystitis. The Certified Nursing Assistant (CNA) Documentation Survey Report (DSR) for December 2022 documented Resident #165 had frequent episodes of bladder incontinence. Radiology Results Report dated 12/16/22 documented sonographic imaging of the entire abdomen showed a lesion on Resident #165's urinary bladder. Correlate with urinalysis and cystoscopy. A Lab Report dated 12/18/22 documented Resident #165 had a urine culture on 12/16/22 that showed no growth. Bladder and bowel assessment dated [DATE] documented the resident was always or usually continent of bladder. Nurse Practitioner (NP) Note dated 12/22/22 documented Resident #165 was incontinent and had a bladder mass following a sonogram. The documented plan was to follow up with urologist. Nursing Note dated 12/23/22 documented Resident #165 had burning on urination and the Medical Doctor (MD) was made aware. The MDO dated 12/24/22 documented Resident #165 was ordered Cephalexin 500mg every 12 hours for 7 days for cystitis. An order was also placed for a urology consult outside the facility Resident #165's bladder mass. The MDO documented provide sonogram and lab report. The order ended on 1/7/23. NP Note dated 12/27/22 and 1/3/23 documented Resident #165 was to follow up with the urologist. A Lab Report dated 1/4/23 documented Resident #165 had a urine culture on 1/2/23 and Pseudomonas aeruginosa was present. NP Note 1/10/23 documented Resident #165 was to follow up with the urologist. The MDO dated 1/12/23 documented a urology consult for Resident #165 was reordered. On 2/7/23, NP note documented Resident #165 to have a urology consult following completion of isolation precautions. Nursing Note dated 2/23/23 documented Resident #165 left the facility against medical advice. NP Note dated 2/23/23 documented Resident #165 was given a referral to see the urologist upon leaving the facility. There was no documented evidence the facility scheduled a urology consult for Resident #165 in accordance with MDO to address Resident #165's recurrent UTIs. On 03/27/23 at 02:49 PM, Registered Nurse (RN) #2 was interviewed and stated the first MDO for Resident #165 to have a urology consult at an outside clinic was approved by the overnight supervisor. After the order is put in, the nurse writes out a consult slip and sends it to the Nursing Secretary (NS) who schedules the consults. There were 2 MDOs for Resident #165 to have an outside urology consult. The first MDO was not done and dropped off after 14 days. Nursing does not keep a record of the consult sheets sent downstairs. If the resident refuses to have a consult, the nurse documents. If the NS cannot make an outside consult appointment, the NS informs the nurse, and the nurse will attempt to make the appointment. There is no timeframe for when an appointment needs to be scheduled. It can be up to 2-3 months before a resident secures an appointment with an outside consulting physician. On 03/27/23 at 03:26 PM and 03/28/23 at 09:47 AM, the NS was interviewed and stated the facility acquired an in-house consulting urologist approximately 2 months ago. Prior to this, outside urology clinic appointments could take up to 3 months to schedule. The NS would check with the nurse on the unit to see if the resident can wait or if they want to try another place for a sooner appointment. The facility policy is that residents should have an outside clinic appointment scheduled within 3 months. The urologist for Resident #165 wanted a compact disc (CD) of Resident #165's sonogram prior to the appointment. The NS had trouble getting the sonogram CD from the radiologist. There were 3 attempts to make the appointment for Resident #165 with the most recent date being 4/14/23. The urologist secretary called one week prior to the other appointments and when the NS did not have the sonogram CD, the urologist secretary rescheduled the appointment for Resident #165. The NS asked the Director of Nursing (DNS) to assist by calling the radiology clinic for the sonogram CD. The NS verbally informed the charge nurse on the unit. On 03/28/23 at 09:56 AM, the DNS was interviewed and stated they were not aware there was an issue with obtaining the sonogram CD for Resident #165 prior to their urology appointment. The DNS stated Resident #165 did not want to go to the appointment and it needed to be rescheduled. A sonogram CD is very easy to get. That should not delay an appointment because that can be obtained the same day. On 03/28/23 at 10:26 AM, the Doctor of NP (NP) was interviewed and stated Resident #165 had a sonogram because the resident was having recurrent UTIs. they wrote the order for Resident #165 to have a urology consult to evaluate a bladder mass found by the sonogram and to rule out bladder cancer. The DNP spoke with the nurse after the original order was placed on 12/24/22 and was told the urology consult appointment was not scheduled. The DNP reordered the urology consult and was not aware of a delay due to a sonogram CD. The appointment was scheduled but Resident #165 left the facility against medical advice. The bladder mass was an urgent issue and that is the reason the DNP reordered the urology consult. 415.12(d)(1)

Based on observation, interview, and record review conducted during the Recertification Survey from 3/21/23 to 3/28/23, the facility did not ensure a resident's right to privacy. This was evident for 1 (Resident # 157) of 3 residents reviewed for Dignity out of 37 total sampled residents. Specifically, Resident #157's lower body was observed exposed while the resident was in bed and their incontinence brief was visible to passersby in the hall. The findings are: The facility policy titled Care Planning - Interdisciplinary Team created 2/2018 documented the care plan is based on the resident's comprehensive assessment. Resident # 157 had diagnoses of unspecified dementia and repeated falls. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 157 had severely impaired cognition, no behavior problem, and required extensive assistance of 2 people for dressing. On 03/21/23 at 12:04 AM, Resident # 157 was interviewed and stated they did not like to wear clothes or gown or be covered by sheet while staying in bed. On 03/21/23 at 12:04 AM and 03/27/23 at 09:14 AM, Resident # 157's lower half was observed from the hallway and Resident #157's bare legs and incontinent brief were visible. Resident #157 was not covered by a sheet. The privacy curtain was partially drawn and blocking the view of Resident # 157's upper body from the hallway. Psychiatry consult dated 2/10/23 documented Resident # 157 was calm, cooperative, able to make needs known, and there was no evidence of psychosis. The behavior note dated 2/21/23 documented the CNA entered room and saw Resident # 157 taking off their gown and put it on the floor. On 03/24/23 at 03:07 PM, the Certified Nursing Assistant (CNA) # 1 was interviewed and stated Resident # 157 was alert, confused, and required extensive assistance of 2 people for dressing. CNA #1 stated Resident # 157 does not like to wear gown or clothes, takes off their gown themselves, and only wears an incontinent brief when in bed. Resident #157 had no problem wearing clothes when out of bed. CNA #1 covers Resident # 157's body with the sheet as needed and notified the nurse that Resident #157 had a behavior problem of refusing to wear their gown while in bed. On 03/24/23 at 03:41 PM, the Registered Nurse (RN) #1 was interviewed and stated Resident # 157 had a behavior problem of only wearing an incontinent brief while in bed and often refused to be covered by sheet. RN # 1 stated the RNs were responsible for creating and updating CCPs for residents and Resident #157's behavior should have been care planned. RN #1 was unable to explain the reason there was no CCP for Resident #157. On 03/24/23 at 04:01 PM, the Director of Nursing (DON) was interviewed and stated residents wearing only incontinent brief and being naked to other people on any occasion is a behavior problem. There should be a care plan to address the behavior problem for the residents. The DON also stated they were not aware that Resident # 157 did not like to be dressed and only wore an incontinent brief while in bed. Resident # 157 did not have a care plan to address the behavior problem of wearing incontinent brief only and being naked in bed. The DON stated they would reinforce with the unit manager to develop the care plan to address behavior problem. 415.11(c)(1)

Based on observation and staff interviews during the Recertification survey, the facility did not ensure that handwashing was performed prior to food preparation in accordance with professional standards for food service safety. Specifically, the cook did not perform hand hygiene prior to performing food preparation and handling food with gloved hands. This was evident during the Kitchen Observation facility task. The findings are: The undated facility policy titled Handwashing/Hand Hygiene Policy documented that the facility considers hand hygiene the primary means to prevent the spread of infections. The policy also documented all personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. Employees must wash their hands for twenty to thirty seconds using antimicrobial or non-microbial soap and water after removing gloves. It also documented that the use of gloves does not replace handwashing/hand hygiene. There was no facility policy that specifically addressed hand hygiene in the kitchen area and when handling food items. On 02/25/2020 at 04:06 PM and 04:43 PM, Cook #1 was observed preparing breaded eggplant. The cook placed sauce on the eggplant, removed a pan from the refrigerator, placed a pair of gloves on top of the pair of gloves she was wearing and applied more sauce to the breaded eggplant. The cook then removed the top pair of gloves, covered the eggplant and sauce and placed it in the oven. The cook then removed gloves and walked outside of the kitchen. Cook #1 re-entered the kitchen and donned gloves without performing hand hygiene. The cook removed a metal pan and tray from the steam table, donned gloves on hands that were already gloved, proceeded to pour spaghetti sauce into the metal pan with a metal cup, took metal pan to the dish room and then touched a cart in the dish room and the oven with her gloved hands. The cook then placed blue oven mitts on her gloved hands, removed diced carrots from the steamer and placed on the tray line. The oven mitt was removed, a metal pan with spaghetti sauce was labeled and placed in the refrigerator which the cook closed with gloved hands. The cook then placed a pan of hot water on the grill and wiped down a table with a paper towel with gloved hands. Cook #1 then removed gloves, donned new gloves, and gathered serving utensils from the dish room and took the items to the line for meal service. Cook #1 then removed gloves, donned clean gloves and proceeded to perform additional tasks on the tray line. The Cook consistently failed to remove gloves and perform hand hygiene appropriately during food preparation. On 02/25/2020 at 04:46 PM, an interview was conducted with Cook #1. Cook #1 stated that she always has on more than 1 pair of gloves and that she was in a time crunch and to go wash her hands was too time consuming to run across the kitchen to wash her hands. Cook #1 also stated that she knows she went outside the kitchen and did not wash her hands and normally she washes her hands upon coming back into the kitchen. Cook #1 further stated that hand hygiene is important due to residents with compromised immune systems, to prevent the spread of disease and germs. On 02/25/2020 at 04:57 PM, an interview was conducted with the Director of Dietary (DOD). The DOD stated staff should wash their hands when coming from bathroom or from outside of the kitchen. The DOD also stated that he is using 1 cook to prepare both meals in both kitchens and they are expected to wash their hands, change their apron and go to the other kitchen. The DOD further stated hand washing is important since dealing with elderly with compromised immune systems, for sanitary reasons and infection control. The DOD stated that he did not see the cook wash her hands when she returned to the kitchen and after she came back from speaking with the Surveyor. On 02/25/2020 at 05:07 PM, an interview was conducted with the Assistant Director of Dietary (ADD). The ADD stated that every time you walk into the kitchen you should wash your hands and every time you change gloves you should wash your hands before you put on new gloves. The ADD also stated that he noticed staff change gloves and not wash hands in the kitchen during the day and instructed the cook and another staff member that they needed to wash their hands when changing gloves. He stated that it is important to wash hands as it can lead to cross contamination. 415.14(h)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. Specifically, a resident with severe cognitive impairment was observed for extended periods of time without meaningful activities. This was evident for 1 of 2 residents reviewed for Activities (Resident #178) out of 40 sampled residents. The finding is: The facility policy titled Recreation Department dated 1/6/2020 documented the Recreation Department provides therapeutic and social activity programming for all residents daily, including weekends, holidays and at the hours preferred by residents. The intent of this service is to promote the well-being and quality of life by providing opportunities for participation in individual and group activities that best represent the lifestyle the resident would have enjoyed in his/her own home. Therapeutic activity is designed to accommodate the needs, abilities, and preference of each resident. The assessment is ongoing as residents needs and desires change over time, as do abilities. Residents will be encouraged to express their preferences and have input into their lifestyle. Each member of the recreation staff will have a full understanding of their populations' needs and desires and will work to restore each individuals feelings of security, dignity purpose and satisfaction. Resident #178 was admitted to the facility with [DIAGNOSES REDACTED]. Physicians orders included, but were not limited to restorative nursing program AAROM to BUE, BLE, Out Of Bed (OOB) to wheelchair and foam gel cushion with extensive assistance x 2 The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented that the resident was severely cognitively impaired. The MDS further documented that the resident required extensive assistance for bed mobility, transfer, toilet use, and dressing, and had an impairment on one side of upper and lower extremities. Annual MDS dated [DATE] documented that the resident had severe cognitive impairment and required extensive assistance with bed mobility, transfer, toilet use, and dressing, and has an impairment on one side of upper and lower extremities. The Interview for Activities documented the resident responded that it was somewhat important to listen to music he likes, somewhat important to do favorite activities, and not very important to do things with groups of people. On 02/21/20 at 11:02 AM, the resident was observed sitting in the hallway in wheelchair while News Group was going on in the dayroom. During the group one recreation therapist was talking to alert residents about the newspaper. On 02/24/20 at 09:07 AM, the resident was observed sitting in his wheelchair in the hallway. On 02/24/20 at approximately 11 AM, a Recreation Therapist was observed making smoothies with residents that are alert, oriented and able to participate. The resident, who has a PEG tube was observed in dayroom not participating. On 02/25/20 at approximately 10:35 AM, staff was observed playing dominoes with other residents while resident # 178 was sitting in his wheelchair off to the side. On 02/25/20 at 03:23 PM, the resident was observed in bed sleeping. The radio in the room was not on. On 02/26/20 at 10:42 AM and 11:25 AM, the resident was observed in the day room during scheduled board games activity. The resident was sitting off to the side watching while staff played with other residents. On 02/27/20 10:52 AM, the resident was observed in the dayroom in his wheelchair watching television. There was no activity programming going on at the time. Per activity calendar Morning Stretch was scheduled for 10:30am. The resident was observed to have a radio in his room next to his bed. Throughout the recertification survey from 2/21/20-2/27/20 the radio was not observed to be playing. The Comprehensive Care Plan (CCP) dated 1/29/20 documented the resident is dependent on staff for meeting emotional intellectual, physical, and social needs related to (r/t) physical limitations and cognitive deficits. Interventions included invite to scheduled activities, needs assistance to activity function. CCP dated 1/29/20 documented the resident has limited physical mobility r/[MEDICAL CONDITIONS]. Interventions included non-ambulatory, is totally dependent on staff for locomotion on and off the unit. CCP dated 1/29/20 documented the resident has impaired cognitive function/dementia or impaired thought processes. Interventions included admin meds as ordered, ask yes or no questions, monitor for changes in cognitive function. CCP dated 1/29/20 documented the resident has an alteration in communication r/t [DIAGNOSES REDACTED]. Interventions included anticipate needs, allow time to respond, repeat as necessary, don't rush, request clarification, discuss with family. CCP dated 1/29/20 documented the resident has a psychosocial well-being problem. Interventions included allow time to answer questions and to verbalize feeling, consult with pastoral care, monitor for feelings of isolation, unhappiness, anger, loss, etc. Activity Note dated 10/24/19 documented the care plan was reviewed and goals ongoing, resident is withdrawn. The resident enjoys musical entertainment and special events. The resident is receptive to 1:1 visits and will continue to be invited and encouraged to participate in activities of his choice 2-3 times per week. Activity Note dated1/27/20 documented the plan of care was reviewed and is ongoing. The resident is non-verbal. Per staff, residents preferred activities is music. The resident will continue to be encouraged to participate and escorted to recreation activities. The monthly activities calendar for the fifth floor was reviewed. Activities scheduled included morning stretch, bowling, pancake fun, movie hour, Spanish game club, gardening with Sally, table games, bingo, arts and crafts, news group, word games, sports, table games, basketball, smoothie time, painting class, pizza baking, tennis, and Spanish cooking club. The activities scheduled provided minimal opportunities for the resident with a PE[DEVICE], impairment on one side of upper and lower extremity, and severely impaired cognition. The facility did not provide documented evidence it provided activities the resident prefers or is interested in. There was no documented evidence provided the resident received 1:1 visits from recreation therapists. On 02/25/20 at 02:00 PM, Certified Nursing Aid (CNA) #1 was interviewed. CNA #1 stated the resident needs total care for everything. CNA #1 stated the resident is usually up and out of bed around 10:30/11 am. CNA #1 stated the resident sits in his wheelchair when they have programs in the dayroom. CNA #1 stated the resident does not participate in programs. CNA #1 stated there are different recreation people in the dayroom every day. CNA #1 stated the residents that participate in activities are mostly alert and oriented. CNA #1 stated sometimes they have different programs on different floors where the alert residents can go. CNA #1 stated the resident never goes to another floor for programs. CNA #1 stated the resident is from the islands and music is huge in that culture and he enjoys the music. CNA #1 stated there needs to be more music for the resident, he doesn't have much to do. CNA #1 did not mention playing the radio for the resident while in his room. On 02/25/20 at 02:32 PM, a Recreation Therapist (RT) was interviewed. The RT stated the director decides what programs go on in the dayroom on each floor. The RT stated some programs include cooking, Spanish/Chinese focused programs, stretching, aroma therapy, bingo, dominos, etc. When the State Agent (SA) stated the activities seem to be geared towards residents that are cognitively intact, can eat, have fine motor skills, etc. the RT stated if the resident can't engage in programming she will try and include them so they can at least see the program. The RT stated most programs are geared towards alert residents on the unit. The RT stated resident that do not come to the dayroom get 1:1 visits in the afternoon. The RT stated for example planting group we let the residents smell it or touch the plants if they can't participate. When the SA asked about resident #178 the RT stated they would have to see if the resident was seen for 1:1 visits. The SA asked for follow up on when and what was done with the resident during 1:1 visits. No examples of 1:1 activities or refusals were provided for resident #178. On 02/25/20 at 02:58 PM, Registered Nurse (RN) #1 was interviewed. RN #1 stated the resident gets out of bed in the morning after the feeding of bolus, then he goes to dayroom. RN #1 stated the resident sometimes watches dominos, but he is not able to play, but likes hearing the noise of the pieces falling. RN #1 stated the resident enjoys cards when they are put on the table so he can see. RN #1 stated the resident enjoys the singers and music once a week. RN #1 stated the resident gets 1:1 visits from recreation staff and they will bring him down to other units for parties and things. RN #1 did not mention the resident enjoys music or staff playing the radio for the resident while he is in his room. On 02/26/20 at 11:14 AM, the Director of Recreation (DOR) was interviewed. The DOR stated the facility has a diverse population and different cognitive and physical ability levels. The DOR stated she tries to find programs that are geared towards culture, physical abilities, and interest. The DOR stated she liked to schedule calming, easy programs in the morning like stretching and then in the afternoon sometimes more strenuous. The DOR stated the male floor (5th floor) has more activities geared towards that. The DOR stated the fifth floor has a music therapist who comes once a week. The DOR stated the fifth floor is split between Spanish residents, Jewish residents, and a few other cultures. The DOR stated the department tries to bring groups to different levels for residents. The DOR stated for the residents that don't come out of bed we have diffusers to do aroma therapy daily. When asked about residents that have impaired cognition and activities geared towards them the DOR stated there is a horticultural therapy group and those who aren't cognitively alert can smell it and feel the plants. The DOR stated resident #178 is resistive with recreation. When asked what the resident enjoys and how he is engaged in activity the DOR stated the resident mostly enjoys music and games. The DOR stated the resident enjoys the sound of dominos falling in the dayroom. The DOR stated the resident has a radio and a tv in his room. The DOR stated the staff know his favorite stations but could not elaborate or show the SA the stations the resident enjoyed. The SA asked for documentation the resident had the opportunity to participate in activities he enjoyed, and none were provided. 415.5(f)(1)

Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, a tube of Glucose gel was observed in a cabinet in the medication room past the expiration date. This was evident on 1 of 4 units reviewed for Medication Storage (Unit 3). The findings are: The facility Medication Storage policy dated 11/2019, documented under Removal that medications must be removed and disposed of immediately if they are expired. The undated Licensed Practical Nurse Job Description documented responsibilities included maintain medication/treatment carts which include removing expired medications. An observation of the medication room on the 3rd floor was conducted on 02/25/2020 at 03:22 PM with Licensed Practical Nurse (LPN # 1). One tube of Glucose Gel was observed stored in the medication room cabinet with expiration date of 12/2019. An interview was conducted with LPN # 1 immediately after the observation. LPN #1 stated that she is a per diem nurse and that she checks the expiration dates of items in the medication room especially in the fridge and tries to check it every time she is here. She stated that she has personally not had to use the glucose gel on a resident, and she stated that she is not sure if there are any standing orders for the glucose gel. On 02/25/2020 at 03:48 PM, Registered Nurse (RN #5) was interviewed. RN # 5 stated we have the LPN check the medication room and medication cart on a daily basis. She stated that she checks the medication room weekly and recently she went in there last week and checked everything and that must have been something recently that she missed. She stated that the glucose gel is an emergency medication and expired medications could be ineffective and should be discarded once expiration date is reached. On 02/25/2020 at 05:25 PM, Senior Registered Nurse (Nurse Manager) (RN # 6) was interviewed and stated the medication nurse is to check all medications every shift. 415.18 (d)

Based on observation, record review and interview conducted during the Recertification survey, the facility did not ensure that infection control protocols were followed. Specifically, a phlebotomist was noted entering an isolation room without donning Personal Protective Equipment (PPE) and the phlebotomist failed to perform hand hygiene before and after phlebotomy procedure. This was evident for random observations of Phlebotomist on 1 of 5 units (Unit 2). The findings are: The facility policy Personal Protective Equipment- Using Gowns dated 1/20/2020 documented the objectives are to prevent the spread of infections, prevent the soiling of clothing with infectious material, to prevent the splashing or spilling blood or body fluids onto clothing or exposed skin and to prevent exposure [MEDICAL CONDITIONS] viruses from blood or body fluid. Under miscellaneous use gowns when indicated or as instructed. When use of a gown is indicated, all personnel must put on a gown before treating or touching the resident. The facility policy Isolation-Initiating Transmission-Based Precautions dated 10/01/2019 documented when transmission-based precautions are implemented, the Infection Control Coordinator (or designee) shall post the appropriate notice on the room entrance doors to be aware that they must first see a nurse to obtain additional information about the situation before entering the room. The undated facility policy Handwashing/Hand Hygiene Policy documented all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy also documented hand hygiene is to be performed before and after direct contact with the residents, after contact with resident's intact skin and after removing gloves. In addition, the policy documented hand hygiene is always the final step after removing and disposing of personal protective equipment and the use of gloves does not replace handwashing/hand hygiene. On 02/21/2020 at 02:56 PM, a Phlebotomist was observed entering room [ROOM NUMBER] without first donning PPE. A sign was posted on the room door which documented STOP Check with Nurse Before Entering. The phlebotomist removed gloves and tourniquet from the phlebotomy bag. The phlebotomist was not observed performing hand hygiene before donning gloves. The phlebotomist was not observed donning PPE and was observed dressed in street clothes including a coat and a hat. The phlebotomist collected the blood samples, labeled the samples and placed in a biohazardous bag. The phlebotomist removed gloves and exited the resident's room without performing hand hygiene. On 02/21/2020 at 03:19 PM, the phlebotomist was interviewed and stated she did not check in at the nurse's station before entering the resident's room and had not drawn blood from the resident in the room before. The phlebotomist also stated that she has had training on PPE in 2019 and also in January 2020. The phlebotomist further stated that she normally washes her hands in the resident room and before and after she draws blood. The phlebotomist also stated that next time she does phlebotomy she will wash her hands. On 02/25/2020 at 12:30 PM, a phone interview was conducted with the Phlebotomy Manager who stated handwashing is to be done before and after leaving a resident's room. The Phlebotomy Manager stated that his company provides contact precautions/isolation training to staff when they are hired and on an annual basis training is provided on handwashing and contact isolation. The Phlebotomy Manager further stated his expectation of handwashing includes that staff perform it before and after every patient, and staff should use PPE when required. On 02/26/2020 at 02:01 PM, the Assistant Director of Nursing Services (ADNS)/ Facility Infection Control Representative stated that when the phlebotomist comes into the facility, they should wash their hands when entering and exiting the resident's room. The ADNS also stated that the contract entities have been educated on signage in relation to contact precautions. 415.19(b)(4)

Based on interviews and observations, during the recertification survey, the facility did not ensure that residents received services that accommodated the resident's needs and preferences. Specifically, the call light were not kept within reach of the resident. This was evident for 1 of 5 residents reviewed for the Environment (Resident #13). The findings are: The facility's policy and procedure Call Light Use Of reviewed 8/2017 documented the purpose to assure the call system is in proper working order, including bedside and emergency call lights (in bathrooms). The facility's procedure included guidance to check all call bells daily, be sure all call bells are in residents reach, and call bells that are malfunctioning, resident should be provided with a portable bell. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required extensive assistance of one person assist for bed mobility and toilet use, and the resident required limited assistance of one person for transfers. On 11/05/18 at 11:51 AM and 11/6/18 at 12:50 pm, the surveyor observed the resident's bathroom call light. The call bell's pull string with a black knob on the end was detached from the call light's metal lever/switch. The call light's pull string was hanging on a piece of curved metal just below the call light's metal lever. On 11/08/18 at 02:48 PM, an interview was conducted with Certified Nursing Assistant (CNA #7) currently assigned to the resident. CNA #7 stated the resident usually uses the call light at the bedside to alert staff when assistance is needed to use the bathroom. The resident waits at the bathroom door for staff. CNA #7 stated that the call light in the resident's bathroom was working properly; the CNA and surveyor walked into the resident's bathroom and observed that the pull string with black knob was detached from the metal lever of the call light. CNA #7 stated she was not aware that the pull string was not attached to the call light. She then proceeded to test the call light by pushing down on the metal lever and stated it was working. CNA #7 was asked, if the resident is on the toilet and needs assistance, can the resident use the call light, and the CNA responded no. CNA #7 also placed the black knob with string unto the metal lever and stated that the black knob will not stay on. On 11/08/18 at 03:01 PM, an interview was conducted with CNA #8 who was previously assigned to the resident for (MONTH) (YEAR). CNA #8 was asked to observe the call light in the resident's bathroom, and CNA #8 returned and stated that the call light is working. The CNA was asked if the resident is on the toilet and needs assistance, would she be able to use the call light. CNA #8 responded No. CNA #8 also stated she was not aware that the pull string with black knob was not attached to the call light. The surveyor observed CNA #8 informing Registered Nurse (RN #8) about the resident's call light. On 11/08/18 at 03:45 PM, RN #8 was interviewed. RN #8 stated she routinely visits each resident in their room and test the bedside call lights. She further stated she checked the resident's call light today. RN #8 stated she usually does not check bathroom call lights of residents and was not aware of the issue with the resident's bathroom call light. RN #8 stated the maintenance department was contacted about the matter. In a follow up interview on 11/09/18 at 12:05 PM with RN #8, it was clarified that during morning visits with residents, RN #8 observes if the call lights are within reach of the residents and asks the residents if the call lights are working. RN #8 stated CNAs are responsible for spills, broken items, ensuring appropriate room temperature, heater is working, and other issues in residents' rooms. RN #8 stated that the nursing staff is responsible for determining that call lights work. 415.5(e)(1)

Based on interviews, and record reviews during the recertification survey, the facility did not ensure that the comprehensive care plan (CCP) was revised to reflect resident care needs and that the CCP was prepared by an interdisciplinary team, which included participation of the resident. Specifically, (1) the facility did not review and revise a resident's care plan to reflect application of heel booties while resident is in bed (resident #163); (2) a resident was not able to participate in the care planning process. This was evident for 1 of 2 residents reviewed for Pressure Ulcer (Resident #163), and for 1 of 5 residents reviewed for Participation in Care Planning (Resident #53) out of a total Investigation sample of 35 residents. The finding is: 1) Resident #163 was initially admitted to the facility on [DATE], with a most recent re-admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident is ventilator dependent, alert, and non- verbal. The resident required total care for all activities of daily living. [DIAGNOSES REDACTED]. The Braden Scale for predicting pressure sore risk dated 09/21/18 documented the resident is very high risk for skin breakdown. The Braden Scale for predicting pressure sore risk dated 10/07/18 documented resident is high risk for skin breakdown. A Nursing note dated 9/21/18 documented that redness was noted on both resident's heels, back, and sacrum. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for potential for pressure ulcer, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. The CCP for potential/actual impairment to skin integrity, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. On 11/09/18 at 10:25 AM, the Registered Nurse (RN #1) was interviewed. RN # 1 stated that part of her job responsibilities is to review and revise care plans if a resident has a new [DIAGNOSES REDACTED]. RN #1 stated that the resident's care plans for potential pressure ulcer and skin breakdown were completed on 9/10/18. The Care plans were not revised to reflect application of heel booties. RN #1 further stated that the care plans for skin integrity do not mention anything about applying heel booties while in bed. RN #1 stated that usually, when there is a readmission, the care plans are updated to reflect new orders. RN #1 further stated that when the resident returned to the facility on [DATE], the care plan for skin integrity and pressure ulcer should have been updated by the RN on duty. On 11/09/18 at 11:49 AM, RN #5 was interviewed. RN #5 stated that her job responsibilities include supervising the unit and supervising charge RNs, LPNs and CNAs. RN #5 stated that she confirms Doctors' orders, communicates with Doctors, and updates care plans. RN # 5 stated that if a resident returns from the hospital and there is a new [DIAGNOSES REDACTED]. If there are no new orders, we would revise the care plan quarterly. RN # 5 further stated that when a resident is being readmitted to the facility; the nurse who is admitting the resident is supposed to revise the care plan to reflect the new orders. The resident's care plan should have been revised to reflect application of booties while in bed. The care plan should always get revised if there are any new orders or new diagnoses. 2) Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy Care Planning -Interdisciplinary Team reviewed 5/2017 documented: the Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The policy further documented that the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The Care Plan Conference Summary shall be completed during the conference and include all attendees signatures. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS documented the resident participated in the assessment. On 11/05/18 at 9:34 AM, the resident was interviewed. The resident stated she has not been included in her care plan for the past year. The facility provided the Care Plan Conference Summary document dated 5/16/18 and 8/22/18; which showed the designated area to be signed by the resident/representative was blank. On 11/08/18 at 03:00 PM, an interview was conducted with Register Nurse (RN #8) who stated that after a care plan meeting has ended, each staff who attended the meeting must document a care plan. On 11/07/18 at 03:31 PM, an interview was conducted with the Social Worker (SW) and Social Worker Director (SW Dir.). The SW stated two weeks prior to care plan meetings written invitations are physically handed to the residents, and the residents are also asked where the meeting should be held. The resident's response of yes or no is documented on a sheet that is not kept. A copy of the invitation is kept, but the facility does not have a tracking system verifying delivery to the residents. The SW department presented two out of four requested Care Plan Conference Summary (of who attended the meeting) dated 5/16/18 (blank) and 8/22/18 (resident refused to sign). The document date 8/22/18 was scanned into the EMR (Electronic Medical Record) on 8/23/18, and the scanned version was blank in the area where the resident/representative is designated to sign. On 11/08/18 on 12:11 PM, the SW was interviewed. The SW stated, he dropped the ball and must have the form signed by the resident or document why the resident was not able to sign. The SW stated moving forward, a system to monitor issuance of invitation letters and to ensure that resident/representative signatures or reason not signed is completed on the Care Plan Conference Summary at the end of each care plan meeting will be developed. 415.11 (c) (2) (i-iii)

Based on observation, record review, and interview, during the recertification survey, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Specifically, during multiple observations, a resident was observed in bed without heel booties in place as ordered. This was evident for 1 of 2 residents reviewed for Pressure Ulcer(Resident #163). The finding is: Resident #163 was initially admitted to the facility on [DATE], with a most recent re-admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident is ventilator dependent, alert, and non- verbal. The resident required total care for all activities of daily living. [DIAGNOSES REDACTED]. On 11/05/18 at 09:45 AM, 11/06/18 at 10:47 AM and 03:43 PM, 11/07/18 at 09:51 AM and 12:47 PM, 11/08/18 at 9:50 AM, and 11/09/18 at 10:24 AM, the resident was observed in bed with no heel booties in place. The Braden Scale for predicting pressure sore risk dated 09/21/18 documented the resident is very high risk for skin breakdown. The Braden Scale for predicting pressure sore risk dated 10/07/18 documented resident is high risk for skin breakdown. A Nursing note dated 9/21/18 documented that redness was noted on both resident's heels, back, and sacrum. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for potential for pressure ulcer, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. The CCP for potential/actual impairment to skin integrity, last reviewed on 10/10/18, did not reflect application of heel booties while resident is in bed among the interventions documented. The Nursing Notes from 09/21/18 to 11/09/18 did not document application of heel booties while resident is in bed. The CNA Accountability sheets from (MONTH) 1, (YEAR) to (MONTH) 8, (YEAR) did not document application of heel booties while resident is in bed. On 11/08/18 at 03:59 PM, the Certified Nursing Assistant (CNA #3) was interviewed. CNA #3 stated that the charge Nurses inform CNAs of any changes in the resident's plan of care. CNA #3 stated that the charge nurses would explain to the CNAs what they are responsible for. CNA #3 further stated that she does skin checks daily, and if she sees any changes in resident's skin condition, she would inform the charge nurse so that the RN can assess the resident. On 11/09/18 at 10:30 AM, the Licensed Practical Nurse (LPN #1) was interviewed. LPN #1 stated that the resident's personal aide is always there monitoring her. LPN #1 stated that she checks to ensure that the personal aide is doing what she is supposed to be doing. LPN #1 stated that if the personal aide is doing something she is not supposed to be doing, we would correct it. LPN #1 stated that the application of heel booties while resident in bed is an active order, and the resident should have heel booties on when she is bed. LPN #1 stated that she is not sure why the resident is not wearing booties. LPN #1 further stated that she will talk to the personal aide to ensure the resident wears the heel booties while she is in bed. On 11/09/18 at 10:25 AM, the Registered Nurse (RN #1) was interviewed. RN #1 stated that on a daily basis, she checks the electronic Medical Record (EMR) to see if there are any new orders, pending orders and labs results. RN #1 stated that she confirms orders and then she carries the orders out. RN #1 stated that at the beginning of the shift, she gets shift report from the nurses on the previous shift. The nurses on the previous shift also inform her about any new orders. RN #1 further stated that she is not sure why the resident is not wearing the heel booties while in bed. RN # 1 further stated that since there is an active order for application of heel booties, the resident should be wearing the heel booties while in bed. RN #1 stated that she recently informed the personal aide that heel booties must be applied while the resident is in bed. On 11/09/18 at 10:52 AM, RN #4 was interviewed. RN #4 stated that the previous shift would inform the incoming shift about any new orders or pending orders. RN # 4 stated that when a doctor puts in new orders, we have to confirm it. If an order is active that means it was confirmed. RN #1 stated that the application of heel booties is an active order and the resident is supposed to have heel booties on while she is in bed. RN #4 stated that the resident has a personal aide so the aide should put it on. RN #4 further stated that it is nursing staff's responsibility to ensure that all physician's orders [REDACTED]. The application of heel booties should be on the CNA task/responsibilities, but the heel booties are not on the current CNA Accountability sheet. RN # 4 further stated that going forward, she will ensure the resident is wearing heel booties while she is bed. On 11/09/18 at 11:49 AM, RN #5 was interviewed. RN #5 stated that her job responsibilities include supervising the unit and supervising RNs, LPNs and CNAs. RN #5 stated that she confirms physician's orders [REDACTED]. RN # 5 stated that after a doctor puts in an order, the nurse checks the order and confirms the order. Once the order is confirmed, the nurse informs the nurse on duty to carry it out. If it falls under CNA tasks, she would add it to their tasks. RN # 5 stated that since the resident has an order for [REDACTED]. RN # 5 further stated that she recently explained to the nurses and personal aide that the heel booties should be on while the resident is in bed. RN # 5 stated that going forward, staff will ensure that all Doctor's orders are carried out. 415.12 (c) (1)

Based on observations, interviews, and record review, during the recertification survey, the facility did not ensure that residents with limited mobility received appropriate services and assistance to maintain or improve mobility. Specifically, residents at risk for contractures with an order for [REDACTED].#25 and #103). The findings are: 1) Resident #25 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. On 11/05/18 at 6:55 AM, 11/05/18 at 8:30 AM, 11/05/18 at 11:39 AM, and 11/06/18 at 9:22 AM, Resident #25 was observed lying in bed in his room without bilateral hand rolls in place. A Comprehensive Care Plan (CCP) dated 2/13/18 and updated on 9/11/2018 documented that Resident #25 was issued bilateral hand rolls for contracture management. The goal of the CCP is that the resident will not develop complications from use of device and to promote prevention of contractures or further deformities. The interventions document that staff are to apply splint/device as ordered, assess quarterly and as needed, monitor skin integrity, and have physical/occupational therapy screen the resident as needed. The resident's current physician's orders [REDACTED]. The day and evening shift are to remove the hand rolls during hygiene care and perform a skin check. The hand roll order was initiated on 4/11/2018. The Treatment Administration Record (TAR) dated 11/2018 documented bilateral hand rolls are to be present at all times for contracture management. The day shift and evening shift signed the TAR to indicate they performed hygiene/skin checks. The Brace/Splint Nursing Rehab Program Form dated 11/2018 documented that the resident has bilateral hand rolls at all times. Every day and evening shift is to perform hygiene and skin checks. The section for CNA Initials on the 7-3 shift does not reflect signatures for 11/3 and 11/4/2018. The 3-11 shift does not reflect any signatures for 11/1, 11/2, 11/3, 11/4, 11/6, and 11/7/2018. On 11/08/18 at 12:17 PM, the Certified Nursing Assistant (CNA #1) was interviewed. CNA #1 has worked with Resident #25 since 6/2018. He assists the resident by providing total care with all activities of daily living. CNA #1 stated that the resident has hand rolls in place to prevent tightening of his hands. CNA #1 stated that he always places hand rolls in Resident #25's bilateral hands after providing care. The resident is unable to remove the hand rolls on his own without assistance from staff. The hand rolls are only to be removed during care and then placed back into the resident's hands once care is done. 2) Resident #103 was admitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented that the resident had severely impaired cognition and required total assistance with all activities of daily living. Observations were made of Resident #103 in his room on 11/05/18 at 6:55 AM, 8:30 AM, and 11:38 AM, 11/06/18 at 9:51 AM, and 11/07/18 at 9:38 AM. Each time, the resident was observed without bilateral hand rolls in place. The hand rolls were observed to be on the resident's bedside table near the wall and out of reach of the resident. The Comprehensive Care Plan (CCP) dated 2/13/18 and revised 9/17/18 documented that the resident was been issued bilateral hand rolls for contracture management. The goal is that resident will not develop complications from use of device and to promote prevention of contractures or further deformities. The documented interventions are to apply the splint device as ordered, assess quarterly and as needed, monitor skin integrity, and physical/occupational therapy screen as needed. The most current physician's orders [REDACTED]. Hand rolls are to be removed for hygiene and skin checks on the day and the evening shifts. The Treatment Administration Record (TAR) dated 11/2018 documented the presence of bilateral hand rolls to be applied for contracture management every day and evening shift. Remove hand rolls for hygiene/skin checks. The day and evening nurses signed the TAR daily. The Brace/Splint Nursing Rehab Program Form dated 11/2018 documents that the resident has bilateral hand rolls at all times. Every day and evening shift is to perform hygiene and skin checks. The section for CNA Initials on the 7-3 shift does not reflect signatures for 11/6 and 11/7/18. The 3-11 shift does not reflect any signatures for 11/1, 11/2, 11/3, 11/4, 11/5, and 11/7/2018. An interview was conducted with the assigned Certified Nursing Assistant (CNA # 2) on 11/08/18 at 11:06 AM. CNA #2 has worked with resident for a long period of time. She is aware that hand rolls were ordered for the resident. According to CNA #2, the resident will only keep the hand rolls on for 5-10 minutes at a time. He has a behavior of wiping his hands along his body, removing the hand rolls. CNA #2 must reapply the resident's hand rolls several times a day. The resident does not currently have hand rolls in place because he has already removed them. CNA #2 stated that she will apply the hand rolls to the resident's hands again once the housekeeper is done mopping the floor in the resident's room. She stated that the physician's orders [REDACTED]. CNA #2 stated that she has informed the Occupational Therapist (OT) regarding the resident's behavior of removing the hand rolls. On 11/08/18 at 11:46 AM, an interview was conducted with the Director of Rehabilitation Services (DORS). The resident is not currently receiving restorative occupational therapy services. Resident #103 was originally evaluated on 1/24/18 and 2 occupational therapy screens were completed on 6/29/18 and 9/12/18. If nursing staff communicated to the therapists that the resident had any non-compliant behaviors or issues with using devices, the occupational therapist would document this in their notes. There are no documented behaviors regarding non-compliance or difficulty with hand roll usage for Resident #103. An interview was conducted with the charge nurse of the resident's unit, RN #3, on 11/08/18 at 12:24 PM. Once the physician has ordered hand rolls to be in place, the RNs are responsible for documenting on the TAR regarding device usage and whether it is in place. RN #3 has not been made aware of any behaviors that would cause Resident #103 to not have the hand rolls in place. 415.12(e)(2)

Based on observation and interview the facility did not maintain a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a staff member was observed without personal protective equipment (PPE) in the room of a resident on transmission based precautions. This was evident for a random observation on 1 of 5 resident units (Unit 2). The finding is: 1) The facility Infection Control Guidelines for All Nursing Procedures policy dated 1/2018 documents that staff should wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. On 11/08/18 at 11:22 AM, a Respiratory Therapist (RT) was observed in room [ROOM NUMBER] leaning over a resident with gloves on her hands. A sign was observed on the door of room [ROOM NUMBER] that documented Instructions for all personnel and visitors - STOP - contact precaution - wear gown and gloves. A cart containing PPE items (masks, gloves, and gowns) was observed directly outside of room [ROOM NUMBER]. The RT in the resident's room was not wearing a gown. The RT began gathering supplies near the resident's bedside. She then removed her gloves and walked out of the resident's room and used hand sanitizer in the hallway. An interview was conducted on 11/08/18 at 11:22 AM with the RT. The RT stated that PPE equipment should be used when entering room [ROOM NUMBER]. The RT stated that she knows that she should have had a gown in place when entering the resident's room to provide any type of care. On 11/09/18 at 12:03 PM, an interview was conducted with the facility Assistant Director of Nursing Services (ADNS)/ Infection Control Coordinator. The ADNS stated that PPE is to be used for residents on contact precautions. Every staff member and visitor entering the room must put on the ordered PPE. A sign is used to inform each person entering the room of the specific precautions. Infection control in-services are provided quarterly and as needed to update staff and to reinforce adhering to the policies. All staff are provided with the in-service, and all staff must adhere to the infection control policies. §483.80

Based observation, interview, and record review, during the recertification survey, the facility did not ensure that a resident was adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, a resident was observed on multiple occasions without an operating call bell in place. This was evident for 1 of 5 residents reviewed for the Environment out of an initial pool of 40 residents (Resident #67). The findings is: The facility's Call Light, Use Of Policy and Procedure dated 8/2017 documented the purpose to assure call system is in proper working order. The policy further documented that staff are to position the call bell conveniently for the resident to use, check all call bells daily and report any issues to the charge nurse immediately, and if the call bell is malfunctioning, provide the resident with a portable bell. Resident #67 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition. On 11/05/18 at 6:55 AM, 11/06/18 at 10:01 AM, and 11/07/18 at 9:46 AM, Resident #67 was observed in his bed with no call bell attached to the wall. There was no observed call bell cord hanging from the call bell unit on the wall behind the resident's bed. No other call bell system or manual bell was observed in the resident's room. The call bell light in the hallway above the resident's door was not lit. The Risk For Falls Comprehensive Care Plan (CCP) initiated on 3/5/2018 and updated on 8/30/2018 documents that resident #67 is at moderate risk for falls due to gait and balance problems, incontinence, and the resident being unaware of safety needs. Goals-Will be free of falls through review date. The CCP further documents that the interventions to prevent falls includes ensuring that the resident's call light is within reach and encouraging the resident to use it for assistance as needed. An interview was conducted with the resident's Certified Nursing Assistant (CNA), CNA #1, on 11/07/18 at 12:15 PM. CNA #1 has worked in the facility since 2/2018 and has worked directly with the resident since 6/2018. CNA #1 confirmed that there is no call bell present in the resident's room. He stated that normally, the call bell is placed close to all residents. CNA #1 stated that the resident can ambulate independently, and he believed this was the reason that the resident did not have a call bell in his room. CNA #1 stated that he believes that the resident has not had a call bell in place since he first started working with the resident in 6/2018. He did not inform the nurses or other staff about the resident's missing call bell cord and button. CNA #1 assists the resident with bed baths and toileting. The resident can get out of bed, walk to the door of his room, and wave to staff members to indicate whether he needs something. CNA #1 states that the resident will mainly go to his door and wave for staff when he requires the assistance of the respiratory therapist (RT). CNA #1 states that he believes it is his responsibility to ensure that a call bell is present in each resident's room and to ensure that the call bell is placed within the resident's reach. He stated that he learned in school that the call bell needs to be placed near the resident after providing care in order for residents to communicate with staff if they need something. CNA #1 further stated that he had been in-serviced at the facility regarding alarms, abuse, and infection control but not specifically regarding call bell use. He does not recall whether he was trained and/or ever in-serviced regarding the call bell policy in the facility. CNA #1 stated that his training included shadowing another CNA from the 3rd floor for one day to be competent in providing care to residents. On 11/07/18 at 12:33 PM, an interview was conducted with Registered Nurse (RN), RN #1. She has been a nurse with facility since 6/2018 and a nurse on the resident's unit since 6/2018. RN #1 stated that she is familiar with Resident #67 and she does not believe he uses the call bell. The resident is near the nursing station and staff check on him very often. RN #1 could not recall seeing the resident ring the call bell; however, she stated that the resident would know how to use the call bell if it were placed next to him. She stated that the resident has a behavior of letting the staff know that there is a concern when they conduct their rounds of the unit. RN #1 was not aware that Resident #67 did not have a call bell and/or call bell cord in his room. She will ensure that the Maintenance Department will be contacted to address the fact that the resident does not have a call bell button and cord present. RN #1 was not aware of any physician's orders [REDACTED]. Generally, if the call bell is not functioning, or if it is detached from the wall, the call light above the resident's door will light up and stay on. In addition to the call light above the resident's door, every shift is responsible for completing daily rounds which includes taking note of any issues with call bells or the call bell system. The charge nurse and a RN on the unit are responsible for environmental rounds that are to be completed several times per month. A form with the environmental assignment to be completed is handed out to the charge nurses and RNs by the nursing administration. Environmental rounds were completed on the previous Monday. RN #1 was part of the environmental rounds last Monday and stated that Resident #67 had no observed issues with his call bell. RN #1 stated that every resident is supposed to have their own call bell. She further stated that only residents who are alert and oriented will be able to use the call bells; however, all residents should have a call bell present in their room. Even if the resident has cognitive impairments, a call bell should still be present. An interview was conducted with the Director of Maintenance (DOM) on 11/09/18 at 11:51 AM. He has worked with the facility for approximately 11 months. The DOM stated that the maintenance department is responsible for maintaining all call bells. He personally performs weekly environmental rounds and checks every resident room, common areas, and bathrooms that have call bells. The last weekly check was performed on the resident's unit last Thursday. During rounds, every bell is pressed and the lights are checked to ensure they light up when a call button is pressed, and the general presence of call bell cords are ensured. If the call bell station is malfunctioning, the DOM will try to trouble shoot the issue or will call CCI (the call bell consulting company). The DOM found it hard to believe that Resident #67's call bell light and an audible sound were not triggered by the resident's call bell cord not being in the wall. This is the first time that a resident's cord had ever been out of the wall without any alarms sounding. Whenever there is an issue with call bells, the nursing staff will either call the maintenance department and/or use the maintenance log books located on each floor to ensure communication of the issue. There has been no communication from the nursing staff regarding Resident #67's call bell. On 11/09/18 at 12:17 PM, an interview was conducted with RN #2. He has been with the facility since 1995. RN #2 stated that the CNA #1 reported that there was no call bell in the resident's room following his interview with the SA. RN #2 is not the person that staff would normally contact for call bell issues; however, CNA #1 chose to contact him in this particular case. RN #2 was first made aware of the fact that Resident #67 did not have a call bell cord in his room on 11/7/18. No other issues or reports were made regarding any residents not having a call bell cord or functioning call bell. RN #2 asked maintenance department for a call bell cord and went directly to Resident #67's room to insert the cord in the wall. Once the cord was inserted into the wall, it was pressed and was determined to be functional. A maintenance worker was also sent to the resident's room to ensure that the call bell is functioning properly. RN #2 stated that this is the first time that he has ever encountered a resident who had a cord missing and that the alarm did not sound or go off. 483.90(g)(1)(2)

Based on record review and interview, during the recertification survey, the facility did not ensure that the resident's right to manage his or her financial affairs was maintained. Specifically, two residents stated that the facility does allow them to withdraw more than fifty dollars each month from their personal accounts. This was evident for 2 of 3 residents reviewed for personal funds (Resident #s 13 and 138). The findings are: The facility's policy Resident Funds, reviewed 4/2018, documented: residents will be entitled to access their funds 24 hours/7 days a week at the facility. 1) Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had intact cognition. During the initial interview on 11/05/18 at 11:11 AM, the resident stated she can only withdraw fifty dollars a month. The resident stated if it runs out I will do without for the rest of the month. On 11/09/18 at 12:50 AM a follow up interview with resident #13 was conducted. The resident stated that she can only withdraw a total of fifty dollars every month. The resident further stated she previously attempted to withdraw an additional $10 within that same month but was not allowed. Resident #13 Funds ledger showed consistent monthly withdrawals of $50 between (MONTH) (YEAR) through (MONTH) (YEAR). On 8/8/18 a total of $50 was debited with a remaining balance of $261.50; on 09/06/18 a total of $50 was debited with a remaining balance of $261.50; and on 10/8/18 total of $50 was debited with a remaining balance of $262.17. 2) Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented the resident had intact cognition. On 11/05/18 at 10:27 AM, an interview was conducted with the resident who stated that she could not withdraw more than fifty dollars a month. Resident #138 Funds ledger showed monthly withdrawals of less than or equal to $32 between (MONTH) (YEAR) through (MONTH) (YEAR). On 8/9/18 a total of $20 was debited with a remaining balance of $682.37; on 09/05/18 a total of $20 was debited with a remaining balance of $717.37; on 10/4/18 total of $20 was debited with a remaining balance of $742.09. On 11/09/18 at 09:36 AM, an interview was conducted with the Medicaid Coordinator (MC). The MC stated residents receive fifty dollars a month from Medicaid, and the residents can withdraw that amount each month even if the residents' balance is greater than fifty dollars. The MC stated she believed Medicaid regulations limited withdrawals to fifty dollars, but there is a misunderstanding by residents who have stated only fifty dollars can be withdrawn each month. The MC stated for large withdrawals, the resident is asked questions related to the need for the amount and how the money will be used to determine if the money would just be stored in the resident's room rather than being used. The MC stated that residents would not be denied their funds. On 11/09/18 at 01:04 PM, an interview was conducted with the Administrator (Admin.). The Administrator stated residents can withdraw any amount from their personal funds, and he was not aware of the fifty dollar withdrawal limit to residents or why staff were asking how the funds would be used when residents requested larger funds. The Admin. stated a staff member would be directed to inform each cognitively intact resident with an account (verbally and in writing) that all residents are entitled to withdraw any amount based on needs or wants without limitation. 415.26(h)(5)

Based on observation, record review and interview, the facility did not ensure that a resident's drug regimen was free from unnecessary drugs. Specifically: 1) Insulin was administered to a resident when the blood glucose level was below the ordered parameters (Resident #44) and; 2) [MEDICAL CONDITION] medication was re-ordered for a resident with a [DIAGNOSES REDACTED]. This was evident for 2 of 5 residents reviewed for Unnecessary Medication Use. (Resident # 44 and #148). The findings are: 1) Resident #44 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/31/17 at 11:00 am during the initial tour of the unit, the resident was observed in the day room, alert and wake. The resident was sitting with other residents at a table and easily engaged in conversation with the SA (State Agency). The Admission MDS (Minimum Data Set) 3.0 assessment dated [DATE] documented intact cognition and limited assistance for activities of daily living. The Comprehensive Care Plan (CCP) for Endocrine/Diabetes dated 9/17/16 and revised 12/16/16 documented the following interventions: Administer med's (medications) as ordered by MD (Medical Doctor), monitor for effectiveness of medications, monitor blood glucose level as ordered, monitor glucose level three times daily. Goals included: resident will be free of signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION] and resident will maintain blood glucose level within acceptable ranges. Physician orders dated 9/16/16 documented: Humalog Subcutaneous Solution 100 Unit/ML Insulin [MEDICATION NAME] (Human) 14 unit(s) subcutaneous 3 times daily before meals. Medical condition: Type 2 Diabetes Mellitus If blood sugar < ( less than) 70 then call MD (Medical Doctor) If blood sugar > ( greater than) 400 then call MD [MEDICATION NAME] Subcutaneous Solution 100 Unit/ML (Insulin) 40 unit(s) subcutaneous bedtime The Medication Administration Records (MAR) dated 9/2016 to 2/2017 were reviewed and documented that on 1/14/17 at 11:30 am, the fingerstick reading was 68 mg/dl (milligrams/deciliter). The documented dosage of Insulin that was administered was 14 units of Humalog Insulin. On the same day 1/14/17, the LPN documented in the comment section of the MAR indicated [REDACTED]. The note further documented that 14 units of Insulin was administered per the resident's request. There was no documented evidence that the Physician was contacted in accordance with the order for contacting the doctor if the blood sugar was below 70. On 2/2/17 at 1:31 PM, an interview was conducted with the LPN (Licensed Practical Nurse) who administered the insulin on 1/14/17. The LPN acknowledged that the Physician order documents that the Physician is to be called if the blood sugar is less than 70 mg/dl and greater than 400 mg/dl. The LPN further stated that she administered the Insulin because the resident insisted that the Insulin be administered after her blood sugar was rechecked. The nurse was unable to explain why the physician was not contacted. On 2/3/17 at 12:45 PM, an interview was conducted with the resident who stated that she has been diabetic for many years and receives insulin three times a day. The resident further stated that sometimes she does not have an appetite and when they give her the insulin her blood sugar drops. The resident also stated many times they have to give me some orange juices and I will begin to shake or have blurred vision. 0n 2/3/17 at 1:00 PM, an interview was conducted with the unit RN (Registered Nurse) Nurse Manager who stated that the resident is on a standing scale order for Humalog insulin. The RN further stated that she does had not directly observe the LPN's administering Insulin but believed they were following the doctors orders. The facility policy for Guidelines for Safe Administration of Insulin dated 6/2016 documented the following: the nurses must check the physician order. Confirm the blood glucose result as ordered, recheck the amount of insulin drawn before injection, document the amount of insulin administered. 2) Resident #148 is an [AGE] year old admitted to facility 1/12/16 from an acute hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented severe cognitive impairment with no mood impairment or behavioral symptoms. The MDS further documented extensive assistance for activities of daily living and always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 1/12/16 documented interventions that included observe for side effects, psych consult as needed, monitor for changes in mood, behavior, mental status, approach res in calm, gentle manner The evaluation section of the CCP for [MEDICAL CONDITION] drug Use dated 7/28/16 documented that the resident continues on [MEDICATION NAME] 2.5 mg (milligrams) po (by mouth) q hs (every hour of sleep). Psych (Psychiatry) f/u (follow up) as needed. The Medication Regimen Review completed on 9/17/16 documented currently receiving [MEDICATION NAME] 2.5 mg QD for behaviors associated with Dementia. No recent behavior problems apparent on review of documentation in clinical record. Please evaluate, consider trial discontinue if appropriate. Physician's response- was documented as agree, will do. Physician's orders dated 9/20/16 documented [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg (milligrams) by mouth at bedtime was discontinued. Physician's Orders dated 1/20/17 documented [MEDICATION NAME] 2.5 mg by mouth was re-ordered. Review of the Medication Administration Record [REDACTED]. Review of the Mood and Behavior Flow Record from September 2016 to December 2016 documented that no behavior was exhibited. Review of nursing progress and Nurse Practitioner notes from 9/26/16 to 1/20/17 document no behavioral issues. Psychiatry Consult dated 1/19/17 documented patient appears confused and psychotic-dressed up with her coat on, had a bag with her clothes ready to go home. She is unable to state where exactly she wants to go. The consult further documented restart [MEDICATION NAME] 2.5 mg HS for [MEDICAL CONDITION]. There was no documented evidence in the medical record of specific behaviors or rationale to support the reordering of the antipsychotic medication on 1/19/17. On 02/02/2017 at 2:21 PM, an interview was conducted with the Certified Nursing Assistant assigned to the resident in January 2017. The CNA stated that the resident is confused and needs reminders and prompts to complete her ADL's (Activities of Daily Living). She also stated that the resident is monitored for holding onto garbage and hiding it in her pockets and bed. She stated that the resident can refuse care on occasion but responds to redirection and calms down when she is spoken to about her son who is involved in her care. On 02/06/2017 at 11:28 AM, the Registered Nurse Supervisor was interviewed and stated that the resident has been stable and has not been exhibiting any behaviors and is unsure of why the [MEDICATION NAME] was restarted. She also stated that there is no behavior flow sheet for January 2017 because the resident had not exhibited behaviors for the past three months which would have necessitated daily monitoring. She further stated communication about medication changes occurs between the physician and the Nurse Practitioner and that she is not consulted. On 02/06/2017 11:36:48 AM, the Nurse Practitioner was interviewed and stated that she has been providing care for the since March 2016 and that the resident is very demented. She also stated that the resident had no behavioral issues and a gradual dose reduction was done for the resident in September 2016. She further stated that [MEDICATION NAME] and [MEDICATION NAME] were added and adjusted to better manage the resident's Dementia. She also stated that the behavior documented as [MEDICAL CONDITION] is the resident's usual behavior and not an indication for ordering of antipsychotic medication and she would re-evaluate the need for the medication with the psychiatrist. A telephone interview was conducted with the Psychiatrist on 02/06/2017 at 11:46 AM who stated that she is at the facility once a week and conducts evaluations every other month or as requested. She also stated that the resident has a history of [MEDICAL CONDITION] and she prescribed the medication based on what she observed during her evaluation of the resident. She further stated that even if the staff did not document resident behaviors in the medical record, she cannot be held responsible when prescribing the medication. Review of the facility policy Antipsychotic Medication Use dated November 1, 2016 documents residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective nursing staff will document in detail an individual's target symptom(s). 415.12(l)(1)

Based on observations, record reviews, and interviews, the facility did not ensure that a resident identified as high risk for pressure ulcer development, did not develop a pressure ulcer. Specifically: 1) Preventive measures were not identified and implemented to address the care of the residents feet and; 2) the Licensed and Registered unit nurses did not provide ongoing assessment and monitoring of the residents feet prior to the development of an unstageable pressure ulcer of the right foot and a stage 3 pressure ulcer to the right lateral heel in a timely manner. This was evident for 1 of 4 residents reviewed for Pressure Ulcers. (Resident # 223). The findings are: Resident # 223 is a [AGE] years old was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing Initial assessment dated [DATE] documented: Buttocks Stage 2 pressure ulcer on admission. The CCP Potential for developing skin break due to decreased mobility dated 2/10/16 and revised 3/3/16 documented the following interventions: alternating pressure mattress, elevate legs, keep skin dry and clean, monitor skin for signs of pressures and turning & positioning . There were no preventive (off loading) pressure relief interventions to address the care of the residents feet documented on the CCP dated 2/10/16. The admission Braden Scale assessment dated [DATE] documented: a total score of 10, which indicated High Risk (Total Score 10-12) for pressure ulcer development. The Occupational Therapy Evaluation & (and) Plan of Treatment dated 2/11/16 documented: [MEDICAL CONDITION] and [MEDICAL CONDITION] following non-traumatic subarachnoid hemorrhage affecting right dominant side. Right upper extremity strength-impaired, functional limitations as a result of contracture, reaching, repositioning self, fine/gross motor coordination-impaired. Clinical Impressions: patient presents with deficits, increased assistance needed to perform activities of daily living. Putting on & removing footwear-dependent. The Medical progress note dated 2/15/16 documented: Chief Complaint-Wound, left buttock stage 2 pressure ulcer. The note further documented: Additional Orders: Pressure Relief/Offloading-Follow facility pressure ulcer prevention policy/protocol, offload heels per facility policy/protocol. There was no documented evidence that the additional medical orders documented on the medical progress note dated 2/15/16 were implemented. The Minimum Data Set (MDS) Admission assessment dated [DATE] documented impaired speech, rarely understood and severe cognitive impairment. The MDS further documented the residents risk for pressure ulcer development, the presence of a stage 2 pressure ulcer and interventions which included pressure reducing devices for chair and bed, turning/repositioning program, nutrition or hydration interventions and the application of dressings. The Medical progress note dated 2/22/16 documented: Integumentary (Hair, Skin)-Skin and subcutaneous tissue without rashes, [MEDICAL CONDITION] or discolorations. Hair and skin color texture normal and healthy in appearance. Nursing progress note dated 2/29/16 documents the following: Resident was noted during morning (am) rounds with 2 PUs (Pressure Ulcers) to R (Right) foot. R malleolus 3 x 3 cm (centimeter) stage 3 and R lateral side of heel 5 x 2.5 cm unstageable. 3+ (plus) [MEDICAL CONDITION] to entire foot. Wound consult ordered, Treatment with NS cleanse, apply Hydrogel and wrap with Kerlix. There was no documented evidence that the unit nurses provided ongoing monitoring and assessment of the residents feet prior to the development of a stage 3 pressure ulcer to the right malleolus and an unstageable right lateral heel pressure ulcer prior to 2/29/16. The wound care evaluation (wound care nurse note) dated 2/29/16 documented: identified new skin breakdown (pressure ulcers) as Stage 3, Right malleolus 3 x 3 cm and unstageable right lateral heel 5 x 2.5 cm. The Braden Scale assessment dated [DATE] documented: a total score of 11- indicating high risk for pressure ulcer development. The CCP for Altered skin integrity: Right heel unstageable pressure ulcer dated 3/1/16 documented:. R heel-unstageable- 3 x 5 cm necrotic. R Outer ankle/malleolus-Unstageable R Lateral ankle- necrotic-dry black eschar 3 x 2 cm. The Certified Nursing Assistant Accountability Record (CNAAR) documented skin checks every shift (qs) for the month of February 2016. On 2/29/16 at 3:30 PM, the accountability record documented 'yes' for the question, Do you see a new skin problem (including the feet) On 2/27/16 at 3:30 PM and 2/28/16 at 7:30 AM there were omissions for the skin checks. There were no skin problems documented on the CNAAR from 2/1/16 to 2/29/16. There were no preventive (off loading) pressure relief interventions to address the care of the residents feet documented on the CNAAR. On 4/4/16 at 10:35 am, the resident was observed in the wheel chair in the dayroom. During the observation, the resident was non verbal, confused and speaking unintelligibly in Creole. On 4/6/16 at 12:15pm, the Registered Nurse (RN) Manager was interviewed and stated that the resident's skin was intact on admission and these are nosocomial (facility -acquired) ulcers. She further stated that while applying the residents heel booties on 3/1/16, she noticed the necrotic area on the outer ankle and assessed the area as an unstageable ulcer. She further stated that the skin assessment protocol requires weekly checks by the Licensed Practical Nurse (LPN) or RN (registered Nurse) on shower days and by the CNA's every shift. She further stated that no one reported the necrotic area on the heel until 2/29/16 and added that altered skin should be reported and identified at Stage 1 when the skin becomes reddened. On 4/7/16 at 10:52 AM, the CNA (on the 7-3 shift) was interviewed and stated that the skin checks entail the CNA's checking for any skin break down over the elbows, buttocks, heels, ankles and back. She also stated that while applying lotion to the resident's skin, she observes the heel and other areas. She further stated that on 2/25/16 she did not observe any skin break down. On 4/7/16 at 12:15 PM, the Wound Care RN was interviewed and stated she conducts the wound care evaluations once a week, along with the wound care doctor. She stated that she saw the resident on 2/15/16 (after admission on 2/10/16) and at that time the resident had a left buttock Stage 2 PU. The next assessment that she conducted was on 3/1/16 when two ulcers where noted-one stage 3 right heel and an unstageable right ankle ulcer. The RN further stated that the resident had [MEDICAL CONDITION], was not actively mobile, at risk for skin breakdown and that in 3 or 4 days a pressure ulcer could develop. The facility policy and procedure, dated 5/2015, for Pressure Ulcer Prevention and Management documented a resident who enters the facility without pressure ulcers, does not develop one. Identify residents who are at risk to ensure early deduction of any change in resident's conditions and to reduce the incidents of pressure ulcer through effective assessment, prevention and treatment. 415.12 (c) (1)