Every finding on record at Berkshire Nursing & Rehabilitation Center

Based on record review and interviews the facility did not ensure each resident received preadmission screening for individuals with a mental disorder. This was identified for one (1) (Resident #9) of 32 residents reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, Resident #9 with diagnosis of schizophrenia (a chronic, severe brain disorder that distorts how a person thinks, feels, acts, and perceives reality) was originally admitted to the facility on [DATE]; there was no documented evidence that a Preadmission Screening and Resident Review was completed for Resident #9, prior to their admission to the facility. Additionally, the Preadmission Screening and Resident Review screen form completed on 07/18/2025 was incomplete and did not assess the need for a Level II referral.The finding is:The facility's policy titled Preadmission Screening and Resident Review (PASRR), last reviewed December 2025, documented all residents have a screen upon admission to the facility and thereafter, when there is a significant change that has a bearing on the resident's specialized service needs. The screen assesses residents' mental illness, dementia, and intellectual disability/developmental disability and ensures that they are placed in the least restrictive setting and receive recommended interventions to improve their quality of life. Upon admission, a Preadmission Screening and Resident Review screen is either sent with the Patient Review Instrument (PRI- a mandatory clinical assessment tool in New York State used to determine a person's medical, physical, and cognitive condition for admission to a skilled nursing facility) or completed by a qualified Preadmission Screening and Resident Review screener.Resident #9 was admitted with diagnoses including schizophrenia, Parkinson's disease, and diabetes mellitus. The 01/23/2026 quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status as the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set assessment documented the resident was receiving antipsychotic medications.A physician's order dated 02/12/2026 documented Seroquel (antipsychotic medication) 25 milligram tablet, give one (1) tablet by oral route once daily at bedtime, for diagnosis of schizoaffective disorder, bipolar type; and major depressive disorder, recurrent, severe with psychiatric symptoms.Review of the resident's electronic medical record revealed that the resident was originally admitted to the facility on [DATE]. There was no initial Preadmission Screening and Resident Review screen form in the medical record.The facility provided a Preadmission Screening and Resident Review screen form dated 07/18/2025 that was completed by Social Work Director #1 upon Resident #9's readmission to the facility on [DATE] from the hospital. This form documented that the resident had a serious mental illness (Yes to Question 23); however, this form was incomplete because the directions were not followed for the steps to be taken if question 23 was marked as Yes to determine if the resident required a Level II referral.During an interview on 02/13/2026 at 11:10 AM, Social Work Director #1 stated the Preadmission Screening and Resident Review screen form is supposed to be provided by the hospital and the Preadmission Screening and Resident Review form was not received from the hospital on [DATE]. Social Work Director #1 stated they initiated the Preadmission Screening and Resident Review screen for the Resident #9 on 07/18/2025 as they were a qualified Preadmission Screening and Resident Review screener. The 07/18/2025 Preadmission Screening and Resident Review screen form was not completed correctly and would have to be re-done. Social Work Director #1 stated they could not find the initial Preadmission Screening and Resident Review screen when the resident was first admitted to the facility in 2023.On 02/13/2026 at 11:36 AM, Social Work Director #1 provided a revised Preadmission Screening and Resident Review screen form dated 02/13/2026 for Resident #9. Social Work Director #1 stated the new screen indicated the resident was receiving the appropriate services at the facility and did not require a Level II referral.During an interview on 02/13/2026 at 1:15 PM, Social Work Director #1 stated they have not been able to find the Preadmission Screening and Resident Review screen form for the 04/25/2023 admission.During an interview on 02/13/2026 at 2:00 PM, the Administrator stated they were unable to find the Preadmission Screening and Resident Review screen for Resident #9. The facility should receive the Preadmission Screening and Resident Review screen form from the hospital upon resident's admission to the facility. If the screen form is not provided during the admission process by the hospital, Social Work Director#1 should complete the Preadmission Screening and Resident Review screen as they are a qualified screener.10 NYCRR 415.11(e)

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan was implemented for one (1) (Resident #13) of three (3) residents reviewed for skin integrity. Specifically, Resident #13 was assessed to have fragile skin and required use of the Geri sleeves according to the Comprehensive Care Plan. During multiple observations, Resident #13 was observed without the use of the Geri sleeves.The finding is: A facility policy and procedure titled Comprehensive Care Plan, last reviewed 06/2025, documented the Person-Centered Care Plan is developed to include information necessary to properly care for the residents. The Comprehensive Care Plan will be implemented by qualified members of the facility staff. Resident #13 was admitted with diagnoses including non-Alzheimer's dementia, diabetes mellitus, and depression. A quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. Resident #13 did not exhibit behaviors of rejection of care and required partial/moderate assistance for upper body dressing. The comprehensive care plan titled Skin Integrity: Risk for Skin Breakdown, effective 05/06/2025, documented the resident was at risk for skin breakdown secondary to fragile skin and diabetes mellitus. The interventions included using Geri sleeves and providing protective/preventative skin care. A physician's order dated 12/10/2025 documented to monitor skin integrity each shift. During an observation on 02/10/2026 at 9:59 AM, Resident #13 was wearing a short sleeved shirt and did not have the Geri sleeves on their arms. During an observation on 02/12/2026 at 9:27 AM, Resident #13 was in bed wearing a gown and had no Geri sleeves on their arms. During an observation on 02/12/2026 at 2:08 PM, Resident #13 was in bed wearing a short sleeved shirt and had no Geri sleeves on their arms. During an observation on 02/13/2026 at 10:30 AM, Resident #13 was wearing a short sleeved shirt and had not Geri sleeves on their arms. During an interview on 02/13/2026 at 11:01 AM, Certified Nursing Assistant #1 stated they refer to Certified Nursing Assistant Accountability Record to determine required care and receive updates from the Charge Nurse. Certified Nursing Assistant #1 stated the Activities of Daily Living (ADL) instructions on the Certified Nursing Assistant Accountability Record did not indicate Geri sleeves as one of the interventions for Resident #13. During an interview on 02/13/2026 at 11:27 AM, Registered Nurse Charge Nurse #3 stated that registered nurses were responsible for initiating the care plans and copying the care plan interventions into the Certified Nursing Assistant Accountability Record. Registered Nurse Charge Nurse #3 reviewed the Certified Nursing Assistant Accountability Record and confirmed that Geri sleeves were not listed as an intervention for Resident #13. During an interview on 02/13/2026 at 11:34 AM, the Assistant Director of Nursing stated the intervention for using the Geri sleeves are documented on Resident #13's care plan; however, these interventions were not documented on the Certified Nursing Assistant Accountability Record, therefore Certified Nursing Assistant #1 likely did not apply the Geri sleeves. During an interview on 02/18/2026 at 11:04 AM, the Director of Nursing Services stated that care plan interventions should be carried over to the Certified Nursing Assistant Accountability Record for the staff to implement appropriate interventions according to each resident's plan of care. The Director of Nursing Services stated Resident #13 should have been provided with the Geri sleeves according to their care plan to prevent any skin damage. 10 NYCRR 415.11 (c)(1)

Based on observations, record review, and interviews, the facility did not ensure that each resident who needs respiratory care is provided care in accordance with the professional standards of practice and the comprehensive person-centered care plan. This was identified for one (1) (Resident #128) of four (4) residents reviewed for Respiratory Care. Specifically, Resident #128 indicated they use the Continuous Positive Airway Pressure machine (CPAP- a machine used for obstructive sleep apnea: a condition with temporary pauses in breathing during sleep) that was observed on their nightstand. Resident #128 did not have a physician's order or a Comprehensive Care Plan (CCP) with goals and interventions for the use of the Continuous Positive Airway Pressure machine. The finding is:The facility policy titled, Non-Invasive Ventilation Devices last revised on 09/2025 documented that a Physician, Physician Assistant, or Nurse Practitioner order is required for the use of the Non-Invasive ventilation devices. The order is to include initiation of the device, diagnosis, pressure settings, and oxygen requirements. Non-invasive ventilation devices will be utilized for nocturnal (nighttime) use. The settings may not be adjusted without a provider order. The tubing and masks will be kept in a bag, when not in use. A Pulmonology consult is to be ordered as indicated. The device will be applied and monitored by the licensed Nurses.Resident #128 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD, progressive lung disease that restricts airflow and causes breathing difficulties), heart failure (a chronic condition where the heart muscle cannot pump blood efficiently) and hypertension (high blood pressure). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #128 had intact cognition. The Minimum Data Set assessment documented that Resident #128 had shortness of breath or trouble breathing when lying flat and was receiving continuous oxygen therapy.A review of Resident #128's electronic medical record revealed that Resident #128 did not have a physician's order or a care plan developed for the use of the Continuous Positive Airway Pressure (CPAP).A physician's order dated 01/07/2026 documented continuous supplemental oxygen therapy via nasal cannula at two (2) liters per minute, every shift.A Comprehensive Care Plan (CCP) titled, Respiratory Disorders: Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure dated 12/12/2025 documented interventions including monitoring respiratory status, administering oxygen as per physician's order, and administering medications as per physician's order. The care plan did not include the use of the Continuous Positive Airway Pressure machine.During an observation on 02/10/2026 at 12:12 PM, Resident #128 was sitting in a wheelchair in their room. A Continuous Positive Airway Pressure (CPAP) machine was observed on Resident #128's nightstand. The machine was not connected to the oxygen concentrator. Resident #128 stated that the Continuous Positive Airway Pressure machine did not have to be connected to an oxygen source and worked on room air.During an observation on 02/10/2026 at 2:11PM, Resident #128 was lying in bed. A Continuous Positive Airway Pressure (CPAP) machine was observed on Resident #128's nightstand.During an interview on 02/10/2026 at 12:39 PM, Resident #128 stated they had used the Continuous Positive Airway Pressure (CPAP) machine at times since they have been at the facility. Resident#128 stated that they were familiar with the use of the Continuous Positive Airway Pressure machine and did not need a nurse to set it up.During an observation on 02/11/2026 at 8:15 AM, Resident #128 was lying in bed. A Continuous Positive Airway Pressure (CPAP) machine was observed on Resident #128's nightstand.During an interview on 02/11/2026 at 1:38PM, Licensed Practical Nurse #1, the Medication Nurse, stated that they had seen the Continuous Positive Airway Pressure machine on Resident #128's nightstand. They did not check if there was a physician's order for the use of the machine because they only work during the 7:00 AM-3:00 PM shift and the Continuous Positive Airway Pressure was used during the evening shift.During an interview on 02/11/2026 at 1:59 PM, Registered Nurse #1, the Charge Nurse, stated Resident #128 did not have a Physician's Order for the use of the Continuous Positive Airway Pressure machine. Registered Nurse #1stated they did not know who brought the Continuous Positive Airway Pressure machine to the resident's room. Registered Nurse #1 stated that there should have been a physician's order if Resident #128 was using the machine. During an interview on 02/13/2026 at 8:15AM, the Pulmonologist stated if Resident #128 was utilizing the Continuous Positive Airway Pressure machine at the facility, there should have been a physician's order for the proper setting, frequency of use, and the care of the Continuous Positive Airway Pressure machine.During an interview on 02/17/2026 at 8:58 AM, the Director of Nursing Services stated that they did not know who had brought the Continuous Positive Airway Pressure machine for Resident #128. The Director of Nursing Services stated that they expect the staff to be aware of their surroundings and report any observations including equipment found in the resident's room.10NYCRR 415.12(k)(6)

Based on observation, record review, and interviews, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the appropriate instructions and the expiration date to facilitate considerations of precautions and safe administration of medications. This was identified on one (1) (East A unit) of three (3) nursing units. Specifically, on 02/10/2026, a medication cart on the East A nursing unit was observed with a vial of Insulin lispro (fast acting insulin to be administered pre-meal based on a sliding scale to prevent blood sugar from spiking after the meal) with an open date of 01/03/2026. The insulin vial was not discarded after 28 days as per the manufacturer's guidelines.The finding is:The facility's policy titled Insulin Administration, last reviewed 10/2025, documented under Procedure: Check and verify physician order; check blood glucose levels as per physician order; verify insulin type, dose, timing, and expiration date. The policy did not indicate when to discard the open insulin.The facility's policy titled Medication Storage, reviewed 10/2025, documented medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Multiple dose vials of medications that are opened shall have the start (opening) date indicated on them.The Food and Drug Administration data sheet for Humalog (insulin lispro) documented in-use vials, cartridges, pens should be stored at room temperature and must be used within 28 days or be discarded, even if they still contain insulin.Resident #167 was admitted with diagnoses including diabetes mellitus, cerebrovascular accident, and seizure disorder. The 01/10/2026 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact, and the resident received insulin injections for seven days prior to 01/10/2026.A physician's order dated 10/10/2025 and renewed on 02/04/2026 documented Insulin Sliding Scale, insulin lispro 100 unit/milliliter subcutaneous solution, inject by subcutaneous (delivers medication into the fatty tissue layer between the skin and muscle) route three (3) times per day before meals and at bedtime as needed, every day at 11:30 am; 4:30 pm; 6:30 am; and 9:00 pm; if blood sugar equals 200-250 administer 2 Units; 251 - 300 administer 4 Units; 301 - 350 administer 6 Units; 351 - 400 administer 8 Units; If greater than 400 or below 60, call physician; for diagnosis of diabetes mellitus with other specified complications.During an observation of a medication cart with Licensed Practical Nurse #1 on 02/10/2026 at 1:35 PM, an opened vial of insulin lispro insulin was kept in a box with an open date of 01/03/2026 written on the box which was stored in a plastic bag. The plastic bag had a label with Resident #167's name. Licensed Practical Nurse #1 confirmed the insulin vial was first opened on 01/03/2026 and should have been discarded after 28 days from the opening date. There were no other vials of insulin lispro in the cart for Resident #167.During an interview on 02/11/2026 at 9:37 AM, Assistant Director of Nursing Services/Nursing Education #1 stated, I think it is just good practice to discard the insulin after 28 days. I am not aware of anything that happens to the insulin.During an interview on 02/11/2026 at 9:45 AM, the Director of Nursing Services stated the standard is to discard the insulin after 28 days from opening. The nurses should know that. The Director of Nursing Services stated the Pharmacist would know what happens to the insulin after 28 days. I am not sure.During an interview on 02/11/2026 at 2:20 PM, Pharmacist #1 stated the insulin lispro should be discarded after 28 days of being opened; this is the manufacturer's guideline. Insulin loses its potency and may not be as effective in controlling the blood sugar levels. 10 NYCRR 415.18(d)

Based on record review and interviews, the facility did not maintain medical records on each resident that are complete and accurately documented. This was identified for one (1) (Resident #174) of three (3) residents reviewed for Urinary Catheter. Specifically, Resident #174 was admitted with a foley catheter. Primary Physician #2 initiated documentation of an admission History and Physical evaluation on 02/09/2026, prior to the resident's arrival to the facility and did not complete the documentation until 02/10/2026. The evaluation inaccurately documented Resident #174 was continent, had no foley catheter, and had no diagnosis related to urinary tract. The finding is: The facility's policy titled, Physician Visits, last reviewed 1/2026, documented the Medical Staff shall provide for a medical history and physical examination to be done within 48 hours after admission to the facility. The Medical Staff shall record, date, and sign the significant findings of the history and physical examination in the appropriate form in the chart including, but not limited to: a complete medical history, physical examination, a complete list of diagnoses and problems, and admission orders to include, but not limited to: medications, consultations, diagnostic tests, and monitoring. Medical History should be obtained from the resident, family, and transfer forms. During the Physical Examination particular attention should be paid to include but not limited to: presence of urinary or fecal incontinence. Resident #174 was admitted to the facility with diagnoses which included hypothyroidism (a condition which happens when the thyroid gland makes too much thyroid hormone) and hypertension (abnormally high blood pressure). The resident was admitted on [DATE] and a comprehensive Minimum Data Set was not available. The physician's order dated 02/09/2026, ordered by Primary Physician #1 and signed by Primary Physician #2, documented for the resident to have a Foley Catheter #16 French with a 10 cubic centimeter (cc) balloon related to diagnosis of stress incontinence. Review of the resident's Hospital Discharge summary dated [DATE] revealed under the active problem list a diagnosis of acute urinary retention and under the past medical history a diagnosis of urinary disorder and stress incontinence. The Medical Doctor Examination - Comprehensive admission History and Physical dated 02/09/2026 and completed on 02/10/2026 by Primary Physician #2 documented the resident had no urinary incontinence, no urinary retention, and no foley catheter. In addition, there was no documented past or present history of the resident having a diagnosis of neurogenic bladder or Parkinson's disease. The Physician's Order dated 02/13/2026 at 09:32 AM, entered by Assistant Director of Nursing #2, ordered by Primary Physician #1, and signed by Primary Physician #2 at 11:46 AM, documented for the resident to have a Foley Catheter #16 French with a 10 cubic centimeter (cc) balloon related to diagnosis of neurogenic bladder. During an interview on 02/13/2026 at 11:00 AM, Primary Physician #1 stated Primary Physician #2 completed the admission History and Physical and did not document the resident had a foley catheter. During an interview on 02/13/2026 at 12:15 PM, Primary Physician #2 stated they may have started the resident's admission History and Physical template before seeing the resident. Primary Physician #2 stated upon examining the resident, they saw the resident had a foley catheter and just forgot to go back and update the admission History and Physical in the medical record. During an interview on 02/13/2026 at 1:40 PM, the Medical Director stated some Physician's do begin to fill out a resident's Medical Doctor Examination - Comprehensive admission History and Physical before they see the resident and then adjust it accordingly after seeing the resident. The Medical Director stated Primary Physician #2 should have updated the medical record to indicate the presence of the foley catheter after they examined the resident. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observation, record review, and staff interviews during an abbreviated survey (NY002604352) initiated on 09/03/2025, the facility failed to ensure residents received treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for three (3) of (5) residents reviewed. Specifically, 1) Resident #1 had no bowel movements eight (8) consecutive days from (07/19/2025 through 07/26/2025 and again for nine (9) consecutive days from 07/28/2025 through 08/05/2025. 2) Resident #2 had no bowel movements for eight (8) consecutive days from (08/15/2025 through 08/22/2025 and again for (8) consecutive days from 08/24/2025 through 08/31/2025. 3) Resident #3 had no bowel movements for eight (8) consecutive days from 06/06/2025 through 06/13/2025 and again for 11consecutive days from 06/15/2025 through 06/25/2025. There was no documented evidence the physician was notified or that the facility staff were aware of the resident's need for interventions to facilitate regular bowel movements. Subsequently, Resident #1 was hospitalized for bowel impaction. This resulted in actual harm to Resident #1 and the likelihood of serious harm for Resident #2 and Resident #3 that is Immediate Jeopardy and Substandard Quality of Care to three out of five residents' health and safety. The findings are:The facility's policy titled Bowel Management dated June 2025 documented that every shift the nurses will check bowel movement pattern via the Electronic Medical Record and staff/resident interview to verify if resident had a bowel movement and notify the medical doctor accordingly. Nurses document on the Electronic Medical Record for this check. The nurses will monitor resident for any signs of pain, discomfort or complaints of constipation; medical doctor will be notified for further bowel management as needed.Resident #1 was admitted with diagnoses including spinal stenosis spondylosis (a degenerative condition of the spine that affects the intervertebral disc), and constipation (a gastrointestinal condition characterized by infrequent or difficult bowel movements and constipation. The admission Minimum Data Set a resident assessment tool dated 07/17/2025 documented a Brief Interview for Mental Status score of 15 indicating the resident has intact cognitive function.Resident #1's Certified Nursing Aide Documentation Record dated July 2025, and August 2025 documented no bowel movements from 07/19/2025 through 07/26/2025 eight (8) consecutive days and 07/28/2025 through 08/05/2025, nine (9) consecutive days.Resident #1's Physician Order dated 07/10/2025 documented to check bowel movement pattern every shift. If there was no bowel movement in 48 hours, report to the medical doctor.There was no documented evidence in the medical record dated 07/17/2025 through 08/05/2025 that the medical doctor was notified that Resident #1 had no bowel movement for eight (8) consecutive days from 07/19/2025 through 07/26/2025 and for nine (9) consecutive days from 07/28/2025 through 08/05/2025. Resident #1 was discharged to the hospital on [DATE] related to a fall. A computed tomography (CT) scan was completed on 08/13/2025 in the hospital and the impression documented fecal impaction of the rectum with stercoral proctitis (a condition where inflammation of the rectum occurs due to prolonged fecal impaction. The resident did not return to the facility.During an interview with Certified Nursing Aide #2 on 09/03/2025 at 3:29 PM they stated Resident # 1 fell out of their wheelchair while Resident #1 was self-transferring back to their bed without assistance. Certified Nursing Aide #2 stated they were in the room close to the resident but could not reach them in time. Resident #1 stated to them they were constipated. Certified Nursing Assistant #2 stated they called the nurse because the resident fell. During an interview with Certified Nursing Aide #3 on 09/04/2025 at 12:25 PM they stated Resident#1 told them that they did not feel well because they were constipated and had received an enema earlier today 09/04/2025. There is no documented evidence in Resident #1's Medication Administration Record that the resident had an order for an enema. During an interview with Licensed Practical Nurse #2 on 09/04/2025 at 2:03 PM they stated they are to check the computer for a bowel report every shift to see when the residents have a bowel movement. Licensed Practical Nurse #2 they stated they were not sure how to check the computer for a bowel report. During an interview with Registered Nurse #1 on 09/04/2025 at 2:37 PM they stated they do not run the bowel report unless licensed practical nurse reports to them that a resident did not have a bowel movement in 48 hours. During an interview with Medical Doctor #1, who is the primary care physician for Resident #1, on 09/04/2025 at 5:01PM they stated the nurses are supposed to monitor the residents for bowel movements every shift. The nurses should notify them if the residents do not have a bowel movement for 48 hours. A resident could experience nausea, vomiting and abdominal pain. They also stated prolonged periods of no bowel movements place the residents at risk for obstruction and rupture of the colon. Medical Doctor #1 stated they were unaware that Resident #1 did not have a bowel movement in over 48 hours. 2) Resident #2 had diagnoses including hemiplegia, (a medical condition that causes paralysis or weakness on one side of the body), dysarthria (a speech disorder characterized by difficulty in articulating words and producing clear speech, and constipation (a gastrointestinal condition characterized by infrequent or difficult bowel movements). The Minimum Data Set admission assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating the resident has intact cognitive function.The Certified Nursing Aide Documentation Record dated August 2025 documented no bowel movement from 08/15/2025 through 08/22/2025. There was no documented evidence that Resident #2 had a bowel movement for eight (8) consecutive days. Further review revealed no documented bowel movement from 08/24/2025 through 08/31/2025. During an interview with Licensed Practical Nurse #2 on 09/04/2025 at 2:03 PM they stated they were not sure how to check the computer for a bowel report. They stated they were not aware resident #2 had not had bowel movements for multiple consecutive days.During an interview with Medical Doctor #1, the primary care physician for Resident #2, on 09/04/2025 at 5:01PM they stated the nurses are supposed to monitor the residents for bowel movements every shift. The nurses should notify them if the residents do not have a bowel movement for 48 hours. A resident could experience nausea, vomiting and abdominal pain. They also stated prolonged periods of no bowel movements place the residents at risk for obstruction and rupture of the colon. Medical Doctor #1 stated that the staff did not report to them that resident #2 had not had bowel movements for documented consecutive days but should have informed them.3) Resident #3 had diagnoses including multiple sclerosis, (a chronic autoimmune disease that affects the central nervous system), ulcerative colitis (a chronic inflammatory bowel disease characterized by inflammation and ulcers in the large intestine), chronic obstructive pulmonary disease (lung conditions that cause ongoing inflammation and narrowing of the airway, leading to difficulty breathing). The Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating the resident has intact cognitive function.Resident #3's Certified Nursing Aide Documentation Record dated June 2025 documented lack of a bowel movement from 06/06/2025 through 06/13/2025 (eight (8) consecutive days) and 06/15/2025 through 06/25/2025 11 consecutive days). Resident #3's Certified Nursing Aide Documentation Records dated June 2025, and July 2025 documented a lack of a bowel movement from 06/29/2025 through 07/5/2025 six (6) consecutive days).Resident #3's Certified Nursing Aide Documentation Records dated July 2025, and August 2025 documented a lack of a bowel movement from 07/30/2025 through 08/06/2025 for seven (7) consecutive days. Further review revealed no documented bowel movement from 08/11/2025 through 08/16/2025, six consecutive days and from 08/18/2025 through 08/28/2025 for 11 consecutive days. Resident #3's Certified Nursing Aide Documentation Records dated September 2025 documented no bowel movement from 09/01/2025 through the morning shift on 09/04/2025 There was no documented evidence that Resident #3 had a bowel in over three days.During an observation on 09/04/2025 at 4:35 PM Licensed Practical Nurse #2 was not able to demonstrate obtaining a bowel report from the electronic medical record. They stated they were not aware that Resident #3 did not have a bowel movement for 48 hours and did not report it to the charge nurse or the medical doctor. During an interview with the Director of Nursing Services on 09/05/2025 at 5:29 PM they stated they were not aware that the bowel reports were not being run. They stated the certified nurse aides document the bowel movements, and the licensed practical nurses must review the bowel charts. The Director of Nursing Services stated the registered nurses should run the reports every shift.During an interview with the Administrator on 09/05/2025 at 4:27 PM they stated they were made aware of the issue with the bowel protocol by the Director of Nursing Services on 09/04/2025. They further stated that the expectation is the facility policy and procedure be followed by the staff. The Administrator submitted evidence that the issue of bowel protocol was not discussed during their Quality Assurance and Performance Improvement meetings for the past year. 10 NYCRR 415.12

Based on observations, interviews and record reviews during the Abbreviated Survey (complaint #NY00347913) completed on 10/30/2024, the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health, or the local law enforcement as required. This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, an allegation was reported to the facility by Staff Member #1 that they witnessed Certified Nursing Assistant #1 hitting Resident #1 with their elbow. The facility did not report the allegation within two hours to the New York State Department of Health or the local law enforcement as required. The findings are: The facility policy titled Abuse Prevention and Reporting with a revision date of 2023 documented Federal & State Regulations require the reporting of alleged violations of abuse, mistreatment and neglect, including injuries of unknown origin, immediately to the Administrator and to the Department of Health. CMS (Center for Medicare/Medicaid) has defined immediately as, as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Resident #1 was admitted to the facility on [DATE] with diagnoses including muscle wasting, multiple myeloma and anxiety disorder. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5/15 indicating severe cognition deficit. The resident was sometimes understood with ability limited to making concrete requests and sometimes understood others. A grievance form, titled Grievance Form / Missing Property Report, dated 7/3/2024 documented that Staff Member #1 reported to the facility that they observed Certified Nursing Assistant #1 providing care to the resident who was screaming and pushing themselves back and grabbing onto the Certified Nursing Assistant #1's pant legs. The report documented Staff Member #1 stated that they observed the Certified Nursing Assistant utilizing their elbow to help secure the resident's left leg, while attempting to provide care. The grievance form documented, a conclusion that it was determined that all care was being provided appropriately. The grievance form documented the Administrator reviewed the form on 7/5/2024. There was no documented evidence that the facility reported the alleged abuse within the 2-hour requirement to the New York State Department of Health or to local law enforcement as required. During an interview on 10/10/2024 at 12:15PM, the Assistant Director of Nursing stated they completed a grievance form because Grievances are family care concerns and there were no signs of abuse from the allegation, so it became a resident care concern. The Assistant Director of Nursing stated it wasn't reported because there were no signs of abuse. During an interview on 10/15/2024 at 4:45PM, the Director of Nursing Services stated the allegation was not reported because it was determined that abuse did not occur. During an interview on 10/16/2024 at 12:47PM with the Administrator, they stated that they did not report the allegation of abuse to the New York State Department of Health or to local law enforcement as required because they did not believe abuse occurred or there was any reasonable cause to believe abuse occurred based on what Staff Member #1 reported. Administrator agreed all allegations of abuse should be reported as required. During an interview on 10/30/2024 at 1:17PM, Resident #1's Medical Doctor stated he could not recall if the facility notified them of the abuse allegation because they did not document it, so they refrained from additional comment. 10 NYCRR 415.4 b (2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/14/2024 and completed on 8/20/2024, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #71) of eight residents reviewed for Accidents. Specifically, Resident #71 required the assistance of two staff members for bed mobility as per the Rehabilitation Department screening on 1/4/2024 and 4/4/2024. The resident's comprehensive care plan and nursing care instructions for the Certified Nursing Assistants were not updated to reflect the Rehabilitation Department's recommendations. During the morning care on 6/24/2024, Certified Nursing Assistant #5 turned the resident on their side to clean the resident's back and the resident fell out of the bed. Subsequently, Resident #71 was transferred to the hospital and was diagnosed with a fracture of the right leg. This resulted in actual harm to Resident #71 that is not Immediate Jeopardy. The finding is: The facility's policy titled Rehabilitation Evaluations/Screens/Assessments, last reviewed January 2022, documented the purpose is to ensure the resident receives Physical Therapy, Occupational Therapy, and Speech Therapy evaluation upon admission, quarterly, and as necessary to obtain the resident's baseline function, improve or maintain status, and set appropriate goals/outcome to obtain optimal performance. The undated facility's policy titled Activities of Daily Living documented appropriate care and services will be provided for residents who are unable to carry out Activities of Daily Living independently, in accordance with the plan of care, including appropriate support and assistance with hygiene and mobility. For a dependent resident: the helper does all of the effort; the resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity. Resident #71 was admitted with diagnoses including Dementia, Anxiety Disorder, and Hypertension. The 4/6/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 6, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident was dependent on staff for rolling from lying on their back to the left or right side. The Rehabilitation Department's quarterly screens dated 1/4/2024 and 4/4/2024 documented the resident required maximum assistance of two people for bed mobility (the ability of the resident to move from their back to the left or right side when in bed). A Comprehensive Care Plan titled Activities of Daily Living All Tasks, effective 8/5/2022 and last updated on 4/4/2024, documented the resident required partial/moderate physical assistance of one staff member for bed mobility (the ability of the resident to move from their back to the left or right side when in bed). There was no documented evidence the Rehabilitation Department updated the Activities of Daily Living All Task care plan to include two person assistance for bed mobility. The Resident Nursing Instructions (care instructions provided to Certified Nursing Assistants) from 6/1/2024 through 6/30/2024 documented Resident #71 required one-person partial/moderate physical assistance for bed mobility. The resident had the behavior of yelling and screaming. A review of the Certified Nursing Assistant Accountability Record for June 2024 documented bed mobility was performed by one staff member through 6/24/2024 as indicated by staff signatures. A nursing progress note dated 6/24/2024 at 2:24 PM, written by Registered Nurse #2 (the Risk Manager), documented this writer was called to assess the resident who was on the floor. While Certified Nursing Assistant #5 was providing care to the resident (at 11:15 AM), the resident began reaching for their stuffed animal, which was on the nightstand table near the bed. The resident reached too far and rolled out of bed onto the floor before Certified Nursing Assistant #5 could reach the resident. Upon assessment, the resident was observed with a deformity to their right lower extremity and was complaining of pain. A Nurse Practitioner who was present in the building, assessed the resident and observed obvious deformity to their right lower extremity. Resident complained of pain from the right hip to the right ankle. 911 was called and the resident was transferred to the hospital. A nursing progress note dated 6/24/2024 at 3:16 PM documented the resident was admitted to the hospital with a diagnosis of a fracture of their right lower extremity. A review of the Accident and Incident Investigation dated 6/24/2024, prepared by Registered Nurse #2 (the Risk Manager) concluded the resident was reaching for a stuffed animal. The resident reached too far and rolled out of bed onto the floor before the Certified Nursing Assistant could prevent the fall. All care plan interventions were investigated to have been in place. The interdisciplinary team and medical services are in agreement that there was no evidence of any abuse, mistreatment, neglect, or exploitation. The hospital discharge summary dated 6/27/2024 documented the resident was admitted to the hospital on 6/24/2024 with a fracture of their right tibia/fibula (lower leg bones). A Nurse Practitioner readmission note dated 6/27/2024 at 4:06 PM documented the resident was readmitted from the hospital with a right tibia/fibula fracture and the right lower extremity had a cast from mid-femur (bone in thigh) to mid-foot. During an observation on 8/19/2024 at 12:15 PM, Resident #71 was in the day room waiting for lunch. The resident had a cast on their right leg. The resident stated they had a fall; however, could not remember how. During an interview with the Rehabilitation Director on 8/19/2024 at 1:44 PM, the Rehabilitation Director stated Rehabilitation Department screens are completed quarterly and as needed. The quarterly screens dated 1/4/2024 and 4/4/2024 for Resident #71 documented the resident required maximum assistance of two staff members for bed mobility. The care that the Certified Nursing Assistants provide is based on the Rehabilitation Department assessment. The Therapist completing the assessment should update the resident's All-Task Activities of Daily Living care plans based on their assessment. Once the care plan is updated, the recommendations and instructions are automatically documented on the Resident Nursing Instructions. During an interview with Certified Nursing Assistant #5 on 8/19/2024 at 2:22 PM, they stated the resident was dependent on them for bed mobility. On 6/24/2024 they were providing morning care alone for the resident, which included washing their face, changing their brief, combing their hair, and getting them dressed. Resident #71 reached for their stuffed animal on the bedside table when they (Certified Nursing Assistant #5) turned the resident to their left side to clean the resident's back. Certified Nursing Assistant #5 stated they tried to support the resident, but the resident fell out of bed. Certified Nursing Assistant #5 stated the resident required one person's assistance for the bed as per the Resident Nursing Instructions. Certified Nursing Assistant #5 stated they worked with the resident prior to the fall on 6/24/2024 and always provided care by themselves. During an interview with Physical Therapist #1 on 8/19/2024 at 2:30 PM, stated they completed the quarterly Rehabilitation screening for Resident #71 on 1/4/2024 and 4/4/2024. According to their assessment, the resident required the maximum assistance of two staff members for bed mobility. Physical Therapist #1 stated the resident's care plan should have reflected the resident required two persons for the bed mobility as per the recommendations made on the Rehabilitation screens. Physical Therapist #1 stated their recommendation to use two staff for bed mobility was based on their assessment and observation of the resident while the resident was in bed. Physical Therapist #1 stated they were supposed to update the All-Task Activities of Daily Living care plan to reflect their recommendations to use two staff members for bed mobility. Physical Therapist #1 stated they screen many residents a day and try to make sure that everything matches; however, they could not remember why the care plan for Resident #71 was not updated in January 2024 and April 2024 after they completed the Rehabilitation screen. Physical Therapist #1 stated when the Activities of Daily Living care plan is updated, the recommendations are automatically updated on the Resident Nursing Instructions. During a re-interview with the Rehabilitation Director on 8/20/2024 at 8:45 AM, the Rehabilitation Director stated following Resident #71's Rehabilitation screens on 1/4/2024 and 4/4/2024, there was a conversation among the Interdisciplinary Team, which consisted of all Department Heads, during the morning report. The Rehabilitation Director stated even though Physical Therapist #1 documented the resident required two-person assistance for bed mobility, it was not based on the resident's physical needs but because of the resident's behaviors, so the team decided one person was appropriate for bed mobility. The Rehabilitation Director was unable to state the behaviors exhibited by the resident. The Rehabilitation Director stated they were part of the Interdisciplinary Team and were not sure where the discussion regarding the Interdisciplinary Team's decision not to implement the screen findings was documented. The Rehabilitation Director further stated nurses were responsible for updating the care plan related to the Interdisciplinary Team decision. During an interview with Licensed Practical Nurse #5, the unit charge nurse, on 8/20/2024 at 9:57 AM, they stated they attended Interdisciplinary Team meetings for Resident #71 and did not recall any discussions regarding not following the Rehabilitation Department screen assessment recommendation for Resident #71's bed mobility status. Licensed Practical Nurse #5 stated the All-Task Activities of Daily Living care plan is a Rehabilitation Department care plan and only the Rehabilitation Department can update that. Resident #71's medical record review revealed no documentation regarding the Interdisciplinary Team's decision to not implement the Rehabilitation screen assessment recommendations/findings. During a re-interview with Physical Therapist #1 on 8/20/2024 at 10:29 AM, when they completed the resident's Rehabilitation screen in January and April 2024, the resident was exhibiting behaviors of reaching out for things, grabbing, and trying to pinch the staff. Physical Therapist #1 stated the resident's behavior was one of the reasons they recommended two-person assistance with bed mobility for Resident #71. During an interview with Certified Nursing Assistant #6 on 8/20/2024 at 11:31 AM, they stated during the 11:00 PM - 7:00 AM shift, Resident #71 did not help in turning from their back to the left or right side. Certified Nursing Assistant #6 stated they always needed help to turn the resident in bed. During an interview with Certified Nursing Assistant #7 on 8/20/2024 at 12:07 PM, stated during the 3:00 PM - 11:00 PM shift, they always used two people to turn the resident from their back to the left or right side because the resident had a behavior of hitting the staff during care and the resident did not help with turning. During an interview with Physician #1 on 8/20/2024 at 1:00 PM, Physician #1 stated Resident #71's right leg fracture was the result of the fall from bed on 6/24/2024. During an interview with the Director of Nursing Services on 8/20/2024 at 1:38 PM they stated the Rehabilitation Department is responsible for updating the All-Task Activities of Daily Living care plan. The Director of Nursing Services stated based on the Rehabilitation screening evaluation, the resident required two staff members for bed mobility and if there was a discussion by the Interdisciplinary Team to not implement the assessment findings, the reasons should have been documented in the resident's medical record. They stated Certified Nursing Assistant #5 followed the instructions written on the Resident Nursing Instructions and cared for the resident alone on 6/24/2024. 10 NYCRR 415.12(h)(2)

Based on record review and interviews conducted during a Recertification Survey and Abbreviated Survey (Complaint #NY 00322088) initiated on [DATE] and completed on [DATE], the facility did not have evidence that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, and mistreatment. This was identified for one (Resident #360) of eight residents reviewed for Accident. Specifically, Resident #360 with impaired cognition was found on the floor on [DATE]. The incident was reported to the facility staff by the resident's roommate. The facility did not obtain a statement from the resident's roommate to identify the root cause of the incident. Additionally, the Accident and Incident investigation summary indicated Licensed Practical Nurse #5 observed the resident on the floor; however, the written statement provided by the Licensed Practical Nurse indicated they were caring for another resident at the time of the incident and the inconsistency was not addressed by the facility. The finding is: The facility's undated policy titled Accident/Incident Investigation Management documented that statements, when appropriate, will be obtained from witnesses and others who may have knowledge of the event, for example, other residents. When possible, statements must be written and signed by the person involved. The Supervisor should review for sufficient detail. Resident #360 was admitted with diagnoses including Alzheimer's Disease, Chronic Atrial Fibrillation, and Fracture of the Lumbar Vertebra (lower spine). The Admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 10 which indicated moderately impaired cognition. The Minimum Data Set assessment documented the resident was usually able to understand others. A Comprehensive Care Plan for Falls dated [DATE] last revised on [DATE] documented that the resident was at risk for falls/injuries secondary to a history of falls, Alzheimer's Disease. and impaired gait. Interventions included to place the call bell within easy reach at all times, encourage the resident to call for assistance, and provide anti-skid socks. The care plan interventions were updated on [DATE] to include toileting every ,d+[DATE] hours and as needed while awake. An Accident and Incident Report dated [DATE] at 12:30 PM documented that Resident #360 fell in their room. Resident #360 stated they were sitting and slid down off their bed. The Accident and Incident Report did not identify who initially reported Resident #360's fall. A nursing progress note dated [DATE], written by Registered Nurse #6, documented that at approximately 12:30 PM, Registered Nurse #6 was notified that Resident #360 was found on the floor. Upon assessment, the resident was lying supine on the floor on the left side of their bed with no injuries noted. Resident #360 complained of pain in the left lower posterior (back) leg. The Nurse Practitioner was notified and ordered neuro checks (evaluates brain and nervous system functioning) as per facility protocol and an x-ray of the left tibia and fibula (lower leg bones) related to pain. The summary of the investigation dated [DATE] documented that on [DATE], Resident #360 was observed on the floor on the left side of their bed by staff (Licensed Practical Nurse #5) after the resident's roommate reported that the resident was on the floor. Registered Nurse #6 responded and assessed the resident. Resident #360 stated they slid off the bed. The call bell was within reach and was not activated. Resident #360 requested to be toileted during the nursing assessment. Toileting was provided. The investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred. The facility investigation did not include a written statement from Resident #360's roommate who had initially reported the incident. The written statement from Licensed Practical Nurse #5 dated [DATE] documented that they were assisting another resident at the time of the incident. Resident #360's roommate, who had reported the incident, had expired and therefore was not interviewed. Licensed Practical Nurse #5 was interviewed on [DATE] at 1:21 PM and stated they were the nurse on duty along with Registered Nurse #6 on Unit East B on [DATE]. Licensed Practical Nurse #5 stated that the incident occurred around lunchtime and most of the nursing staff would be in the dining room assisting residents with their meals. Licensed Practical Nurse #5 stated they were in the dining room and did not receive any report from Resident #360's roommate about the resident's fall. Licensed Practical Nurse #5 stated they did not go into Resident #360's room and did not observe the resident on the floor. Licensed Practical Nurse #5 stated they also did not notify Registered Nurse #6 of Resident #360's fall and did not know who did. Licensed Practical Nurse #5 stated that if they had responded to Resident #360's roommate's call for help and had notified the Registered Nurse, they would include that information in their statement. The Accident and Incident investigation report did not include statements from other staff members who allegedly responded to the roommate's call for help and who had notified Registered Nurse #6 to assess Resident #360 on [DATE]. Registered Nurse #6, who no longer works in the facility, was interviewed on [DATE] at 12:43 PM. Registered Nurse #6 stated they were the Unit Manager at the time of the incident related to Resident #360. Registered Nurse #6 stated the unit charge nurses were responsible for initiating Accident and Incident reports. Resident #360's Accident and Incident report was completed by them (Registered Nurse #6) because they were helping the nurse. Registered Nurse #6 stated they did not obtain statements from staff or residents because the Risk Manager was responsible for investigating the Accidents and Incidents and obtaining the statements. Risk Manager #1, who no longer works at the facility, was interviewed on [DATE] at 2:53 PM. Risk Manager #1 stated they were responsible for investigating Resident #360's fall incident that occurred on [DATE]. Risk Manager #1 stated that if the resident's roommate was mentioned in the investigation summary, then the roommate should have been interviewed and their statement should have been attached to the Accident and Incident report. Risk Manager #1 stated they did not recall if they obtained a statement from Licensed Practical Nurse #5 and if the statement was consistent with the investigation report summary. Risk Manager #1 stated the Director of Nursing Services was ultimately responsible for reviewing the Accident/Incident report for completeness. Risk Manager #2 was interviewed on [DATE] at 4:14 PM. Risk Manager #2 reviewed the Accident and Incident report and stated that an interview with Resident #360's roommate should have been attempted and documented. Risk Manager #2 stated if inconsistency in a staff's statement was identified then a follow-up interview should have been conducted and documented. Risk Manager #2 stated that Resident #360's Accident and Incident was missing a statement from the resident's roommate and Licensed Practical Nurse #5's statement was inconsistent with the investigative summary. The Director of Nursing Services was interviewed on [DATE] at 1:10 PM and stated all Accident and Incident reports should be reviewed and investigated thoroughly. The Director of Nursing Services was unable to locate a statement from Resident #360's roommate and a statement from the staff member who was first notified of the incident, involving Resident #360, by the resident's roommate. The Director of Nursing Services stated they trusted Risk Manager #1 and did not see why it was important to figure out and obtain a statement from the person who first saw the resident on the floor. 10 NYCRR 415.4 (b) (3)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 8/14/2024 and completed on 8/20/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident # 95) of two residents reviewed for Pressure Ulcers. Specifically, Resident #95 had a history of a Pressure Ulcer of the Sacral (the portion of the spine between the lower back and tailbone) Region. Resident #95 had a physician's order for an alternating-pressure air mattress. During multiple observations, the adjustable weight setting for the air mattress, which is meant to correspond to the resident's weight, was not set accurately. The finding is: The facility's policy and procedure titled Alternating Pressure/Low Air Loss Mattress, last revised on 10/2023, documented that an alternating pressure/low air loss mattress will be used to maintain adequate circulation to the skin at pressure areas, to prevent the development of skin ulcers in residents with little or no mobility, and to assist in the treatment of skin ulcers. Maintenance will apply the air mattress to the bed frame. Nurses or Maintenance will adjust the pressure control knob to the appropriate setting based on the Resident's weight. The operation manual for the alternating-pressure air mattress documented instructions for setting up the pump with a control knob that adjust the pressure of the mattress with the weight of the resident. Resident #95 was admitted to the facility with Diagnoses including Type 2 Diabetes, Venous Insufficiency, and Chronic History of Stage 4 Pressure Ulcer of the Sacral region (the portion of the spine between the lower region back and tailbone). The Quarterly Minimum Data Set (MDS)assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #95 had intact cognition. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #95 had a Venous (wound caused by a damaged vein) ulcer on the left posterior (back) thigh. A Comprehensive Care Plan (CCP) dated 5/22/2024 and renewed on 8/15/2024 documented that Resident #95 had a skin breakdown on the left posterior thigh and Moisture Associated Skin Damage (MASD) wound over sacral scarring related to impaired mobility and a history of pressure ulcers. Interventions included an air mattress, the use of skin protectant when performing care, providing supplements, and applying treatments as ordered by the Physician. A physician's order dated 8/31/2023 and renewed on 8/13/2024 documented utilizing an Alternating Air Mattress when in bed. A physician's order dated 8/12/2024 documented cleaning the left posterior thigh with normal saline followed by Calcium Alginate (a dressing that absorbs moisture) and abdominal pad dressing twice a day. A physician's order dated 8/15/2024 documented discontinuing the Calcium Alginate and applying Calmoseptine (a moisture barrier ointment) 0.44 percent to 20.6 percent ointment to the left posterior thigh and covering the wound with an abdominal pad every shift. A physician's order dated 8/12/2024 documented cleaning the sacrum with normal saline followed by Collagen (a dressing that breaks inflammation) and Calcium Alginate covered with an abdominal pad and paper tape daily. A review of the electronic medical record indicated that Resident #95's most recent weight dated 7/29/2024 was 176 pounds. A Wound Care Report dated 8/15/2024 documented that Resident #95's wound on the sacrum measured 1 centimeter in length, 2 centimeters in width, and 0.1 centimeters in depth. The wound had serous (yellow or transparent) discharge and a superficial cluster of open areas over scarred tissue. A Wound Care Report dated 8/15/2024 documented that Resident #95's wound on the left posterior (back) thigh had less maceration (softening and breaking down of skin from prolonged exposure to moisture) but remained denuded (exposed raw tissue) and no discharge. The treatment was changed to Calmoseptine ointment after cleaning with normal saline and covering with an abdominal pad every shift. On 8/14/2024 at 9:47 AM, Resident #95 was observed in bed. The air mattress control knob was set at 300 pounds. On 8/14/2024 at 1:45 PM, Resident #95 was observed in bed. The air mattress control knob was set at 300 pounds. Certified Nursing Assistant #1 was interviewed on 8/16/2024 at 2:00 PM and stated they were only responsible for checking if the mattress was deflated. Certified Nursing Assistant #1 stated they would inform the Nurses and Maintenance if there were any problems with the air mattress. Certified Nursing Assistant #1 stated the nurses were responsible for maintaining the air mattress weight setting. Licensed Practical Nurse #1 was interviewed on 8/16/2024 at 2:15 PM and stated they do not check the air mattress weight setting for Resident #95. Licensed Practical Nurse #1 stated the Wound Care Nurse was responsible for checking and monitoring the air mattresses. Registered Nurse #3, the Wound Care Nurse, was interviewed on 8/16/2024 at 3:00 PM and stated when the air mattress is first installed, they set up the air mattress control knob according to the Resident's weight. Registered Nurse #3 stated they do a monthly audit on the air mattress including the weight setting. Registered Nurse #3 stated the Nurses and Certified Nursing Assistants would inform them (Registered Nurse #3) with any malfunction on the air mattress. Registered Nurse #3 stated there is no documentation that a certain discipline monitored the air mattress. The Wound Care Nurse Practitioner was interviewed on 8/19/2024 at 12:03 PM and stated the air mattress should correspond to Resident #95's weight. The Wound Care Nurse Practitioner stated the facility was responsible for monitoring the air mattress. The Director of Nursing Staff was interviewed on 8/19/2024 at 2:15 PM and stated they do not have any issues with the air mattress in the facility. The Director of Nursing Services stated the Nurses and Certified Nursing Assistants were aware to inform the Wound Care Nurse and Maintenance of any concerns with the air mattress. The Director of Nursing Staff stated the Nurses should have been aware that monitoring the air mattress was a nursing responsibility. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and staff interview during the Recertification Survey, the facility did not ensure each resident is treated with respect and dignity and is cared for in a manner that promotes maintenance or enhance his or her quality of life. This was identified for one (Resident #82) of one resident reviewed for dignity. Specifically, Resident #82 was observed in bed, and her right foot wound was being assessed by a Physician in full view from the hallway. The door was open, and the curtains were not drawn. The finding is: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS)assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score of 3 which indicated severely impaired cognition. During an observation conducted on 9/17/20 at 11:45 AM, Resident #82 was observed in bed, dressing to right foot open and the Physician assessing the resident's right heel wound. The resident's room door was open, and the curtain was not drawn to provide privacy. The Physician was interviewed immediately on 9/17/20 at 11:45 AM, he stated that he was checking the resident's wound. The Physician stated to ensure patient privacy is maintained that he should have closed the door. the Registered Nurse (RN) Supervisor was interviewed on 11/17/20 at 11:54 AM, she stated privacy is paramount for the resident during care or with any procedure. The RN stated that the Physician should have closed the door or drawn the curtain to provide resident privacy. the Director of Nursing Services (DNS) was interviewed on 9/24/20 at 12:38 PM, she stated that the Physician should have pulled the curtains and or closed the door to provide privacy for the resident. 415.3(c)(1)(i)

Based on record review and staff interviews during a Recertification survey, the Facility did not ensure that each Resident's comprehensive care plan (CCP) is reviewed and revised by an interdisciplinary team. This was noted for one (Resident #87) out of 26 reviewed. Specifically, for Resident #87, the CCP for the [MEDICAL CONDITION] Drug use was not reviewed and revised to reflect the addition (7/9/20) and discontinuation (7/12/20) of [MEDICATION NAME] (a [MEDICAL CONDITION] medication). The Finding is: Resident #87 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A CCP for Discomfort and Side Effects related to the use of Antipsychotic medications dated 5/28/20 was updated on 8/20/20. The Problem, Goal, Interventions, and Outcome Evaluation sections were not updated to reflect the [MEDICATION NAME] use from 7/9/20 to 7/12/20 including the reason for discontinuation. The unit Charge Registered Nurse (RN) was interviewed on 9/21/20 at 2:40 PM. The RN stated that [MEDICATION NAME] was started for Resident #87 due to increase in behaviors and was discontinued after a fall. The RN stated that he was responsible for CCP development and revisions and should have updated the CCP for Resident #87 to reflect the addition and reasons for discontinuation of the [MEDICATION NAME]. 415.11(c)(2)(i-iii)

Based on observations and staff interviews conducted during a Recertification Survey completed on 9/24/20, the facility did not ensure that all medications and biologicals were stored and labeled properly. This was evident during observations conducted for the Medication Storage and Labeling Task for 1 of the 2 units observed. Specifically, the Unit East B Treatment Cart had topical medication bottles and tubes that were open and not labeled with the date opened. The finding is: The Policy and Procedure dated September 2019 documented to date and initial all bottles, jars upon opening. During an observation of the Unit East B Treatment Cart with the Registered Nurse (RN) #2 on 9/18/20 at 10:53 AM, the Dyna Gel wound care gel, Muscle Rub for pain both opened and not dated; [MEDICATION NAME] Cream for fungal treatment, H-Chlor 12 Topical 0.125% antiseptic solution, Hy[DATE].25% Topical antiseptic solution, [MEDICATION NAME] antiseptic bottle, all used, half-empty, and not labeled. RN #2, Unit East B Charge Nurse, was interviewed on 9/18/20 at 10:56 AM and stated that he was not sure if the opened and unlabeled medications were still being used for any resident. RN #2 stated that the medication tubes and bottles were not labeled and that is why he did not know which resident the opened medications belonged to. The Director of Nursing Services (DNS) was interviewed on 9/18/20 at 11:46 AM and stated that when treatment medications are received from the pharmacy, they are all labeled, the medications should be thrown away if they are not labeled. The DNS stated that the staff is expected to date the stock medication when they are first opened and ensure that the medications received from the pharmacy are labeled. The Licensed Practical Nurse (LPN) #2 was interviewed on 9/24/20 at 11:27 AM and stated that stock medications should be dated once they are opened and the medications that are used and not labeled should be discarded. 415.18(e)(1-4)

Based on interviews and record review during an abbreviated survey (Complaint #NY 186), the facility did not ensure resident rights to be free from abuse for one (Resident #2) of three residents reviewed for sexual abuse. Specifically, a cognitively intact resident (Resident #1) inappropriately touched Resident #2 who had severely impaired cognition. Furthermore, the facility did not initiate an investigation until 2 days after the incident. The findings were: The facility's policy titled Abuse Prevention and Reporting dated 9/7/16 documented all residents will be free from verbal, sexual, physical and mental abuse. All alleged violations involving mistreatment, neglect or abuse will be thoroughly investigated and findings will be documented in a report format. Abuse is defined as inappropriate physical contact with a resident while the resident is under the supervision of a facility. Inappropriate physical contact includes, but is not limited to sexual molestation and resident to resident altercations. The policy also documented that any staff who witnesses or suspects an incident of abuse, neglect, mistreatment, misappropriation of the residents' property must immediately separate the resident to a safe area and report to the Charge nurse. The Charge nurse must immediately notify the Nursing Supervisor of the incident who will then notify the Director of Nursing (DON) and the Administrator. An investigation will commence immediately by the Nursing Supervisor or by the most senior official in the facility at the time of the report. 1) Resident #2 (victim) was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 4/3/19 documented the resident's cognitive status as severely impaired. She required supervision with transfer walking and locomotion. The resident utilized a walker and wheelchair as the assistive devices. The Comprehensive Care Plan (CCP) dated 1/11/19 documented Resident #2 had severely impaired cognition related to [MEDICAL CONDITION]. Interventions included to aid/supervise the resident, provide daily stimulation and monitor cognition/mental status. The Social Work (SW) #2's note dated 3/25/19 documented that a male resident (Resident #1) was in Resident #2's room late at night. Resident #2 denied anyone being in her room. She stated that she was friends with the other resident (Resident #1). The Nurse's Progress Note (NPN) by the Licensed Practical Nurse (LPN) dated 4/24/19 documented the LPN overheard Resident #1 saying to Resident #2 that whatever happened between them should stay between them and what they did was their business. His tone was threatening. Resident #2 appeared confused and stated ok. The male resident (Resident#1) returned to his unit. Resident #2 showed no distress and denied feeling scared. Interoffice communication was sent to the SW #2. The NPN by the LPN dated 5/1/19 documented, while Resident #2 was sitting in her room, a male resident (Resident #1) was observed forcefully grabbing Resident #2's breast through her shirt. Resident #2 attempted to back up in the wheelchair away from the male peer (Resident #1). The LPN instructed Resident #1 to leave the room and return to his unit. The LPN also told the RNS of the incident. Interoffice memorandum was sent to the SW (#2). The NPN by the DON dated 5/3/19 documented Resident #2 was interviewed by SW #2, DON, and the Administrator and she told them that Resident #1 had grabbed her breast. Resident #1 was also interviewed and said that he was helping Resident #2 find her lost earring. He was talking with his hands and may have touched her breast. No injury or psychological harm was noted for both residents. The SW #2 note dated 5/3/19 documented, Resident #1 was observed (by the LPN) grabbing Resident #2's breast. Resident #2 reported that the male resident grabbed her breast and she told him to stop. The CCP titled Potential for Abuse and Potential to be a victim dated 5/3/19 documented, Resident #2 was inappropriately touched on her right breast by another resident. The interventions included Psychological evaluation, body check, and social work visits. The Psychiatry consult dated 5/7/19 documented that Resident #1 from another unit had gone to Resident #2's room on 2 occasions on 4/24/19 and 5/1/19. He had grabbed her breast as witnessed by a staff member. The resident (#2) had a history of [REDACTED]. She was alert but disoriented and her memory was poor. Her insight and judgment were poor. SW #2 was no longer employed at the facility and was not available for an interview. 2) Resident #1 (aggressor) was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 4/17/19 documented the resident's cognitive status as intact. He required extensive assistance with one person for transfer and supervision with locomotion on and off the unit using a walker and wheelchair. The Comprehensive Care Plan (CCP) titled Potential to Abuse and Potential to be a victim of abuse dated 10/25/18 documented the resident was verbally abusive, verbalized dissatisfaction with staff performance, overly critical of others and demonstrated impatience with staff. The CCP lacked documented evidence of any resident-centered interventions related to the identified problem. The Social Worker (SW #1) note dated 3/25/19 documented the resident was visiting a female peer in her room. He was counseled on appropriate visiting areas and agreed to visit friends in public areas. The Nursing Progress Notes (NPN) by the DON dated 5/3/19 documented Resident #1 was witnessed touching another resident's (#2) right breast. Resident #1 stated he was helping her find her earring and may have touched her breast. SW #1 progress note dated 5/3/19 documented Resident #2 confirmed that Resident #1 touched her breast. Resident #1 stated he was helping Resident #2 find her earring; he was Italian and he talked with his hands. The CCP titled Potential for Abuse dated 5/3/19 documented, the resident inappropriately touched another resident's breast. Interventions included setting limits on behavior, 15-minute check for two weeks, discuss guidance and goals of behavior and Psychiatric consult. The CNAAR (Certified Nurse's Aide Accountability Record) dated 5/2019 documented Resident #1 was not permitted in Resident #2's room. The incident report dated 5/3/19 at 12 PM documented, resident (#2) reported that resident (#1) touched her breast and the LPN observed the incident. The LPN witnessed and reported to SW #2 via interoffice communication on 5/1/19. The SW #2 brought up the incident during the morning report on 5/3/19. The interdisciplinary team (IDT) decided to do a full investigation. This was reported to the DOH on 5/6/19. Resident #1 stated that he did not grab Resident #2's breast and may have inadvertently touched her breast while looking for Resident # 2's earring. Resident #2 was interviewed and stated that Resident #1 inappropriately grabbed her right breast when he was in her room by the door, the nurse saw him and told him to leave and he did. The facility concluded that inappropriate touching of Resident #2's right breast did occur. Resident #2 was observed on 8/21/19 at 1:25 PM sitting in a wheelchair in her room. She was alert and oriented to person and place, not to time. She stated that Resident #1 abused her and handled her not well. He touched her on her groin, belly, and breast a couple of times. She told him to stop and he left her alone. Resident #2 stated it happened 4 times in her room while she was sitting in a wheelchair and nobody saw it. She did not report the incident as she was not comfortable and felt awkward. She also stated that Resident #1 touched her right breast. Resident #1 was observed and interviewed on 8/21/19 at 1:47 PM. He was alert and oriented x3. He stated he never touched Resident #2 inappropriately and nothing happened. He had no reason to touch her. The Social Work (SW) #1 was interviewed on 8/21/19 at 2:23 PM and stated that staff reported that Resident #1 was inappropriately touching the aides and also asked to provide extended care to his genital area. On 3/25/19, Resident #1 had gone to Resident #2's room. Resident #1 said he was just visiting and nothing inappropriate happened. SW #1 was not aware of any incident dated 4/24/19. On 5/1/19 Resident #1 inappropriately touched Resident #2's breast. SW #1 became aware of the incident on 5/3/19 during morning report and that was when she spoke to both residents and an investigation was initiated. The Assistant Director of Nursing (ADON) was interviewed on 8/21/19 at 3:52 PM and stated the incident occurred on 5/1/19, but it was not reported until 5/3/19. The LPN should have reported the incident to the RNS. The RNS should have called the DON. The ADON initiated the investigation on 5/3/19. Resident #2 was interviewed, and she stated that Resident #1 had grabbed her breast. Resident #1 denied that he touched her inappropriately. The incident was reported to the Department of Health (DOH) as sexual abuse. Resident #1 was specifically told on 5/1/19 that he was not allowed to go in Resident #2's room. On 5/3/19, Resident #1 was placed on every 15-minute checks. The 4:00 PM-12:00 AM RNS was interviewed on 8/21/19 at 4:07 PM and stated that on 5/1/19 the LPN verbally notified her of the incident of Resident #1 appearing to be reaching for Resident #2's breast. The LPN denied witnessing the actual touching. Resident #2 denied the incident, she was assessed and had no bruising. The RNS did not interview Resident #1. RNS did not read the LPN's note on 5/1/19. The RNS did not initiate an investigation; based on the LPN's report the RNS did not perceive the incident as sexual abuse. The 4:00 PM-12:00 AM LPN was interviewed on 8/21/19 at 4:20 PM and stated that she had seen Resident #1 in Resident #2's room on prior occasions. On 4/24/19, the LPN heard Resident #1 say to Resident #2, what happens between the two of them was between the two of them. His tone seemed agitated; Resident #2 said ok, she did not look fearful. The LPN communicated the incident with SW #2 via an interoffice memorandum but did not report it to the RNS. On 5/1/19 the LPN saw Resident #1 and Resident #2 sitting close to each other. Resident #1 launched his arm towards Resident #2's breast but did not actually touch. The LPN spoke to Resident #2 and she stated nothing happened. She verbally reported the incident to the RNS and brought Resident #1 back to his unit. A subsequent interview with the LPN on 9/9/19 at 4:00 PM she stated on her notes she meant that Resident #1 was reaching for Resident #2, however, she did not actually witness Resident #1 touching Resident #2's breast. The LPN stated she should have worded her notes differently. The DON was interviewed on 8/21/19 at 4:40 PM and she stated that she was informed of the incident between Resident #1 and Resident #2 on 5/3/19. She started the investigation on 5/3/19. The facility concluded that inappropriate touching occurred however, it was not considered sexual abuse. Resident #2 had impaired cognition and could not tell if the touching was inappropriate or not. The DON was not aware of any other incidents between Resident #1 and Resident #2. The DON acknowledged that the abuse CCP did not have any documented interventions for Resident #1. 415.4(b)

Based on record review, and staff interviews during the recertification survey, the facility did not ensure that a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care is developed within 48 hours of the resident's admission. This was evident for 1 (Resident #315) of 1 resident reviewed for Transmission-based Precautions. Specifically, Resident #315 was admitted with a physician's orders [REDACTED]. There was no baseline care plan developed for VRE Infection of Urine within 48 hours of the resident's admission. The finding is: Resident #315 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident was moderately impaired in cognition. The MDS documented the resident had an indwelling catheter and had an active [DIAGNOSES REDACTED]. The resident received an Intravenous (IV) medication during the review period. The physician's orders [REDACTED]. The physician's orders [REDACTED].#16 with 10 cubic centimeter (cc) balloon secondary to [MEDICAL CONDITION] and to change the Foley catheter every (q) month, and to change the Foley bag weekly. Review of the medical record revealed that there was no Comprehensive Care Plan (CCP) developed for VRE Infection of the Urine since admission. An interview with the Attending Physician was conducted on 1/24/19 at 10:48 AM. The Physician stated that the resident had a VRE urine infection when admitted to the facility. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 1/24/19 at 1:58 PM. The RN stated that the resident was admitted to the facility with VRE urine infection and she could not locate a CCP for VRE Infection in the urine. The RN stated that the CCP should have been initiated. An interview with the Director of Nursing Services (DNS) was conducted on 1/25/19 at 11:00 AM. The DNS stated that a VRE Urine Infection CCP should have been developed on admission. 415.11

Based on record review and interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical and nursing needs, identified in the comprehensive assessment is developed and implemented. Specifically, Resident #105 had a Comprehensive Care Plan (CCP) developed for Ineffective Breathing Pattern as related to (r/t) [MEDICAL CONDITIONS]. The interventions included to monitor respiratory rate, depth, and effort; monitor lung sounds, pallor, cough, and character of sputum and respiratory treatments. There was no documented evidence that the licensed nursing staff implemented each of these interventions. Additionally, there was no CCP developed for Non-Compliance of nebulizer treatments. The finding is: Resident #105 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 5 indicating severely impaired cognition. The MDS documented an active [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The CCP developed for Ineffective Breathing Pattern as r/t [MEDICAL CONDITION] dated 12/11/18 documented to monitor the resident's respiratory rate, depth, and effort; to monitor lung sounds, pallor, cough, and character of sputum; and to administer medications, respiratory treatments, and oxygen as ordered. Review of the medical record revealed that there was no documented evidence that the licensed nursing staff implemented the intervention of monitoring the resident's respiratory rate, depth, and effort; monitoring lung sounds, pallor, cough, and character of sputum via the facility's Nebulizer Treatment Record Form on pre and post nebulizer respiratory assessments. The form was not completed by the licensed staff. Review of Medication Administration Record [REDACTED]. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 1/25/19 at 11:00 AM. The RN stated that the licensed staff monitors the respiratory status only when the resident is in respiratory distress. The RN stated that the resident was non-compliant with his respiratory nebulizer treatments. The RN further stated that there was no CCP developed for Non-Compliance for the nebulizer treatments. The resident was interviewed on 1/25/19 at 11:45 AM. The resident stated that he refused the nebulizer treatments because it was difficult for him to remove the secretions after the nebulizer treatments. The resident stated that the licensed staff never asked him why he refused his nebulizer treatments. The resident further stated that the licensed staff does not listen to or monitor his lung sounds. The Director of Nursing Services (DNS) was interviewed on 1/25/19 at 12:00 PM. The DNS stated that the facility has the Nebulizer Treatment Record Form for pre and post nebulizer respiratory assessments to monitor the resident's respiratory status. The DNS further stated that the RNs are responsible for the completion of Nebulizer Treatment Record Form. 415.11(c)(1)

Based observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident's Comprehensive Care Plan (CCP) is reviewed and revised by the interdisciplinary team after each assessment, including the comprehensive assessments. This was evident for 1 (Resident #315) of 2 residents reviewed for catheter. Specifically, Resident #315 had a physician's orders [REDACTED]. The CCP for Foley catheter was not revised to reflect the use a leg bag when OOB. The finding is: Resident #315 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident was moderately impaired in cognition. The MDS also documented the resident had an indwelling catheter. The physician's orders [REDACTED].#16 with 10 cubic centimeter (cc) balloon secondary to [MEDICAL CONDITION] and to change the Foley catheter every (q) month, and to change the Foley bag weekly. The CCP developed for Urinary Incontinence dated 1/11/19 documented the resident had a Foley catheter in use and the resident was not a candidate for urinary toileting. There was no documentation on the CCP regarding the use of the urinary leg bag when OOB. The resident was observed in a wheelchair by the dayroom entrance door on 1/17/19 at 11:18 AM. The resident was wearing a leg bag urine catheter attached to his right lower extremity. On 1/22/19 at 1:45 PM, the resident was observed in a wheelchair in the hallway with an empty Foley bag privacy pouch. The resident had a urine leg bag in place. The Registered Nurse (RN) Unit Charge Nurse was interviewed on 1/22/19 at 1:55 PM. The RN stated that the resident is switched from a Foley bag to a leg bag when OOB. The RN stated that the CCP for Foley use does not include intervention of using a leg bag when the resident is OOB. Review of the Certified Nursing Assistant Accountability Record (CNAAR) for (MONTH) 2019 revealed no documentation for the use of a urinary leg bag when the resident is OOB. An interview with the assigned 7:00 AM-3:00 PM shift CNA was conducted on 1/23/19 at 11:00 AM. The CNA stated that when the resident is OOB to a wheelchair, a urinary leg bag is used in place of a Foley bag. An interview with the Director of Nursing Services (DNS) was conducted on 1/25/19 at 1:00 PM. The DNS stated that the use of leg bag should be included as an intervention in the CCP. 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good grooming and personal hygiene. This was identified for one (Resident #86) of two residents reviewed for ADLs. Specifically, Resident # 86, who requires staff assistance to trim his fingernails, was observed with untrimmed and soiled finger nails. The finding is: Resident #86 has [DIAGNOSES REDACTED]. The Resident's significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severely impaired daily decision making skills. The MDS also documented the resident required extensive assistance of one person for bathing, dressing and personal hygiene. A Comprehensive Care Plan (CCP) for ADLs dated 11/17/18 documented the resident required extensive assistance of one person for bathing, dressing and personal hygiene. During tour of the unit on 01/17/19 at 10:30 AM Resident #86 was observed in his wheel chair in the hallway. His four left finger nails were untrimmed and approximately 0.5 centimeters (cm) long with a visible black substance underneath the elongated nails. The resident was interviewed on 01/17/19 at 10:30 AM and stated that the Certified Nurses Assistants (CNAs) trim his nails for him. The resident was observed on 01/17/19 at 12:31 PM in unit Dining Room during lunch. He was served cottage cheese and a fruit platter and was observed using his left hand fingers to put the pieces of cut watermelon in his mouth. Resident #86's 7:30 AM to 3:30 PM CNA was interviewed 01/23/19 at 8:23 AM. The CNA stated that she had cared for the resident since (MONTH) (YEAR) and just returned from a 2 week vacation yesterday (1/22/19). She stated that the resident has right sided weakness and feeds himself using his left hand. She stated she cut his nails before she went on vacation and usually cuts them every two weeks or when they seem long. She stated she noticed his long dirty nails during his shower yesterday and should have trimmed them but could not get to do it at that time. She stated that during the day she had no time during his morning care, was assigned lunch duty and was assigned a half hour day room watch, then started to attend to residents requiring brief changes. She stated that yesterday her assignment was not full, she had 7 or 8 residents, but still did not have time. She stated that trimming the resident's nails is her responsibility and she should have done it. The Unit Charge Registered Nurse (RN) was interviewed on 01/23/19 at 8:39 AM and stated the resident requires one person for personal hygiene and staff from all shifts are responsible for cutting and maintaining nail cleanliness as part of care. She reviewed the staff assignments and stated that it looks like he has had two different CNAs for the evening shift the past week and more than two different CNAs the week before. She stated further that he had 4 different CNAs since last week for both day and evening shifts. 415.12(a)(3) .

Based on observation, record review, and interview, during the recertification survey, the facility did not ensure appropriate alternatives prior to installing a side or bed rail were attempted or that the resident was assessed for risk of entrapment from bed rails prior to installation. This was identified for 1 of 3 reviewed for Physical Restraints (Resident #117). Specifically, Resident # 117 had half side rails at the families request. The half side rails were not evaluated to determine if they would be a restraint or an entrapment risk. Additionally, there was no Comprehensive Care Plan (CCP) nor medical indication for their use. The finding is: Resident #48 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident displayed behavioral symptoms not directed toward others and required extensive assist of one person with bed mobility, transfers, toileting, and dressing. The resident ambulated with extensive assistance of one person in her room and was non-ambulatory in the corridor on the unit. The resident was frequently incontinent of bowel and bladder, had no falls in the last quarter, and bed rails were not used for the resident. The Monthly Physician's (MD) Orders dated 1/19/19 documented to apply two half side rails without a medical indication for their use. There was no indication on the monthly orders indicating when the two half side rails were first ordered. On 1/22/19 at 10:20 AM the resident was observed sliding down the bed with both upper side rails up. The call bell was attached to the upper right side rail but was not in reach. The resident stated that she had to go to the bathroom and she knew if she rang the call bell an aide would assist her. There was no Side Rail(s) assessment in the medical record to determine if the side rails were assessed as potential entrapment risk or as potential restraints. A review of the The Comprehensive Care Plan (CCP) revealed that there was no CCP developed for the use of the side rails. The 1/2 side rails monitoring form was last done 7/13/18 and documented that the resident was calm in bed. No attempts to get out of bed were documented. On 1/22/19 at 12:08 PM, the Certified Nursing Assistant (CNA) was interviewed and stated the resident requires total care for Activities of Daily Living (ADLs). The resident required two persons for transfer using a Hoyer lift. When the resident is in bed, she puts the bed in the lowest position, with 1/2 side rails, and floor mats. She stated the resident does not try to get out of bed or have sudden movements. The CNA stated that she checks on the resident when the resident is in bed. The CNA stated the resident had 1/2 side rails since admission, she was not sure why the resident had 1/2 side rails, but it could be because she tries to get out of bed or the family requested them. The 1/2 side rails are to be used at all times when resident is in bed. The resident will grab the rail to turn in bed during care. She also stated that she placed the call bell on the side rail but the resident probably moved herself out of reach. On 1/22/19 at 10:19 AM, the RN Supervisor was interviewed and stated the resident has the side rails because the family requested them since admission. The RN Supervisor stated we educated the family and explained the resident is at high risk for falls with the side rails. The resident attempts to come out of bed at times because she is unaware of bed boundaries. The RN stated that no care plan nor a restraint evaluation were found. She stated normally because it is a device that can impede movement the siderails are assessed to ensure it is not a restraint and a care plan is implemented. She stated that she would not consider it a restraint because it does not impede the resident's bed mobility or view. On 1/22/19 at 10:25 AM, the Physician (MD) was interviewed and stated he ordered the half side rails because the family wanted them. He further stated he did not feel there are any medical indications needed for 1/2 side rails because they are not restraints. On 1/25/19 at 12:25 PM, the Director of Nursing Services (DNS) was interviewed and stated the 1/2 siderails should have been evaluated to determine if they would be considered restraints. A CCP should have been in the medial record. The side rails should be evaluated regardless of what the family wanted. On 1/25/19 at 2:06 PM the Director of Rehabilitation was interviewed and stated they are not involved with siderails assessments and that nursing does the assessments. The Director of Rehabilitation stated that we will start to evaluate siderails in conjunction with Nursing. 415.12(h)(1)

Based record reviews and staff interviews during the recertification survey, the facility did not ensure that medical records on each resident are maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 6 (Residents #50, #105, #315, #312, #313, and #314) residents who had physician's orders [REDACTED]. The findings include but are not limited to: The facility's undated policy and procedure titled MD Orders on Admission and Re-admission documented Whenever a patient is admitted or readmitted to the facility, the MD Orders will be verified by the Doctor . 1) Resident #50 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had an indwelling catheter and received 7 days of antipsychotic and antianxiety medications, and 3 days of Keflex antibiotic treatment. The physician's orders [REDACTED]. -[MEDICATION NAME] 0.5 milligram (mg) by mouth (PO) twice daily (BID) with no medical indication of its use -[MEDICATION NAME] 100 mg daily (qd) x 4 days with no no medical indication for its use -[MEDICATION NAME] 2.5 mg PO at bedtime (HS) with no medical indication for its use -[MEDICATION NAME] 0.4 mg capsule, 1 capsule qd with dinner with no medical indication for its use. 2) Resident #105 has [MEDICAL CONDITION] Exacerbation, DM, and Heart Failure. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 5 indicating the resident was severely impaired in cognition. The MDS documented active [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders had no medical indications documented. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. 3) Resident #314 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 3 indicating severely impaired cognition. The physician's orders [REDACTED]. An interview with the Attending Physician for Residents #50, #105, and #314 was conducted on 1/24/19 at 10:00 AM. The Physician stated that he does not need to write the medical indications in the orders or interim orders since the medications had been discussed in the evaluation form for their usage. An interview with the Director of Nursing Services (DNS) was conducted on 1/25/19 at 11:00 AM. The DNS stated that the Attending Physician should have written the medical indications for the medications. 415.22(a)(1-4)