Every finding on record at Cliffside Rehab & Residential Health Care Center

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure that residents were free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for 5 (Residents #29, 142, #206, #125, and #3) of 8 residents reviewed for physical restraints out of 35 total sampled residents. Specifically, 1.) Residents #29, 142, #206, #125, and #3 were observed on multiple occasions in bed with both upper and lower half side rails raised on both sides. All 5 residents had impaired cognition; were either dependent on staff or required substantial / maximal assistance for bed mobility; and were unable to easily and voluntarily release the side rails. 2.) Resident #142 was observed on a wheelchair with a lap tray that prevents the resident from rising and cannot be removed easily and voluntarily. There was no documented evidence that alternatives were attempted prior to implementing side rails and lap tray use. Additionally, there was no documented evidence of informed consent or that education regarding the risks and benefits of side rail and lap tray use was given to the family. The findings include: The facility's policy titled Physical & Chemical Restraints with a last reviewed date of 05/2025 documented that the facility supports the philosophy that residents/persons served will remain free from any physical and chemical restraints unless residents/person served has medical symptoms that warrant the use of restraints for health and safety measures. The policy documented all residents served requiring a physical restraint shall be assessed by the interdisciplinary team to assess the need for restraints and the least restrictive device to be used. A physician's order must be obtained for any restraint use and must include appropriate medical symptoms that warrants it use, for example active seizure disorder, Huntington's Chorea. All in-house residents who have restraint orders will be assessed quarterly, or more frequently, if necessary, by the interdisciplinary team to determine the need or continued need for restraint or for restraint reduction. The facility's policy included side rails that keep the residents from voluntarily getting out of bed as a type of restraint. The policy further documented that full side rails are considered to be physical restraint. 1. Resident#29 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, Anxiety, Depression and Bipolar Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented that resident had severely impaired cognition, no behaviors, had impairment on both sides of upper and lower extremities, and was dependent on staff for bed mobility, chair transfer, no toilet use, and always incontinent of urine and bowel. The assessment documented that bed rail was not in use. During observation on 07/18/2025 at 9:57 AM at 10:02 AM, Resident #29 was in bed with upper and lower half side rails raised on both sides. At 10:02 AM, the resident was provided care by the Certified Nursing Assistant; the resident was unable to follow instructions, unable to turn, and unable to hold onto the side rails. On 07/21/2025 at 12:25 PM and on 07/22/2025 at 9:08 AM, Resident #29 was observed in bed with upper and lower half side rails raised on both sides. A Full Side Rail Assessment form documented the date of initial assessment was 11/01/2024. The assessment documented that side rail use will limit Resident #29's ability to exit the bed and documented unable to define bed boundaries as the medical symptom for side rail use. The form documented that the family was informed of side rail use but did not indicate whether consent was given by the family member. There was no documented evidence that education regarding the risks and benefits of side rail use was given to the family. The side rail quarterly review documented that reviews were completed by the interdisciplinary team on 02/05/2025 and 05/13/2025. There were no documented attempts to reduce the use of side rails. The review documented positioning legs off bed and continue use of full side rails. A physician's orders dated 07/10/2025 documented bed mobility using full side rail, elevated with bumper guard due to unawareness of bed boundaries, family requested full side rail secondary to history of patient getting out of bed. A comprehensive care plan for restraints was initiated on 11/01/2024, related to poor bed boundaries. The care plan documented to initiate full side rails. The goal include Resident #29 will be safe in the least restrictive device daily. The facility interventions included to monitor and evaluate continued need to use physical restraints per protocol and to discuss with team. A comprehensive care plan for falls was initiated on 11/01/2024. The goal included Resident #29 will have no future falls or sustain any injury. The facility interventions include to keep both upper side rails up when resident is in bed. A comprehensive care plan for total self-care deficit related to hemiparesis / hemiplegia/ and contractures was initiated on 11/26/2024. The facility interventions include applying 2 half bed side rails as enabler to assist in bed mobility and turning and positioning. A nurse's note dated 04/17/2025 documented Resident #29 was met in bed, responsive to tactile stimuli, unable to make needs known, bilateral handrails raised for repositioning. A nurse's note dated 07/12/2025 documented Resident #29 was alert with some confusion and forgetfulness, reoriented, and redirected when needed, both full side rails up due to unawareness of bed boundaries. The Certified Nursing Aide Accountability Record had no instructions on side rail use. A review of Resident #29's medical record revealed no documented evidence that alternatives were attempted prior to implementing side rails. On 07/22/2025 at 10:53 AM, Certified Nursing Assistant #7 was interviewed and stated that Resident #29 needs complete assistance with activities of daily living and can be resistant with care. Certified Nursing Assistant#7 stated Resident #29 is provided side rails, however resident is not able to take it down or use it. They stated that Resident #29's family requested the side rails. On 07/22/2025 at 10:22 AM, Registered Nurse #5, who was the Unit Supervisor, was interviewed and stated that Resident #29's family requested the side rails prior to the resident coming to the unit. The supervisor stated Resident #29 had been in the unit since April 2025 and they had no discussion with the resident's family about the use of side rails. They stated they provided the side rails for the resident because the resident can be restless in bed. Registered Nurse #5 stated there was no instructions in the Certified Nursing Aide Accountability Record regarding the use of side rails. On 07/22/2025 at 2:34 PM, Nurse Practitioner #3 was interviewed and stated Resident #29 had an order for the use of full side rails since November 2024. Nurse Practitioner #3 stated they are planning to talk with the family about reducing the side rail use because the resident had less agitation in the last month. 2. Resident #142 was admitted to the facility with diagnoses that included Encephalopathy, Anxiety Disorder, and Hypertension. The Minimum Data Set assessment dated [DATE] documented that Resident #142 was severely cognitively impaired, had no behavior, had impairment on both sides of lower extremities, and required dependent assistance of staff with transfers and dependent to substantial/maximal assistance with bed mobility. The assessment documented that bed rails were used daily and a chair that prevents rising was used daily. During observation on 07/16/2025 at 10:36 AM, Resident #142 was sleeping in bed with upper and lower half side rails raised on both sides. On 07/21/2025 at 10:39 AM, Resident #142 was observed awake and alert, lying in their bed, with padded upper and lower half side rails raised on both sides. The resident was unable to release the side rails independently. On 07/21/2025 at 11:00 AM, Resident #142 was observed on a wheelchair with a lap tray secured with Velcro straps that the resident cannot easily remove and prevents the resident from rising. The Restraint Assessment Record Form documented the date of initial assessment was 10/15/2022 documented that wheelchair with lap tray and full side rails were ordered. It documented that alternative measures attempted was redirection. The medical symptom for restraint use was unsteady gait and unaware of functional limitations. The form documented the family was informed of side rail use but did not indicate whether consent was given by the family member. There was no documented evidence that education regarding the risks and benefits of side rail and lap tray use was given to the family. The most recent restraint quarterly review was completed on 07/03/2025; there was no documented attempts to reduce the use of side rails and lap tray. The review documented poor bed boundaries and positioning body off bed. A Half Side Rail Assessment Form with undated initial assessment documented that the side rail limits the resident's ability to exit the bed and that the side rail was for enhancing bed mobility. The form documented to initiate half side rails. A review of the physician's orders documented bed mobility, using full side rails elevated with bumper guard due to unawareness of bed boundaries. Both, full side rail up; therapeutic device mobility on/off unit in high back reclining wheelchair with full lap tray. Reason not defined. A comprehensive care plan for restraints was initiated on 01/19/2023. The care plan documented that Resident #142 required the use of full siderails, full lap tray, and bed alarm due to inability to define bed boundaries. The care plan goal was that Resident #142 will be safe in the least restrictive device. The facility interventions included incontinent care, monitor skin condition, monitor for signs and symptoms of changes in cognition, behavior, and activities of daily living, restraint reduction evaluation per protocol. Bed mobility using full side rails evaluated with bumper guard due to unawareness of bed boundaries, both full siderails up for ambulation. A comprehensive care plan for total self-care deficit was initiated on 10/04/2022 and was last reviewed on 07/16/2025. The care plan documented that Resident #142 had the inability to provide for own activities of daily living needs that includes bed mobility and transfer via Hoyer lifter that requires 2 person assist. A nurse's progress notes dated 07/17/2025 documented Resident #142 had periods of confusion and forgetfulness. The resident attempted to climb out of bed between two siderails as usual several times. Full siderails up and bilateral floor mats to prevent fall. Resident was unable to recognize bed boundaries. Continues to position legs outside the bed. Out of bed using high-back reclining wheelchair with full lap tray as Resident #142 attempts to get out of the wheelchair even though Resident #142 required maximum assistance from two staff members. The weekly psychiatric consult note dated 07/20/2025 documented Resident #142 was confused and forgetful at times. Resident #142 tried to remove their lap buddy. Four side rails with bumper guard always up while in bed as ordered. Resident removes bumper guard and tries to come off from bed between the two side rails. Dangles their legs between side rails. A review of Resident #29's medical record revealed no documented evidence that alternatives were attempted prior to implementing side rails and lap tray. On 07/21/2025 at 12:15 PM, Certified Nurse Assistant #5 was interviewed and stated Resident #142 has side rails because the resident was very agitated and wants to come out of bed. They stated when in bed, Resident #142 crosses their legs on the side rails. They stated they remove the side rails when Resident #142 is out of bed. Certified Nurse Assistant #5 stated Resident #142 uses the lap tray because the resident moves a lot and tends to get up. On 07/17/2025 at 11:52 AM, Registered Nurse #4, who was the nursing supervisor, was interviewed and stated they are not aware of any assessments conducted for the use of side rails and lap tray. They stated if they feel that a resident needs side rails, they only call the doctor, and the doctor gives the order. Registered Nurse #4 stated Resident #142 also uses a lap tray so that the resident does not fall when they are out of bed. Registered Nurse #4 also stated that Resident #142 had side rails because the resident had no bed boundaries; the resident keeps putting their feet outside of the bed. They stated the lap tray is used for the resident because the resident is very confused and keeps trying to stand up from the wheelchair. On 07/22/2025 at 11:00 AM, Nurse Practitioner #2 was interviewed and stated Resident #142 had cognitive impairment and uses bed rails for safety, to make sure the resident does not fall. The Nurse Practitioner stated if a resident needs side rails, the nursing staff will call the doctor and gets the order. The Nurse Practitioner stated they are not sure how Resident #142 was assessed for the side rails and not sure how the side rail use was being monitored. 3. Resident #206 was admitted to the facility with diagnoses that included Dementia with agitation, Depression, and Insomnia. The Minimum Data Set assessment dated [DATE] documented that Resident #206 was severely cognitively impaired, had impairment on both sides of upper and lower extremities; and was dependent on staff for all activities of daily living. The assessment documented that the resident used bed rails daily. On 07/16/2025 at 12:39 PM, Resident #206 was observed with upper and lower half side rails raised on both sides. Resident #206 was unable to release the siderails independently. On 07/17/2025 at 12:29 PM, Resident #206 was observed awake, lying in bed with upper and lower half side rails raised on both sides. Resident #206 was unable to unsecure the bed rails independently. On 07/21/2025 at 10:44 AM, Resident #206 was observed awake and alert, lying in bed with upper and lower half side rails raised on both sides. A Full Siderail Assessment Form documented the date of initial assessment was 03/20/2025. The assessment documented that the interdisciplinary team recommended the initiation of full side rail use, the medical symptom for side rail use was unable to define bed boundaries. The form documented the family was informed of side rail use but did not indicate whether consent was given by the family member. There was no documented evidence that education regarding the risks and benefits of side rail use was given to the family. The most recent restraint quarterly review was completed on 06/09/2025; there was no documented attempts to reduce the use of side rails. The review documented positioning body off bed, continue full side rail. A physician's order dated 03/20/2025 documented full side rails with bumper guard elevated due to unawareness of bed boundaries. A comprehensive care plan for restraints related to motor agitation and poor bed boundaries, initiate full side rails, was initiated on 03/08/2024. The facility interventions include to monitor and evaluate continued use of physical restraints and monitor for negative outcome. A care plan note dated 06/09/2025 by the Director of Nursing documented that resident continues with full side rails due to inability to regulate bed boundaries. A care plan for falls was initiated on 12/06/2023. The facility interventions include keeping both upper side rails up when resident is in bed. The nurse's progress notes dated 03/20/2025 and 07/17/2025 documented Resident #206 was unaware of bed boundaries, continues to position their legs off bed, to continue with full side rails with bumper guard. A review of Resident #206's medical record revealed no documented evidence that alternatives were attempted prior to implementing side rails. On 07/21/2025 at 12:22 PM, Licensed Practical Nurse #6 was interviewed and stated Resident #206 has side rails because they keep trying to jump out of bed and kicks very high. They stated the resident had fallen 3 times before and side rails were used for protection. On 07/21/2025 at 11:37 AM, Registered Nurse #4, who was the nursing supervisor, was interviewed and stated that Resident #206's full side rails were initiated on 03/08/2025 because of agitation and resident had behavior of putting their feet outside the bed. They stated there is no restraint assessment form that needs to be filled out prior to initiating the use of side rails. They stated if a resident needs side rails, they call the doctor, tell them what they observed, and ask the doctor for an order. They stated side rails are also recommended by the Rehabilitation Department. On 7/22/2025 at 10:31 AM, Medical Doctor #2 was interviewed and stated Resident #206 is severely cognitively impaired and is unaware of their own safety. They stated side rails are used to protect Resident #206 from falling. Medical Doctor #2 stated the medical reason for the resident use of side rail was that Resident #206 was not aware of their own bed boundaries. They stated that side rail assessment is completed by the nursing staff. The nurses will then call the doctor, and the doctor will put in the order. Medical Doctor #2 stated they are not sure how often the siderails are assessed. 4. Resident #125 was admitted to the facility with diagnoses that included Mood Disorder, Psychosis, and Adjustment Disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #125 was severely cognitively impaired, had impairment on both sides of lower extremity, and required substantial / maximal assistance in rolling left and right; and sit to lying. The assessment documented that bed rails are used daily. During observations on 07/16/2025 at 10:36 AM, 07/17/2025 at 10:05 AM, and on 07/18/2025 at 9:30 AM, Resident #125 was observed in bed with upper and lower half side rails raised on both sides. The resident was unable to release the side rails independently. A Full Siderail Assessment Form documented the date of initial assessment was 04/06/2023. The assessment documented that side rail use limit the resident's ability to exit the bed, the medical symptom for side rail use was unable to define bed boundaries and motor agitation. The form documented that the care plan team recommended full side rail use. The form documented the family was informed of side rail use but did not indicate whether consent was given by the family member. There was no documented evidence that education regarding the risks and benefits of side rail use was given to the family. The most recent restraint quarterly review was completed on 07/03/2025. There was no documented attempts to reduce the use of side rails. The review documented positioning body off bed, continue full side rail. A physician's order dated 04/06/2023 and was last renewed on 07/04/2025 documented bed mobility both full side rails up due to unawareness of bed boundaries. A comprehensive care plan for restraints was initiated on 04/06/2023 and was last reviewed on 05/25/2025. The care plan documented use of 2 full side rails. The facility intervention included to apply and release restraint as per physician's order and to monitor and evaluate continued need to use physical restraint. The care plan evaluation notes completed by the Director of Nursing dated 04/02/2025 documented Resident #125 continued to position legs and body off bed, continue full side rails. A comprehensive care plan for falls was initiated on 03/19/2021 and was last reviewed on 05/25/2025. The facility interventions include keeping both side rails up when in bed. A nurse's progress notes dated 06/03/2025 documented Resident #125 was in bed with both full side rails up due to unawareness of bed boundaries. A review of Resident #206's medical record revealed no documented evidence that alternatives were attempted prior to implementing side rails. On 07/18/2025 at 9:43 AM, Certified Nursing Assistant #6 was interviewed and stated Resident #125 has side rails and that they do not know how long the resident has it. They stated the resident shakes the side rails, wanted to have it taken off, and would scream to get out of bed. On 07/18/2025 at 9:48 AM, Licensed Practical Nurse #5 was interviewed and stated that Resident #125 has side rails because the resident is unpredictable and was falling frequently and would try to climb out of bed. They stated the resident had no falls since they applied the side rails. On 07/17/2025 at 10:00 AM, Registered Nurse Supervisor #5 was interviewed and stated Resident #125 uses side rails because the resident thinks they can still walk and would get out of bed without assistance and had history of frequent falls. They stated side rail use is for the resident's safety, it keeps Resident #125 from falling out of bed. On 7/22/2025 at 10:31 AM, Medical Doctor #2 was interviewed and stated Resident #125 is severely cognitively impaired and is unaware of their own safety. 5. Resident #3 was admitted to the facility with diagnoses that included Dementia, Diabetes Mellitus, and Hypertension. The Minimum Data Set assessment dated [DATE] documented that Resident #3 had moderately impaired cognition, had no behaviors, and had impairment on both sides of upper and lower extremities. The resident required substantial / maximal assistance with rolling left and right and sitting to lying position. The assessment documented bed rails was used daily. During observations on 07/16/2025 at 11:29 AM, 07/17/2025 at 11:18 AM, and on 07/21/2025 at 10:335 AM, Resident #3 was observed in bed with upper and lower half side rails raised on both sides. The resident was unable to release the side rails independently. A Full Siderail Assessment Form documented the date of initial assessment was 06/04/2025. The assessment documented that side rail use limit the resident's ability to exit the bed, the medical symptom for side rail use was unable to define bed boundaries. The form documented that the care plan team recommended full side rail use. The form documented the family was informed of side rail use but did not indicate whether consent was given by the family member. There was no documented evidence that education regarding the risks and benefits of side rail use was given to the family. A physician's order dated 06/09/2025 documented bed mobility using full side rails with bumper guard elevated due to unawareness of bed boundaries. A comprehensive care plan for restraints was initiated on 05/02/2025 as related to motor agitation / poor bed boundaries, initiate full side rails. The facility interventions included bed mobility using full side rails and apply and release physical restraint per physician's order. The 06/04/2025 care plan progress notes documented Resident #3 has been keeping their legs off bed and is unable to define bed boundaries. A comprehensive care plan for falls related to impaired mobility history of falls was initiated on 01/21/2025. The facility interventions included keeping both side rails up when resident is in bed. On 07/21/2025 at 11:49 AM, Certified Nursing Assistant #4 was interviewed and stated that Resident #3 is not mentally good, cannot stand and cannot walk, and slides off bed. They stated the resident has side rails to keep the resident from getting out of bed. Certified Nursing Assistant #4 stated Resident #3 does not know how to put the side rails down. On 07/21/2025 at 12:45 PM, Licensed Practical Nurse #4 was interviewed and stated Resident 33 had double side rails because the resident fell a couple of times before. On 07/21/2025 at 10:50 AM, Registered Nurse #4, who was the nursing supervisor, was interviewed and stated Resident #3 had side rails because the resident tries to get out of bed and puts their legs over the bed. 07/23/2025 10:21 AM, Medical Doctor #2 was interviewed and stated that Resident #3 has history of agitation and tries to get out of bed. They stated the side rails are for the resident's safety. Medical Doctor #2 stated they were not sure what interventions were used prior to the implementation of side rails, they stated that is nursing. They stated, the residents are assessed by the nurse for side rail use, the nurse then calls the doctor for the order. On 07/22/2025 at 11:00 AM, the Medical Director was interviewed and stated side rails are used for resident safety. On 07/18/2025 at 1:33 PM, the Director for Rehabilitative Therapy was interviewed and stated that side rail referral comes from nursing. They stated side rails are used by residents to enable them to move and reposition in bed, and the residents must be able to hold and grab the side rails. The Director stated that the nursing department determines and recommends the use of side rails, and that Rehabilitation Department is not involved in the assessment of side rails and restraints. They stated nursing department determines and recommends the use of side rails. They stated that the side rail form is filled out by nurses and kept by the Director of Nursing. They stated that nurses do the reassessment for side rail use and not Rehabilitation Department. On 07/18/2025 at 1:21 PM, the Maintenance Director was interviewed and stated Maintenance Department install the side rails after the nurses got the doctor's order for side rail use. The Director stated that side rails are not removable, and it cannot be removed by the residents, but it can go up and down. They stated that side rails cannot be operated by the residents and residents have to call for staff assistance to lower them. On 07/23/2025 at 3:19 PM, the Director of Nursing was interviewed and stated that residents with poor cognition, who places their legs and body off the bed, and who are not aware of bed boundaries are identified for side rail use. They stated they initiate full side rails to provide boundary for residents who does not know where the bed ends. They stated that side rails are also used for motor and physical agitation. They stated that residents had not fallen when the side rails are in use and that they do not see an issue with the use of side rails. 10 NYCRR 415.4(a) (2-7)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure that residents admitted with a limited Range of Motion and/or mobility, are provided services and/or treatment to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility, including the provision of equipment for limited mobility. This was evident for 2 (Residents # 20 and #85) of 4 residents reviewed for Position Mobility/Limited Range of Motion, out of 35 total sampled residents. Specifically, Residents #20 and #85, who had contractures, were observed without hand rolls as ordered by the physician to improve the residents' contractures. The findings include:The facility's Policy titled Care of Resident with Adaptive Devices dated 02/17/2009 and was last updated on 05/2025 documented that the purpose of the policy was to prevent reduction of Range of Motion (contracture). The type of adaptive devices includes hand rolls. The policy documented that Physical/Occupational Therapy Department will assess and recommend appropriate devices; will in-service nursing staff on application of device; the Certified Nursing Assistant will apply and remove device as instructed on accountability record; charge nurse will revise accountability record of devices as needed; and charge nurse will also monitor for discomfort and irritation and report problem to rehabilitation nurse, supervisor and therapist.1. Resident #20 had diagnoses that included Hypertension, Respiratory Failure, Amyotrophic Lateral Sclerosis.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #20 had severe impairment in cognition and was totally dependent on staff for all activities of daily living. The assessment also documented Resident #20 had pressure reducing device for chair and for bed. A Comprehensive Care Plan for contractures, position/mobility was initiated on 02/10/2023 and was last updated on 06/23/2025. The care plan documented that Resident #20 had contractures to both hands and both feet. The facility interventions: to inspect skin condition around contracture site daily, monitor for sign of pain during range of motion/therapy, provide adaptive devices as per orders, and provide routine hygiene to contracture site every shift.The occupational therapy evaluation plan and treatment dated 11/01/2024 documented Resident #20 presented with stiffness on both hands. The rehabilitation communication / order form dated 11/13/2024 documented to apply bilateral hand rolls at all times. A physician's order dated 06/25/2025 documented Therapeutic devices apply both hand rolls at all times, remove for skin checks, hygiene care, and range of motionThe Certified Nursing Assistant Accountability Record from 07/01/2025 to 07/22/2025 had no consistent documentation that the hand roll was being provided to Resident #20 as per order.On 07/16/2025 at 11:02 AM, Resident #20 was observed in bed, noted with contractures on both hands. The resident was noted without a hand roll on the right hand. Further observations were made between 8:00 am and 1:00 pm on 07/17/2025, 07/18/2025 and 07/21/2025. Resident #20 was observed without a hand roll on the right hand. On 07/22/2025 at 8:14 AM, Resident #20's family member was at the bed side and was interviewed. Resident's family stated that whenever they come to visit, Resident #20 has only one roll applied. They stated resident was supposed to have the device on both hands but was not sure why only one was being applied. The family member stated they had not asked the staff why only one device is applied.On 07/22/2025 at 9:12 AM, Certified Nursing Assistant #1 was interviewed and stated they have been taking care of Resident #20 for the past 3 weeks. They stated they perform range of motion for Resident #20 and that the resident must have hand rolls on both hands. They stated they have been seeing and applying only one hand roll on the resident since having the resident in their assignment. On 07/22/2025 at 9:40 AM, Licensed Practical Nurse #1 was interviewed and stated they had not noticed that only one hand roll was being applied for Resident #20. 2. Resident #85 was admitted to the facility with diagnoses that included Anemia, Respiratory Failure, Amyotrophic Lateral Sclerosis.The quarterly Minimum Data Set assessment dated [DATE] documented Resident #85 had severe impairment in cognition and was totally dependent to staff for all activities of daily living. The Comprehensive Care Plan for impaired physical Mobility was initiated on 12/10/2024 and was last updated on 07/16/2025. The facility interventions included providing assistive device as ordered, to provide range of motion, Physical/Therapy/Occupational Therapy evaluation as needed, bed mobility using both half rails up due to poor trunk control side rails bumper guard. The occupational therapy evaluation and plan of treatment dated 07/15/2025 documented resident exhibited new onset of decreased functional mobility, decreased range of motion and strength. The resident and caregiver roles included applying hand roll on both hands to prevent contracture. A physician's order dated 07/16/2025 documented: Therapeutic Devices Apply bilateral rolls at all times, remove for skin checks, hygiene care, and range of motion. On 07/16/2025 at 10:07 AM, during the initial pool process, Resident #85 was observed in bed, noted with contractures on both hand with no device applied to relief pressure on the contracted hands/fingers.Resident #85 was further observed daily between 8:30 am and 1:00 pm on 07/17/2025, 07/18/2025 and 07/21/2025 with no hand roll applied to both hands.On 07/22/2025 at 8:40 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #85 is on their assignment and that the resident was supposed to have hand rolls in place. They stated they has not seen any hand roll to apply and notified the nursing supervisor, but they were only given a gauze to apply that does not stay in resident's hands. On 07/22/2025 at 9:49 AM, Licensed Practical Nurse #2 was interviewed and stated they were assigned to Resident #85 this morning and was not aware that resident had no hand rolls applied. On 07/22/2025 at 10:00 AM, Registered Nurse Supervisor #1 was interviewed and stated they make rounds when staff are giving care to the residents but did not realize that hand rolls were not applied for the residents as stated in their plan of care. On 07/22/2025 at 11:05 AM, the Rehabilitation Director was interviewed and stated that residents are screened upon admission to see if they need any adaptive devices. They stated referrals are received from nursing, and orders are written for the adaptive device. They stated they bring the hand rolls to try it on the resident to see how it is tolerated; they conduct in-service to the staff before the rolls are issued. They stated they may also train the family members how to put the device on the resident. The Director further stated that they would not know if a resident had no device to use unless the nursing staff notifies them. The Rehabilitation Director stated that instructions for residents' devices are in the Certified Nursing Assistant Accountability Record, and that nursing should make sure that the devices are applied on residents as per their plan of care. On 07/22/2025 at 12:11 PM, the Director of Nursing was interviewed and stated it is the responsibility of the Certified Nursing Assistants to ensure that residents are provided with their devices as per order and the nurses and the supervisor on the unit should be monitoring them to ensure that the Certified Nursing Assistants are doing their jobs. The Director of Nursing was not able to explain why devices are not being provided to residents as per order and as per their plan of care. The Director of Nursing further stated they are mad with the staff for allowing the surveyors to cite them for this kind of deficiencies.10 NYCRR 415.12 (e)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/16/2025 to 07/23/2025, the facility failed to ensure residents are provided comfortable and homelike environment. This was evident for 1 (Unit1) of 3 resident units observed. Specifically, Resident #93's room appeared cluttered and disorderly, with lack of storage for resident's items. The findings include but are not limited to: Resident #93 was admitted to the facility with diagnoses of End Stage Renal Disease. The Quarterly Minimum Data Set, dated [DATE] documented Resident #93 had intact cognition, had no behaviors, and had impairment on both upper extremities. The assessment documented that resident required set up for eating, bed mobility, supervision for transfer and toilet use; and was always continent of bowel and bladder. During multiple observations on 07/18/2025 and 07/22/2025, Resident #93's was observed with cases of water, boxes, and other miscellaneous items placed on the floor next to the resident's beside. On 07/22/2025 at 3:26 PM, Resident #93 stated their daughter sends them goods and other items. A Comprehensive Care Plan for noncompliance manifested by noncompliance with medication administration and hoarding goods at bedside was initiated for Resident #93 on 07/10/2025. The facility interventions include to accept Resident #93's right to refuse and show respect for resident's decisions.There was no documented evidence that discussions were made to resolve Resident #93's hoarding of articles and storing their items on the floor inside resident's room. On 07/22/2025 at 3:16 PM, the Social Worker Director was interviewed and stated they had not spoken with Resident #93 about the resident's hoarding, and they do not know of any actual conversations made between the resident and the Administrator on how to store their items. On 07/22/2025 at 3:32 PM, the Director of Nursing was interviewed and stated they purchased bins for Resident #93 but was not aware if those bins were used. The Director of Nursing stated Resident #93 has lots of items in their room but is not always receptive to it being addressed. On 07/22/2025 at 3:26 PM, the Administrator was interviewed and stated they spoke with Resident #93 about the accumulation of items in their room and that they continue to monitor for rodents. They stated they have not suggested to elevate the items and to not place them on the floor. The Administrator stated they will place some of Resident #93's items in the storage if the resident allows it. 10 NYCRR 415.29

Based on observation, record review, and interviews conducted during the Recertification Survey from 07/16/2025 to 07/23/2025, the facility failed to ensure the nursing staff information posting was accurate and complete. This was evident during the Nursing Staffing Task. Specifically, the daily nurse staffing information posting was missing the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The findings include:The facility policy titled Assignment of Nursing Care with the effective date of 08/2001 and a revised date of 05/2025 documented that the staffing schedule is posted outside the nursing office for each shift: 07:30 AM-3:30 PM; 3:30 PM - 11:30 PM; and 11:30 PM - 07:30 AM. The schedule documents the units and staff: Registered Nurse Supervisors, Licensed Practical Nurses, and Certified Nurse Assistant. The policy also stated that the nursing daily staffing summary is posted. Observations and review of the Daily Nursing Staffing Information sheets posted by the nursing supervisors in the front lobby from 07/16/2025 through 07/23/2025 did not document the resident census and the total number and number of actual hours worked by Registered Nurse, Licensed Practical Nurse, and Certified Nurse Aide. On 07/23/2025 at 9:32 AM, the Assistant Director of Nursing was interviewed and stated the day shift supervisors posts the evening schedule, and the evening shift supervisor posts the night shift schedule, while the night shift supervisor posts the morning shift schedule. The Assistant Director of Nursing also stated they never document the census and the actual breakdown of hours worked by the nursing staff on the posting and was never cited for it. They stated no surveyors from the previous surveys told them that they were doing it wrong. On 07/23/2025 at 3:19 PM, The Director of Nursing was interviewed and stated they have been working at the facility for more than 10 years and 3 surveys had since passed and was never told that the nurse posting was not in compliance.10 NYCRR 415.13

Based on record review and interviews conducted during the recertification survey 5/9/23 to 5/16/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 2 (Resident #108 and #144) of 4 residents reviewed for Resident Assessment out of a sample size of 35 residents. Specifically, the MDS assessments for Resident #108 and #144 were not submitted and transmitted within 14 days of the completion date. The findings are: The CMS RAI Version 3.0 Manual (Dated October 2018), documented the MDS completion date must be no later than 14 days after the assessment reference date (ARD). Comprehensive assessments must be transmitted within 14 days of completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. The MDS assessment for Resident #108 with ARD of 3/13/23, documented a completion date of 03/27/23 and a submission date of 05/15/23, more than 14 days after the completion date. The MDS assessment for Resident #144 with the ARD of 01/20/23, documented a completion date of 02/03/23 and submission date of 05/15/23, more than 14 days after completion date. On 05/16/23 at 03:09 PM, the MDS coordinator was interviewed and stated they work with another facility to submit the MDS assessments in batches to QIES. The MDS department has a plan to address assessment submissions. The MDS Coordinator stated they are aware there are concerns with timely MDS submissions. 415.11 (a)(1-5)

Based on record review and interview conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments accurately reflected the resident's status. This was evident for 2 (Resident #112 and #23)of 35 sampled residents. Specifically, 1) the MDS assessment for Resident #112 did not document the resident's dialysis treatment, and 2) the MDS assessment for Resident #23 did not document the resident's Gradual Dose Reduction (GDR) status. The findings are: The facility policy titled Assessments, Comprehensive (Minimum Data Set 3.0) dated 8/2022 documented the MDS is inclusive to all pertinent issues for the resident. 1) Resident #112 had diagnoses of anemia and coronary artery disease. The MDS dated [DATE] documented Resident #112 was cognitively intact and did not receive dialysis. On 05/10/23 at 10:10 AM, Resident #112 was interviewed and stated they have been receiving dialysis continuously since 2019. The Comprehensive Care Plan (CCP) for Hemodialysis dated 06/14/2021 documented that Resident is on Hemodialysis. Physician's order dated 4/25/2023 documented Resident #112 received dialysis 3 times weekly. There was no documented evidence the MDS for Resident #112 included the resident's dialysis treatment. On 05/11/23 at 11:20 AM, an interview was conducted with the Registered Nurse Supervisor (RNS #1) who stated Resident #112 has been on dialysis since admission to the facility. On 05/11/23 at 11:30 AM, an interview was conducted with the MDS Coordinator (MDSC) who stated when documenting residents' MDS, they physically look at the resident and check the progress notes, physician's orders, and physician's notes. They always check the data input with the assessment documented to ensure that each portion of the assessment matches what they saw physically. Every team member that does the MDS assessment is responsible for checking accuracy after completion. The MDSC stated they check and sign for the completion before submission. Omission of dialysis treatment from Resident #112's MDS was human error that was just discovered and will be corrected. 40686 2) Resident #23 had diagnoses of schizophrenia and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #23 was cognitively intact and received antipsychotic medication 6 out of the 7 days prior to the assessment. The Antipsychotic Medication Review section (N0450) documented Resident #23 did not receive antipsychotic medication and did not document whether a GDR had been attempted. On 05/15/23 at 12:19 PM, Resident #23 was interviewed and stated they are currently receiving Risperidone and began receiving the medication prior to their admission to the facility. The Medical Doctor Order last renewed 4/28/23 documented Resident #23 should receive Risperidone 1mg at bedtime for paranoid schizophrenia. There was no documented evidence the MDS for Resident #23 included their accurate antipsychotic use and GDR status. On 05/16/23 at 12:39 PM, the MDS Coordinator (MDSC) was interviewed and stated they filled out the MDS for Resident #112 and stated it was a mistake to document that Resident #112 did not receive antipsychotic. They missed this question. No one else checks the MDS assessments for accuracy. These mistakes do not happen often. On 05/16/23 at 10:40 AM, the Psychiatrist was interviewed and stated Resident #23 receives Risperidone and a GDR was not attempted due to the resident's risk for decompensation. 415.11(b)

Based on observation, interview, and record review, conducted during the recertification survey from 5/9/23 to 5/16/23, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented for each resident to meet the resident's medical needs identified in the comprehensive assessment. This was evident for 1 (Resident #23) of 35 total sampled resident. Specifically, Resident #23 did not have a CCP developed to address antibiotic therapy (ABT) use for a bacterial infection in their Arteriovenous graft (AVG). The findings are: The facility policy titled Comprehensive Care Plan dated 3/2023 documented the goals will address the resident's medical needs. Resident #23 had diagnoses of end stage renal disease (ESRD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #23 was cognitively intact and received dialysis treatment. On 05/15/23 at 12:19 PM, Resident #23 was interviewed and stated the Nephrologist at dialysis informed Resident #23 their AVG had a bacterial infection and the resident was placed on ABT. Resident #23 stated the nursing staff in the facility should know the resident is receiving ABT because the Hemodialysis Nurse (HDN) calls the facility nursing staff to update them. The Medical Doctor Order (MD) last renewed 4/28/23 did not document Resident #23 was receiving ABT. The Interfacility Situation-Background-Assessment-Recommendation (SBAR) Communication form dated 5/9/23 documented a pre-dialysis assessment of Resident #23 completed by the facility nurse. The post-dialysis section was completed by the HDN and documented Resident #23 had a AVG bacterial infection and received Vancomycin 1 gm intravenous (IV) drip at 1:45 PM. The Interfacility SBAR Communication form dated 5/11/23 and 5/13/23 documented Resident #23 received Vancomycin 1 gm IV at dialysis. The CCP related to ESRD and dialysis treatment for Resident #23, initiated 11/22/21 and last updated 3/7/23, documented to report abnormal labs to the Medical Doctor (MD) and administer medications as ordered. The CCP related to ESRD and AVG, initiated 11/22/21 and last updated 3/7/23, documented Resident #23 had no bleeding or infection at the AVG site. Documented interventions included monitoring Resident #23's AVG site daily for signs of infection. There was no documented evidence a CCP related to AVG bacterial infection and ABT were developed and implemented for Resident #23 once ABT was administered to the resident in dialysis. On 05/16/23 at 11:02 AM, Registered Nurse (RN) #1 was interviewed and stated Resident #23 does not have an infection and is not receiving ABT. After reviewing the Interfacility SBAR Communication form, RN #1 stated they did not receive a call from the HDN re: Resident #23's ABT and will have to get more information from the HDN, inform the MD, and document in the progress notes. Resident #23 is at risk for experiencing side effects on ABT and a CCP related to infection and ABT use would be developed by the RN. The dialysis unit and RN #1 communicate via the SBAR form but the if there are any special endorsements, the HDN calls the RN in the facility. On 05/16/23 at 11:21 AM, the Nurse Practitioner (NP) was interviewed and stated they communicate with the dialysis center re: and changes to Resident #23's medication regime. If Resident #23 had an infection and was receiving IV ABT, the dialysis center would call and communicate this to the NP. The dialysis center has not informed the NP Resident #23 is receiving IV ABT in dialysis. The NP and nursing staff would document and update the Resident #23's chart if they were aware the resident was receiving ABT. On 05/16/23 at 11:52 AM, the Director of Dialysis (DOD) was interviewed and stated the SBAR form was implemented to improve the communication between the dialysis center and the facility staff. The Nephrologist assessed Resident #23's AVG and it showed signs of infection. The Nephrologist ordered ABT for Resident #23 and the medication is being administered via IV when Resident #23 goes to dialysis. The facility staff are responsible for reviewing the SBAR form when the resident returns to the facility from dialysis to see if there are any changes to the resident's condition or treatment. On 05/16/23 at 01:42 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated the nurse on the unit is supposed to check the SBAR form from dialysis. The HDN is supposed to call the RN in addition to documenting ABT use on the SBAR form. Then the RN should document the ABT and inform the MD. Staff need to monitor for adverse reactions to ABT and this would be included in a CCP to address infection. 415.11(c)(1)

Based on observations, record review, and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure that a resident participated in the review of their Comprehensive Care Plan (CCP, and a resident's CCP was not reviewed and revised upon each assessment. This was evident for 2 (Resident #112 and #23) of 35 total sampled residents. Specifically, 1) Resident #112 was not invited to attend CCP meetings to discuss their plan of care, and 2) Resident #23's CCP related to mood was not reviewed and revised upon each Minimum Data Set 3.0 (MDS) assessment. The findings are: The facility policy titled CCP dated 3/2023 documented the goals will address the resident's medical needs. 1) Resident #112 had diagnoses of Coronary Artery Disease (CAD) and end stage renal disease (ESRD). The MDS dated [DATE] documented that Resident #112 has intact cognitive status. On 05/10/23 at 10:08 AM, Resident #112 was interviewed and stated that they have been in the facility since 2021, and they have never been invited to any care plan meetings. Notice of Quarterly Meeting from 06/21/2021 to 04/17/23 did not document Resident #112 was invited to CCP meetings. Care Plan Meetings attendance dated 12/19/2022, 1/16/2023, and 4/17/2023 did not document Resident #112's attendance. There was no documented evidence Resident #112 was invited to their scheduled CCP meetings on 12/19/22, 1/16/23, and 4/7/23. On 05/11/23 at 11:20 AM, an interview was conducted with the Registered Nurse (RN) #1 who stated CCP meetings are held upon a resident's admission, quarterly and annually. Residents are invited to all the CCP meeting by the social services ahead of time. RN #1 does not recall seeing Resident #112 attend the CCP meetings. On 05/11/23 at 11:50 AM, the Director of Social Services (DSS) was interviewed and stated they send CCP invite letters to the families, and the recreation department helps with delivering the notices to the alert residents on the units. The DSS stated there was no documented evidence a CCP invitation was provided to Resident #112 and no documented evidence the resident attended CCP meetings. 40686 2) Resident #23 had diagnoses of schizophrenia and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #23 was cognitively intact, had little interest or pleasure in doing things and felt down and depressed. Resident #23 also received an antidepressant. On 05/15/23 at 12:19 PM, Resident #23 was interviewed and stated they receive Zoloft and Risperidone to treat their depression. Resident #23 also sees the psychiatrist. The Medical Doctor Order (MDO), last renewed 4/28/23, documented Resident #23 was ordered to receive Sertraline 150mg daily for depression and Risperidone 1 mg for paranoid schizophrenia. The psychiatry consult dated 5/6/23 documented Resident #23 has periods of agitation and needs help and support. The CCP related to mood stated initiated 11/11/21 documented Resident #23 was withdrawn, sad, tearful, sleepless, and restless. The CCP was last updated 2/17/22 with an evaluation that Resident #23 sees the psychiatrist and is cooperative with care. There was no documented evidence the CCP related to Resident #23's mood was reviewed and revised upon MDS assessments dated 10/29/22, 12/5/22, and 3/7/23. On 05/16/23 at 11:02 AM, Registered Nurse (RN) #1 was interviewed and stated Resident #23 has periods of agitation that have improved but the resident still randomly gets upset and irritated. The resident is seen by psychiatry and receives Risperdal and Zoloft. On 05/16/23 at 11:21 AM, the Nurse Practitioner was interviewed and stated Resident #23 was admitted to the facility on Zoloft and Risperdal, and they had a history of attempting suicide. Resident #23 is currently stable with no suicidal ideation. On 05/16/23 at 12:28 PM, the Director of Social Service (DSS) was interviewed and stated the social workers are responsible for initiating and updating the CCP related to mood. After reviewing Resident #23's CCP related to mood, the DSS stated the CCP should have been updated to include quarterly evaluations and MDS assessments. The social work department tries their best, but sometimes they miss something. They perform audits of their documentation. 415.11(c) (1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that required physician visits were conducted personally by the physician. This was evident but not limited to 3 of 30 Stage two sample residents. Specifically, Residents # 15, # 51 and #173 were not seen at required intervals. The findings are: 1) Resident #15 was admitted to the facility in 2013. The resident was last readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score documented on the 12/4/16 Minimum Data Set (MDS) Assessment was documented as 10 out of a possible score of 15, indicating Resident #15 had moderately impaired cognition. Physician Monthly Progress Notes were reviewed for 2016/2017. The resident was not seen by the attending physician in 2017 and was seen twice by the physician in 2016, on 7/20/16 and 7/21/16. All Monthly physician progress notes [REDACTED]. 2) Resident # 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The BIMS score documented on the 12/4/16 MDS assessment was documented as 3 out of a possible score of 15, indicating Resident #51 had significantly impaired cognition. Physician Monthly Progress Notes were reviewed for 2016/2017. The resident was not seen by the attending physician in 2017 and was seen six times in 2016 by the physician on the following dates: 4/7/16, 4/8/16, 7/1/16, 7/18/16, 8/25/16 and 10/1816. All Monthly physician progress notes [REDACTED]. 3) Resident #173 was admitted on [DATE] with [DIAGNOSES REDACTED]. The BIMS score documented on the 12/27/16 MDS Assessment documented that the resident had both short and long term memory impairment as well as severely impaired decision making ability. Physician Monthly Progress Notes were reviewed for 2016/2017. The resident was not seen by the attending physician in 2017 and seen three times by the physician in 2016 on the following dates: 7/18/16, 12/12/16 and 12/21/16. All monthly physician progress notes [REDACTED]. The Director of Nursing was interviewed on 1/27/17 at 11:30 AM. She stated that residents followed by the NP are seen initially by the Physician, but then are followed the NP for monthly and as needed evaluations. The Assistant Director of Nursing was interviewed on 1/27/17 at 12:00 PM. She stated that Residents # 15, # 51 and # 173 were seen only by the NP who works under the attending physician's supervision. The attending physician only sees the patients for the initial admission and readmission assessments. The Senior Medical Director for the medical group that supplies the facility with two physicians and one nurse practitioner was interviewed on 1/30/17 at 12:13 PM. He stated that he was aware that the MD should see the residents at a minimum of every 60 days and may alternate visits with the NP. He said that he was unaware that this policy was not being followed. He further stated that the NP reports to and consults with the attending physician and is supervised by the attending physician. Physician #1 of 2 was interviewed on 1/30/17 at 12:20 PM. Physician #1 is the Physician for Resident #15, #51 and #173. The physician stated that she only became aware of the required frequency of physician visits on Friday, 1/27/17. The physician further stated that she only sees the residents at admission and readmission or when requested from the NP. Physician #2 of 2 was interviewed on 1/30/17 at 1:20 PM. The physician stated that he does not see residents at scheduled intervals and only covers when Physician #1 is away. The physician stated that he was not aware of any requirement relating to frequency of physician visits. The NP was interviewed on 1/31/17 at 10:52 AM. She stated that she was unaware of any need to alternate visits with the physician. She stated that she follows the residents herself and only refers to the physician when necessary or on readmission. She stated that she does not work under the supervision of the physician but will consult when necessary. The Physician Services Policy and Procedure, dated 8/16/2007, was reviewed. It documented under procedure item #4, The physician will see the resident at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. No provision for the NP was documented in the policy and procedure. 415.15 (b)(4)(I)(ii)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that required physician visits were coordinated under the Medical Director's supervision. This was evident but not limited to 3 of 30 Stage two sample residents. Specifically, the Medical Director was unaware that residents were not seen at required intervals by the physician. This was identified for, but not limited to, Resident #15, #51 and #173. The findings are: 1) Resident #15 was admitted to the facility in 2013. The resident was last readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score documented on the 12/4/16 Minimum Data Set (MDS) Assessment was documented as 10 out of a possible score of 15, indicating Resident #15 had moderately impaired cognition. Physician Monthly Progress Notes were reviewed for 2016/2017. The resident was not seen by the attending physician in 2017 and seen twice by the physician in 2016, on 7/20/16 and 7/21/16. All Monthly physician progress notes [REDACTED]. 2) Resident # 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The BIMS score documented on the 12/4/16 MDS was documented as 3 out of a possible score of 15, indicating Resident #51 had significantly impaired cognition. Physician Monthly Progress Notes were reviewed for 2016/2017. The resident was not seen by the attending physician in 2017 and was seen by the physician six times in 2016 on the following dates: 4/7/16, 4/8/16, 7/1/16, 7/18/16, 8/25/16 and 10/1816. All Monthly physician progress notes [REDACTED]. 3) Resident #173 was admitted on [DATE] with [DIAGNOSES REDACTED]. The BIMS score documented on the 12/27/16 MDS that the resident had both short and long term memory impairment as well as severely impaired decision making ability. Physician Monthly Progress Notes were reviewed for 2016/2017. The resident was not seen by the attending physician in 2017 and seen by the physician three times in 2016 on the following dates: 7/18/16, 12/12/16 and 12/21/16. All Monthly physician progress notes [REDACTED]. The Director of Nursing was interviewed on 1/27/17 at 11:30 AM. She stated that residents followed by the NP are seen initially by the Physician, but then are followed the NP for monthly and as needed evaluations. Physician #1 of 2 was interviewed on 1/30/17 at 12:20 PM. Physician #1 is the Physician for resident #15, #51 and #173. The physician stated that she only became aware of the required frequency of physician visits on Friday, 1/27/17. The physician further stated that she only sees the patients at admission and readmission or when requested from the NP. Physician #2 of 2 was interviewed on 1/30/17 at 1:20 PM. The physician stated that he does not see patients at scheduled intervals and only covers when physician #1 is away. The physician stated that he was not aware of any requirement relating to frequency of physicians visits. The Medical Director was interviewed on 1/30/17 at 1:35 PM. He stated that he was aware that face to face physician visits are required every 60 days and that the NP may alternate visits with the physician. He stated that he does not supervise the NP, but that the NP is supervised by the Senior Medical Director of the Agency that provides the physicians and the NP. He stated that Physicians # 1 & 2 are staff of the agency and are expected to know to see the patients at the required intervals. He stated that he interacts with the NPs and Physicians quarterly at board meetings. He further stated that he was unaware that the required visitation schedule was not being followed. The Physician Services Policy and Procedure, dated 8/16/2007, was reviewed. It documented under procedure item #4, The physician will see the resident at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. No provision for the NP was documented in the policy and procedure. An undated copy of the Medical Director Job Description was reviewed. It documented under Position Description, Provides leadership and direction for Cliffside Rehabilitation and Residential Health Care Center staff while being responsible for the overall management of the medical department. Ensures medical staff's compliance with all facility and medical policies and procedures as well as compliance with regulatory requirements. 415.15(a)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that the Comprehensive Care Plan (CCP) for residents with indwelling catheters was reviewed and revised to address the resident's needs for 1 of 3 residents reviewed for Pressure Ulcers and for 1 of 3 residents reviewed for hospitalization from a total Stage 2 sample of 30 residents. Specifically, 1) Resident #161 had a Foley catheter; however, the size of the catheter and the balloon volume was not specified in the physician's orders [REDACTED].#11 was readmitted to the facility with a Foley catheter and there was no documentation in the physician's orders [REDACTED]. The findings are: 1) Resident #161 has [DIAGNOSES REDACTED]. The 11/10/2016 Annual Minimum Data Set (MDS) Assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had an indwelling catheter. A physician's orders [REDACTED]. There was no catheter size, balloon volume, or [DIAGNOSES REDACTED]. A Comprehensive Care Plan (CCP) for Indwelling Catheter, dated 11/21/2016, documented an intervention to change the Foley catheter every two weeks and when needed. There was no catheter size or balloon volume documented in the CCP. Review of the Treatment Administration Record (TAR) for January 2017 revealed that the resident's Foley catheter was changed on 1/8/2017 and 1/22/2017. There was no Foley catheter size documented in the TAR. Review of nursing notes dated 1/8/2017 and 1/22/2017 revealed no documentation regarding the size of the Foley catheter that was inserted. On 1/27/2017 at 12:37 PM the Registered Nurse (RN) Unit Supervisor was interviewed. She stated that Resident # 161 has a size 18 French Foley catheter. She stated the 18 French was the size catheter that the resident was admitted with. She added that the catheter size is documented in the admission nursing assessment and on the catheter itself. On 01/27/2017 at 2:04 PM the Assistant Director of Nursing (ADNS) was interviewed. She stated it is not the facility's policy for the doctor to specify the Foley catheter size, and that the size was in the admission paperwork. She stated that a float nurse not familiar with the resident would have to look at the admission paperwork to find out what the Foley catheter size was. On 1/31/2017 at 8:58 AM the RN Unit Supervisor was re-interviewed. She stated that the Foley catheter insertions on 1/8/2017 and 1/22/2017 were routine and the size was not necessary to be documented. On 1/31/2017 at 9:51 AM the ADNS was re-interviewed. She stated if the Foley catheter change is routine per the physician's orders [REDACTED]. The size would only be documented if it was an as needed (PRN) change. On 1/31/2017 at 10:40 AM the Director of Nursing Services was interviewed. She stated the size of the catheter and the balloon volume should be in the order and in the care plan as per the facility's policy. The facility's Policy and Procedure on Catheter-Foley-Insertion, dated August 2015, states under the heading Equipment: Sterile Foley catheter tray (catheter size specified by physician) and Chart on nursing record pertinent observations, i.e., date and time of catheter insertion, catheter size, and amount of urine withdrawn. 2) Resident #11 had [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with a Foley catheter for wound care. The readmission nursing progress note dated 11/18/2016 documented that Resident #11 was readmitted to the facility with a size 16 French Foley catheter draining clear amber urine. Review of the Physician orders [REDACTED]. Additionally, there was no documentation of the volume (amount of fluid used to fill the balloon which maintains the Foley in place). The Readmission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #11 had a Foley catheter on readmission to the facility. The Comprehensive Care Plan (CCP) dated 11/21/2016 titled Indwelling Catheter was not updated to include the size of the Foley catheter in place or the size to be used for replacement. There was no documentation on the CCP of the volume needed to fill the catheter balloon. The Treatment Administration Record (TAR) dated November 2016 did not document the size of the Foley catheter to be used on replacement or the volume of fluid needed to fill the catheter balloon. The Physician Bladder assessment dated [DATE] documented under Bladder Function Assessment Incontinent. The Assessment did not document that Resident #11 had a Foley catheter. An interview was conducted with the resident's covering Physician on 01/31/2017 at 10:00 AM. The Physician stated that she completes the bladder assessment for all admissions and readmissions to the facility and that she could not explain why she had not indicated on Resident #11's readmission on 11/18/16 that the resident was readmitted with a Foley catheter. The Physician further stated that she had not documented the size of the catheter or the volume to be used to fill the balloon on the readmission Physician order [REDACTED]. On 01/31/2017 at 11:30 AM an interview was conducted with the Registered Nurse (RN) Nursing Supervisor who had readmitted Resident #11 to the facility on [DATE]. The RN had developed the CCP for Indwelling Catheter on readmission. The RN stated that she must have over looked placing the size of the Foley catheter and the volume of fluid to be used to fill the balloon to keep the Foley in place. The RN stated that she normally would have included that information on the CCP. 415.11(c)(2)(i-iii)

Based on record review and staff interviews during the recertification survey the facility did not ensure that a Comprehensive Care Plan (CCP) was periodically reviewed and revised to address the specific needs of 1 of 1 resident reviewed for Ventilator services in a stage two sample of twenty five residents. Specifically, Resident #168 is a ventilator-dependent resident with a [MEDICAL CONDITION]; however, the CCP for Respiratory Therapy Ventilator was not updated to address the current size and description of the [MEDICAL CONDITION] in use. Additionally, there were no physician's order for the specific size of the [MEDICAL CONDITION] in use. The finding is: Resident #168 was originally admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The 11/12/2015 Quarterly Minimum Data Set (MDS) assessment documented that Resident #168 was in a persistent vegetative state (Section B0100) and required total assistance for activities of daily living. On 12/31/2015 at 11:30 AM Resident #168 was observed in bed receiving ventilation support. The resident's eyes were open and the resident was in no distress. The resident was observed responding to tactile stimulation from the Respiratory Therapist (RT). A CCP for Respiratory Therapy Ventilator, created 10/5/2011 and updated 11/6/2015, included an intervention for the [MEDICAL CONDITION], which was documented as [MEDICATION NAME] Size [MEDICAL CONDITION]. A review of the Physician's orders on 12/31/2015 for Resident #168 showed no documentation regarding the size and type of [MEDICAL CONDITION] being utilized. On 12/31/2015 at 1:30 PM the RT caring for Resident #168 was interviewed regarding where it documents the size and type of [MEDICAL CONDITION] to be used for the resident. The RT showed the spare emergency [MEDICAL CONDITION] at Resident #168's bedside, which was a Shiley size 8.0 XLT. On 12/31/2015 at 1:50 PM the Registered Nurse (RN) Ventilator Unit Supervisor was interviewed regarding where it states what size and type [MEDICAL CONDITION] is to be used for Resident #168. She was unaware of where the Trachestomy tube size was documented. On 12/31/2015 at 2:00 PM the RT Director on the Ventilator Unit was interviewed regarding where it documents what size and type of [MEDICAL CONDITION] is to be used for Resident #168. He said that the size and type of the [MEDICAL CONDITION] is documented by RT in progress notes. A RT progress note, dated 6/22/2015, documented that Resident #168 was transferred to the hospital to change [MEDICAL CONDITION] 9 [MEDICATION NAME] due to leaking cuff. A review of RT progress notes for Resident #168, following 6/22/2015, documented size [MEDICATION NAME] tube. On 1/4/2016 at 9:15 AM the RT caring for Resident #168 was interviewed regarding the CCP for Respiratory Therapy Ventilator. The RT stated that the resident now has a size [MEDICATION NAME] tube, and that the [MEDICATION NAME] mentioned in the CCP was no longer used. She stated that during a hospitalization the [MEDICAL CONDITION] was changed to [MEDICATION NAME] the [MEDICATION NAME] because the resident was having difficulty ventilating and now the resident is much more comfortable. On 1/4/2016 at 9:30 AM the RT Director was interviewed regarding the CCP for Respiratory Therapy Ventilator for Resident #168. He stated the [MEDICATION NAME] was the former [MEDICAL CONDITION], and it was changed to the 8.0 XLT. He added that the current care plan was incorrect. On 1/4/2016 at 11:00 AM the Director of Nursing Services (DNS) was interviewed. She stated that she did not see the size and type of the [MEDICAL CONDITION] in the Physician's orders. She referred to a document in Resident #168's chart titled Ventilator/Respiratory Care MD Order, dated 11/9/2015, which documents the physician's orders for Ventilator and Respiratory care. The DNS said the size and type of the [MEDICAL CONDITION] should be included in this order and that it was not. She stated that she advised the RT Director that going forward the size and type of the [MEDICAL CONDITION] has to be included in the Ventilator/Respiratory Care MD Order form. On 1/4/2016 at 12:45 PM Resident #168's Attending Physician was interviewed. He stated that the size and type of the [MEDICAL CONDITION] should be in the order. 415.11(c)(2)(i-iii)

Based on observations, record reviews and staff interviews during the recertification survey, the facility did not ensure that resident assessments accurately reflected a resident's medical status. This was identified for 1 of 2 residents reviewed for pressure ulcers from a total of 18 Stage 2 sampled residents (Resident #241). This resulted in no actual harm, with the potential for more than minimal harm, that is not immediate jeopardy. The finding is: Resident #241 has [DIAGNOSES REDACTED]. The Minimum Data Set assessments dated 1/25/14, 4/19/14, 8/5/14 and 11/5/14 documented the resident's BIMS (Brief Interview for Mental Status Score) as 15, indicating that the resident was cognitively intact. Each MDS noted above identified the presence of one, Stage 3 pressure ulcer. None of the referenced MDSs identified the presence of a diabetic ulcer or of a Stage 4 ulcer. The resident was hospitalized in July 2014 for left heel [DIAGNOSES REDACTED], status [REDACTED]. The visiting wound care specialist documentation was reviewed for the period of 1/7/14 to 8/5/14. The documentation described an unstageable pressure sore which was present from the hospital on the left heel. The site was debrided via surgical excision on 1/7/14. Subsequent visiting wound care specialist consults document the left heel wound site as Stage 3 from 1/14/14-1/28/14, as unstageable from 2/4/14-2/25/14 and as a Stage 3 from 3/4/14-8/5/14. On 8/6/14, the resident was seen by a surgical consultant from the hospital where the July debridement was performed. The consult documentation identified the wound as a diabetic wound of the left heel. The same description of the wound site was identified in subsequent surgical consults on 8/13/14, 8/20/14, 8/28/14, 9/10/14, 9/24/14, 10/8/14, 10/29/14 and 11/26/14. A pressure ulcer care plan initiated on 6/18/14 identified a Stage 4 site and a left heel DM ulcer with no indication of when the site was identified as a diabetic wound. Current physician orders [REDACTED]. The orders documented [MEDICATION NAME]-AG [MEDICATION NAME] External Pad once a day to be applied to the left heel after cleansing with normal saline and covering with a dry dressing. The medical condition identified for this order was documented as a " pressure ulcer, heel. " The physician monthly assessments and physician notes for the period of 1/28/14 through 11/19/14 were reviewed. No staging of the left heel wound site or identification of a diabetic wound was documented by the physician. On 12/4/14 at 9:20 AM, the wound site was observed. On 12/4/14, at 10:30 AM, the MDS coordinator was interviewed. The MDS(s) and consultant evaluation sheets were reviewed. The MDS Coordinator stated that she completes the pressure ulcer section of the MDS and that she reads all of the documentation in the record prior to completing the MDS. She stated that she read the documentation in the record but may not have read it thoroughly resulting in incorrect information documented in the MDS. On 12/4/14, at approximately 11:45 AM, the attending physician was interviewed. He stated that he sees the wound personally at every monthly visit, but admitted that he does not generally identify the Stage, size or the precise type of wound but rather a general description. On 12/4/14, at approximately 10:00 AM, the nursing supervisor was interviewed. The pressure sore care plan was reviewed. She stated that the facility does not maintain a tracking system for pressure ulcers followed by outside consultants. She stated that the consultant classification and sizing is what is used for monitoring by the facility. In reviewing the consultation sheets she identified that the changes to classification were not identified in the care plan and should have been. 415.11(a)(2)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that a comprehensive assessment was completed for a resident who had a significant change in behavior. This was evident for 1 of 2 residents reviewed for Emotional and Behavior Status from a total of 19 Stage 2 sampled residents. Specifically, Resident # 116 had documented Psychosocial changes as a result of new behaviors, diagnosis, medications and initiation of restraints without the determination that there had been a significant change in the resident's condition. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #116 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognition. There were no behavior problems, no Psychiatric [DIAGNOSES REDACTED]. The resident was totally dependent on staff for all activities of daily living. The Physician ordered a full lap tray on 7/2/14 (tray placed on the wheelchair that prevents the resident from rising) for restlessness. A Psychiatric Consultation dated 7/25/14 documented that the resident was disoriented with an unstable mood. The Psychiatrist recommended to begin [MEDICATION NAME] (an antipsychotic medication) 50 milligrams (mg) at Hour of Sleep (HS) for a [DIAGNOSES REDACTED]. On 8/4/14 a follow up Psychiatric Consultation documented that the resident was to have an increase in [MEDICATION NAME] to 25 mg in the morning and continue 50 mg HS. The new [DIAGNOSES REDACTED]. There was no documented evidence in the Medical Record that the decline in the resident's behavior and emotional status, the addition of the psychoactive medication, and a new [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented that the resident had exhibited Physical Behavior to Others. The MDS documented that the resident had a new [DIAGNOSES REDACTED]. In addition, the MDS documented that the the resident was utilizing a restraint daily. The resident was observed on 12/14/14 at 10:15 AM. The resident was positioned in the wheelchair with a full lap tray. The resident was calm. The resident was unable to respond to simple communication attempts. The resident's Social Worker (SW) was interviewed on 12/4/14 at 12:17 PM. The SW stated that there was no formal meeting with the team regarding the resident's changes in behavior. The MDS Coordinator/Registered Nurse (RN) was interviewed on 12/4/14 at 12:40 PM. The RN stated that a Significant Change Assessment should have been discussed for this resident. 415.11(a)(3)(ii)

Based on observation, record review and staff and resident interviews during the recertification survey, the facility did not ensure that resident's displaying mental or psychosocial adjustment difficulties received appropriate treatment and services to address their needs. This was evident for two of two residents reviewed for Behavior and Emotional Status in a total of 19 Stage 2 sampled residents. Specifically, 1) Resident #230 was admitted to the facility without a psychiatric [DIAGNOSES REDACTED]. The resident was not evaluated for alternative treatment approaches prior to being placed on [MEDICAL CONDITION] medication and the institution of restraint devices. 2) Resident #116 was administered psychoactive medications and positioned in restraints for non-compliance and restless behavior. There was no documented evidence that alternative treatment approaches were initiated or evaluated to meet the resident's psychosocial needs. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident # 230, was admitted to the facility on [DATE], from the community for short term rehabilitation due to a fractured ankle. The resident had [DIAGNOSES REDACTED]. The Social Service initial assessment dated [DATE] documented that prior to admission the resident was living at home with family, attended a special program for Persons with Developmental Disabilities five days a week, and was planning to return to those prior living arrangements. There were no documented behavior or emotional issues. The family reported to the Social Worker that the resident is oriented to person and was able to say some sentences including, "Where is my mom, how are you." The family reported that the resident generally smiles, laughs, nods, or makes sounds to communicate. The family reported that the resident was able to ambulate independently at home. The family also stated that the resident enjoys tearing up newspapers as a past time at home. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #230 had unclear speech, could rarely be understood and could rarely understand. The resident had short and long term memory problems and had severely impaired skills for decision making. The MDS documented that the resident had behavioral symptoms directed at self and that the resident rejected care 4-6 days a week. The resident interview for daily preferences documented that it was important for the resident to have snacks, choose her own bedtime, and have her family involved in her care. The MDS documented that it was important for the resident to listen to music, participate in her favorite activities, go out into fresh air and to participate in religious services. The MDS documented that Resident #230 was totally dependant on 1-2 staff for all activities of daily living. The resident was using a wheel chair for mobility. The resident was receiving pain medication. The MDS documented that active discharge planning was occurring for the resident to return to the community. Resident #230 was observed over three days of the survey at various times. Observations on 12/02/14 at 9:30 AM included the resident seated in the middle of the bed with diaper shreddings in the bed and on the floor, all four side rails were observed up and the pads from the side rails were observed on the floor. The resident was actively moving around in bed. On 12/02/14 between 1:30 through 2:15 PM Resident #230 was observed in a high back chair with a table top attached. The resident was constantly moving, speaking to herself and intermittently banging her hands on the table. The resident yelled out at times. When spoken to, the resident did not make eye contact but was heard to repeat sentences spoken to her. The resident was positioned near the nurse's station. There were no tabletop activities provided for the resident. At approximately 2:20 PM a Certified Nursing Assistant (CNA) stated she was taking the resident to see her mother who was a resident on the 1st floor of the nursing home. On 12/03/14 at 10:00 AM Resident #230 was observed in bed with her body turned so that her head was at the foot of the bed. The resident was continually moving her arms and legs, speaking and would intermittently yell. When spoken to the resident did not make eye contact but again was heard to repeat parts of the sentences spoken to her. The four side rails were observed in the up position and the padding from the left upper side rail was observed on the floor, there was also diaper shreddings observed on the floor and in the resident's bed. On 12/03/14 at 2:15 PM the resident was observed seated in a high back chair with a table top attached. The resident was positioned by the nursing station and was heard speaking to herself, intermittently yelling out, banging her hands on the table top and rocking back and forth in the chair against the table top. No activities were provided for the resident. At approximately 2:40 PM a CNA wheeled the resident from the nursing station. On 12/04/14 at 8:45 AM Resident #230 was observed in bed with diaper shredding all over the bed and on the floor. The resident was moving around in the bed, talking and again when spoken to could be heard repeating part of the sentences spoken to her. At 12:45 PM the resident was observed to be in bed with the entire diaper shredded. The shreddings were observed on the floor and in the bed, the resident remained in a patient gown, had removed her CAM (protective ) boot and was rocking in bed. The CNA caring for the resident entered the room and stated that she had changed the resident and applied a clean diaper at 11:00 AM. The CNA stated that she had been instructed to wait until after lunch to get the resident out of bed. The CNA stated that the resident had removed the sheets, rail pads and the cam boot and had shredded her diaper. The CNA stated that she had fed the resident breakfast with no difficulty and that when she changed her she was cooperative. A review of the nursing progress notes dated 10/23/14 through 12/03/2014 was completed, examples included but were not limited to: 11/11/14 3-11 PM: bangs hand on lap buddy, restless at times, pulling away at lap buddy, threw it on floor. 11/12/14 at 3:23 PM: resident agitated last night and today when OOB (out of bed) she was making loud noises. Dr. ordered a psychiatric consult. 11/13/14 2:04 PM: Behavior this tour:restless, irritable and often agitated with moments of screaming, hitting her chair and slapping her body parts...remains at nurse's station for the remainder of the tour. 11/17/14 2:43 AM: sleeps for long intervals during the night. When awake becomes restless but is not aggressive. 11/22/14 at 2:53 AM: Removes right CAM boot at night and became restless if when staff tries to reapply. The nursing progress notes did not document alternate interventions to attempt to redirect the resident's behaviors other then, performing routine nursing care, moving from bed to chair to bed and placing resident near nursing station, prior to receiving orders from the physician to administer [MEDICATION NAME] (an antipsychotic medication). A physician's orders [REDACTED]. The physician progress notes [REDACTED]. Start [MEDICATION NAME] 25 mg HS, [MEDICATION NAME] 2 tabs q (every) 6 hours prn (as needed) for pain.' Physician order [REDACTED]. An initial Psychiatric Evaluation dated 11/24/14 documented that the resident does not communicate, and recommended to continue [MEDICATION NAME] 25 mg daily. Review of the Social Work Progress Note dated 11/24/2014 documented: "She was agitated and did not respond to interventions; [MEDICAL CONDITION] medication was added which has helped her. She will be monitored and guided by staff." The Comprehensive Care Plan dated 10/22/14 titled Psychosocial Well-Being documented interventions which included but were not limited to: encourage family support; monitor for changes in mood, affect, behavior; one to one visits; provide education; and psych consult. There was no documentation that the interventions were reviewed for effectiveness and there are no new interventions documented. The Comprehensive Care Plan dated 10/22/14 titled Mood State documented interventions which included but were not limited to: anticipate needs and provide assistance; monitor change in behavior; monitor change in cognition and mood; provide calm environment; provide opportunity to express self; provide support systems-social service visits; and redirect when confused. There was no documentation that the interventions were reviewed for effectiveness and there are no new interventions documented. The Comprehensive Care Plan dated 10/23/14 titled Therapeutic Activity documented interventions which included but were not limited to: include in religious services; provide 1:1 visits; provide monthly calendar; provide escort to patio if weather is nice; provide opportunities to attend favorite activities; provide sensory stimulation; provide snoezelon room visits or snoezelon at bedside (a multi-sensory room and or equipment to engage the resident cognitively) and stimulate senses to help provoke memories and positive emotions. There was no documentation that the interventions were reviewed for effectiveness and there are no new interventions documented. An interview was held with the Registered Nurse (RN) unit supervisor on 12/04/14 at 12 PM. The RN stated that there had not been a meeting with the team to discuss interventions to address Resident #230's behavior and adjustment to the facility. The RN stated that the side rails and lap tray were being used to keep the resident safe. The RN stated that no revisions had been made to the resident's plan of care prior to the addition of table top for restraint and [MEDICATION NAME] for behaviors. The Social Worker currently assigned to Resident #230 was interviewed on 12/04/14 at 12:55 AM and stated that she was not to familiar with the resident since she was transferred to the unit from the first floor. The Social Worker that worked with the resident on the first floor was interviewed on 12/4/14 at 1:10 PM. The Social Worker stated that when the resident was first admitted she was placed in a room with her mother. The placement did not work out well because the mother and the daughter were both attempting to help each other, attempting to get out of bed. The resident was then moved onto the 5th floor. The Social Worker stated that there had not been and interdisciplinary team meeting for the resident, but that she had met with the resident's brother. The Social Worker stated that the family were making adjustments at home to bring the resident home. The Social Worker stated that the brother stated that the resident enjoys ripping up papers at home. The Recreation Assistant that was assigned to Resident #230, along with the Director of Recreation were interviewed on 12/04/14 at 1:15 PM. The recreation staff stated that she had met with resident for 1:1 visits and had brought her to the snoezelon room. The recreation staff stated that she had brought a ball to the resident yesterday and that she threw it to her and she seemed to like it for a few minutes. The recreation staff stated there had not been an IDT meeting to discuss the resident. She also stated that she had not attempted to try a sensory box. Resident #230's Primary Care Physician was interviewed on 12/4/14 at 1:30 PM. The physician stated that the staff had tried multiple interventions prior to placing the resident on [MEDICATION NAME]. The physician stated that he did not want to have to place the resident on the medication but when he did it was due to aggressive behavior. There was no documented evidence in the medical record of a review and assessment by the Interdisciplinary Team regarding the use of Antipsychotic medications or of alternative measures that could be attempted to delay the use of the antipsychotic drugs for Resident #230. 2) Resident #116 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident understands only Spanish and requires and interpreter. The MDS assessment dated [DATE] documented that the resident had severely impaired cognition. The Mood Score was 6, indicating mild depression. There were no signs and symptoms of [MEDICAL CONDITION] and no behavior symptoms documented. The MDS documented that the resident was totally dependant on staff in all activities of daily living. The MDS also documented that the resident was not receiving any Psychoactive Medications. The physician ordered a full lap tray on 7/02/14 (tray placed on the wheelchair that prevents the resident from rising up) for restless behaviors. A Psychiatric Consultation dated 7/25/14 documented that the resident was disoriented with an unstable mood. The recommendation documented to begin [MEDICATION NAME] (an antipsychotic medication) 50 milligrams (mg) at Hour of Sleep (HS) with a [DIAGNOSES REDACTED]. The Care Plan (CCP) for [MEDICAL CONDITION] Drug Use was developed 7/25/14. The interventions for the behaviors lacked [DIAGNOSES REDACTED]. On 8/4/14 the Psychiatric follow up Consultation documented that the resident was to have an increase in the [MEDICATION NAME] to 25 mg in the morning and continue the 50 mg HS. The Psychiatrist documented that [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented that the resident was exhibiting physical behaviors to others, as well as, other behavioral symptoms not directed toward others for up to three days during the assessment period. The were no signs and symptoms of [MEDICAL CONDITION] and no potential indicators of [MEDICAL CONDITION] documented on the MDS. The MDS also documented that the resident was receiving Antipsychotic medication daily. In addition, the MDS documented [MEDICAL CONDITION] as a new diagnosis. A review of the Nurses Notes (N/N) from 9/30/14 through 11/5/14 documented that the resident remained confused and disoriented. The N/N documented that the resident was maintained in the wheelchair with a full lap tray and two full side rails in bed with bumper guards. The N/N also documented that the resident remained restless in bed and combative and was receiving antipsychotic medications. There was no documented evidence that alternative treatment approaches were considered by the Interdisciplinary Team (IDT) for the increasing behaviors. The resident was examined by the Psychiatrist on 11/3/14. The Psychiatrist documented that the resident remained resistive to care despite the administration of [MEDICATION NAME] (an antipsychotic) and does not participate in activities. The Psychiatrist documented that the resident had a [DIAGNOSES REDACTED]. The Social Worker documented that the resident was seen by the Psychiatrist on 12/01/14 and had a [DIAGNOSES REDACTED]. The Registered Nurse/(RN) Supervisor of the resident's unit was interviewed on 12/04/14 at 10:00 AM. The RN stated that the CCP should be updated when the resident has changes in behavior and when the resident is seen by the Psychiatrist. An interview with the resident with a Spanish interpreter (Certified Nursing Assistant-CNA) was attempted on 12/04/14 at 10:15 AM. The resident was unable to respond to simple questions. The resident was positioned in the wheelchair with a full lap tray. The CNA stated during an interview at that time that the resident remains restless. The CNA stated that the resident's speech is not easy to understand. The CNA stated that there has been small amount of improvement in the resident's behaviors with the medication, however, the resident interacts the best when the resident's family visits. The resident's Social Worker (SW) was interviewed on 12/04/14 at 12:17 PM. The SW stated that there was no formal meeting with the team regarding the resident's changes in behavior. The SW stated that the plan of care for the resident's behavior is documented by nursing and reviewed during care plan meetings. Th Psychiatrist was not available for interview during the survey. The resident's attending Physician/Medical Doctor (MD) was interviewed on 12/04/14 at 12:30 PM. The MD stated that he looks to the Psychiatrist is the area of behaviors and the use of Psychoactive Medications. The MD stated that the team discusses the residents' behaviors as needed. 415.12(f)(1)

Based on record review and staff interview during the recertification survey, the facility did not ensure that a gradual dose reduction (GDR) of an antipsychotic medication was attempted for one of five residents reviewed for Unnecessary Medications in a total sample of nineteen Stage 2 residents. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #143) The finding is: Resident #143 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident was understood and could understand and had a Brief Interview for Mental Status (BIMS) score of 14 which indicated that the resident was cognitively intact. The physician's orders [REDACTED]. The [MEDICAL CONDITION] Drug Use Comprehensive Care Plan (CCP) dated 11/26/12 revealed as one of the goals that attempts would be made to taper the medication every 90 days. The 2nd Floor Registered Nurse (RN) Supervisor was interviewed on 12/04/14 at 11:25 AM and stated that the resident was receiving [MEDICATION NAME] due to his hallucinations, although it was quite a while since he had one. The RN stated that it would be up to the CCP Team to ensure that a dose reduction of the resident's antipsychotic medication be attempted. The RN also stated that the CCP Team was usually herself, the Social Worker, and the resident's Primary Physician. The resident's Primary Physician was interviewed on 12/04/14 and stated that with complicated cases, such as with hallucinations, he would lean towards the guidance of the resident's Psychiatrist of when to taper a resident's antipsychotic medication. The resident's Psychiatrist was unavailable for interview. 415.12(l)(1)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that each resident received the necessary care and services to maintain the highest practicable physical well-being. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, the nurses observed that Resident #1's stump from an above the knee amputation was draining pus and blood and later had a foul-smelling odor. The facility did not timely address the change in the condition of the resident's stump for 5 days. Subsequently on the sixth day, the resident was transferred to the hospital for an infected stump and underwent a left hip disarticulation (amputation of the lower extremity through the hip joint) secondary to [MEDICAL CONDITION]. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 624 Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 7/24/2014 identified that the resident's cognitive skills for daily decision making were intact with the Brief Interview for Mental Status (BIMS) score of 13 out of 15. The Hospital Patient Review Instrument (PRI) dated 7/16/2014 documented that Resident #1 had a left AKA on 6/30/2014. The Hospital Discharge Summary dated 7/17/2014 documented that the resident was advised to see his vascular surgeon for a follow-up evaluation in one week after the discharge from the hospital. The nurse's admission note dated 7/17/2014 documented that the resident had a left AKA stump with 40 staples. The note documented that the stump was intact with no signs or symptoms of infection. The Care Plan for left AKA dated 7/17/2014 documented that the goal was having no infection on the surgical site. The facility's interventions included administering treatment to the stump, monitoring the response to the treatment, and monitoring for signs or symptoms of infection. The Medical Doctor (MD)'s order dated 7/17/2014 instructed to clean the left stump with normal saline, then apply [MEDICATION NAME] with Zinc ointment and cover with gauze once daily. The Treatment Administration Record (TAR) for July 2014 documented that Resident #1's left stump was treated as ordered by the MD. The MD's communication book revealed that on 7/23/2014 a nurse documented that Resident #1's left stump was draining pus and blood. The MD documented his initial on the nurse's note. The facility's clinic appointment transportation form dated 7/24/2014 documented that Resident's vascular clinic appointment for the left stump was scheduled for 7/29/2014. A nurse's progress note dated 7/25/2014 documented that Resident #1's left stump was draining with a foul smelling odor. A nurse's progress note dated 7/26/2014 documented that Resident #1's stump had a "large amount of drainage." The MD's communication book revealed that on 7/27/2014 a nurse requested the MD to check the resident's stump. The nurse documented "When he (Resident #1) was admitted it (stump) was clean and dry, now it's draining and the flesh looks raw." The MD documented his initial on the nurse's note. The 24-hour report dated 7/27/2014 during the 7:30AM to 3:30PM shift documented that Resident #1's stump was "still draining purulent content" and that during the 11:30PM to 7:30AM shift the stump was draining pus and blood. The MD's orders from 7/23/2014 to 7/27/2014 had no new orders related to Resident #1's stump. The MD's progress notes from 7/23/2014 to 7/27/2014 had no documentation related to Resident #1's stump. The 24-hour report dated 7/28/2014 during the 7:30AM to 3:30PM shift documented that Resident #1 refused to eat and that his stump had "purulent thick drainage" with a foul odor. A nurse's progress note dated 7/28/2014 documented that the resident's stump appeared to be infected. The note also documented that at 12:30PM the resident's blood sugar was 37 mg/dL (less than 70 mg/dL = low blood sugar). The MD ordered to administer [MEDICATION NAME] injection 1 mg. The MD's progress note dated 7/28/2014 documented that Resident #1 was observed with [DIAGNOSES REDACTED] and [MEDICAL CONDITION] with "possible stump infection." The MD ordered to transfer the resident to the hospital. The hospital emergency room report dated 7/28/2014 documented that Resident #1 arrived at the emergency room with an infected stump and [MEDICAL CONDITION]. The resident was "taken urgently to the operating room by vascular surgery for [REDACTED]." The emergency room report further documented that the stump was "grossly infected with purulent drainage," requiring a consult for a possible left hip disarticulation surgery. The hospital vascular surgeon's note dated 8/15/2014 documented that Resident #1 had a left hip disarticulation surgery for [REDACTED]. On 8/2/2014 at 1:30PM an interview was conducted with RN #2. RN #2 stated that following Resident #1's admission to the facility, she reviewed the resident's hospital discharge summary. She stated that the hospital instructed Resident #1 to see his vascular surgeon for a follow up one week after the hospital discharge. RN #2 stated that she did not arrange an appointment for the resident because she assumed that the admitting nurse had already made the arrangements. RN #2 stated that when she assessed the resident on 7/18/2014, the resident's stump was clean and dry with no sign of infection. RN #2 stated that when she saw RN #1's note dated 7/23/2014 in the MD's communication book, she instructed the Patient Care Coordinator to urgently call the vascular surgery clinic and schedule an appointment for the resident. RN #2 stated that she assessed the resident's stump on 7/25/2014 and observed that the stump had drainage with a foul-smelling odor. She stated that she documented her observation in the nurse's progress note. She stated that she did not document in the MD's communication book or call the MD because RN #1 had already documented a similar observation of the resident's stump in the MD's communication book on 7/23/2014. On 8/2/2014 at 3:15PM an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that during the 11:30PM to 7:30AM shift on 7/23/2014, she assessed Resident #1's left stump. RN #1 stated that she observed that the stump was draining pus and blood. She stated that she documented her assessment in the MD's communication book expecting that the MD would review the book and address the issue. She stated that on the next day she observed that the MD wrote his initial on her note in the communication book and assumed that the MD had evaluated the resident. RN #1 stated that she did not verbally speak to the MD about the resident's stump. RN #1 stated that when she noticed that a vascular surgery appointment was scheduled for the resident, she assumed that the resident's stump was addressed. RN #1 stated that she did not conduct any further follow up for the resident's stump. On 8/4/2014 at 11:39AM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that if a nurse assessed or observed a resident to have any symptoms of infection, including a wound having a foul-smelling discharge, the nurse should notify the MD by phone and document in the MD's communication book. The ADON stated that the nurses should also follow up to ensure that the concerns have been addressed. The ADON stated that the charge nurses and supervisors are authorized to call the MD directly for such notifications. On 8/4/2014 at 1:04PM an interview was conducted with the MD. The MD stated that he read and initialed the nurse's note regarding the resident's stump in the communication book dated 7/23/2014. He stated that since he did not write any progress notes regarding the resident on 7/23/2014, he "must have determined" that his examination of the resident's stump was "not significant enough" to change the on-going treatment to the stump. The MD stated that he did not believe that a drainage of pus from a stump meant it was infected. The MD stated that he could not recall if he was notified about RN #2's assessment of the stump on 7/25/2014. The MD stated that he "believes" he evaluated the resident on 7/25/2014, but he had no significant findings to document. In regards to RN #2's assessment that the resident's stump had drainage with a foul-smelling odor on 7/25/2014, the MD stated that in his judgment, the stump was not infected at that time as the resident did not have an elevated temperature. He stated that he ordered to transfer the resident to the hospital on [DATE] when the resident was observed with [DIAGNOSES REDACTED] and a possible infection. On 8/13/2014 at 12:08PM an interview was conducted with Resident #1's vascular surgeon. The vascular surgeon stated that as soon as Resident #1's stump was observed as draining pus and blood with a foul smell, the facility should have immediately transferred the resident to the hospital. On 8/18/2014 at 11:28AM an interview was conducted with RN #3. RN #3 stated that she admitted the resident on 7/17/2014. RN #3 stated that on 7/17/2014, she did not arrange an appointment for the resident to see a vascular surgeon one week after the hospital discharge because she did not see that instruction in the hospital discharge summary. RN #3 stated that when she assessed the resident's stump on 7/27/2014 during the 3:30PM-11:30PM shift, she noticed that the condition of the stump "had gotten bad" compared to what she observed on 7/17/2014. She stated that she documented in the MD's communication book that the stump was draining and that the flesh was raw, but she forgot to document that the stump also had a foul smell. 415.12

Based on interviews and record review during an abbreviated survey, the facility did not ensure that the physician documented, signed and dated progress notes at each visit. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, Resident #1's stump from an above the knee amputation was observed with draining pus and blood. The physician did not document his evaluation of the resident's condition and the decision about the continued appropriateness of the treatment to Resident #1's stump. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint # NY 624 Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 7/24/2014 identified that the resident's cognitive skills for daily decision making were intact with the Brief Interview for Mental Status (BIMS) score of 13 out of 15. The Hospital Patient Review Instrument (PRI) dated 7/16/2014 documented that Resident #1 had a left AKA on 6/30/2014. The nurse's admission note dated 7/17/2014 documented that the resident had a left AKA stump with 40 staples. The note documented that the stump was intact with no signs or symptoms of infection. The Care Plan for left AKA dated 7/17/2014 documented that the goal was having no infection on the surgical site. The facility's interventions included administering treatment to the stump, monitoring the response to the treatment, and monitoring for signs or symptoms of infection. The Medical Doctor (MD)'s order dated 7/17/2014 instructed to clean the left stump with normal saline, then apply [MEDICATION NAME] with Zinc ointment and cover with gauze once daily. The Treatment Administration Record (TAR) for July 2014 documented that Resident #1's left stump was treated as ordered by the MD. The MD's communication book revealed that on 7/23/2014 a nurse documented that Resident #1's left stump was draining pus and blood. The MD documented his initial on the nurse's note. A nurse's progress note dated 7/25/2014 documented that Resident #1's left stump was draining with a foul smelling odor. A nurse's progress note dated 7/26/2014 documented that Resident #1's stump had a "large amount of drainage." The MD's communication book revealed that on 7/27/2014 a nurse requested the MD to check the resident's stump. The nurse documented "When he (Resident #1) was admitted it (stump) was clean and dry, now it's draining and the flesh looks raw." The MD documented his initial on the nurse's note. The 24-hour report dated 7/27/2014 during the 7:30AM to 3:30PM shift documented that Resident #1's stump was "still draining purulent content" and that during the 11:30PM to 7:30AM shift the stump was draining pus and blood. The MD's orders from 7/23/2014 to 7/27/2014 had no new orders related to Resident #1's stump. The MD's progress notes from 7/23/2014 to 7/27/2014 had no documentation related to Resident #1's stump. On 8/2/2014 at 3:15PM an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that during her 11:30PM to 7:30AM shift on 7/23/2014, she assessed Resident #1's left stump. RN #1 stated that she observed that the stump was draining pus and blood. She stated that she documented her assessment in the MD's communication book expecting that the MD would review the book and address the issue. She stated that on the next day she observed that the MD wrote his initial on her note in the communication book and assumed that the MD had evaluated the resident. On 8/4/2014 at 1:04PM an interview was conducted with the MD. The MD stated that he read and initialed the nurse's note regarding the resident's stump in the communication book dated 7/23/2014. The MD stated that he did not write a progress note related to the resident on 7/23/2014. He stated that since he did not write any progress notes, he "must have determined" that his examination of the resident's stump was "not significant enough" to change the on-going treatment to the stump. The MD stated that he could not recall if he was notified about RN #2's assessment of the stump on 7/25/2014. The MD stated that he "believes" he evaluated the resident on 7/25/2014, but he had no significant findings to document. The MD stated that it is his standard of practice not to document any notes if his examination did not indicate a significant change in condition that may require a new order. On 9/3/2014 at 11:36AM an interview was conducted with the Medical Director. The Medical Director stated that the facility's policy is that whenever an MD sees a note in the MD's communication book, the MD is supposed to examine the resident and document the impression regardless of whether the MD is in agreement with what is written in the communication book or not. The Medical Director stated that the MD must document all their visits and their impressions. 415.15(b)(2)(iii)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that all alleged violations involving misappropriation of property are reported immediately to the Administrator of the facility and to the State Agency. This was evident for 1 of 3 sampled residents (Resident #1). Resident #1 reported that his cellphone was missing. The facility had a reasonable cause to believe that a housekeeper deliberately took the resident ' s phone. The facility reported the allegation to the Department of Health (DOH) 6 days after the incident. Additionally, the facility did not prevent further potential misappropriation of property. The facility did not remove the housekeeper from his assignment until 6 days after the incident. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint # NY 809 The findings include: Resident #1 was an [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 09/21/2013 Minimum Data Set (MDS) 3.0 assessed that the resident was moderately impaired in cognition. The facility ' s investigation revealed that on 11/14/2013 at approximately 10:00AM, Resident #1 informed his Certified Nursing Assistant (CNA) that his cellphone was missing. The CNA reported it to the Registered Nurse Supervisor (RNS) and began searching for the phone throughout the unit. The housekeeper on the unit denied seeing the cellphone. When the RNS called the cellphone she heard a ringing nearby and followed the ring. The RNS and other staff members heard the ringing from the housekeeper who was mopping the floor at the nurse ' s station. The RNS asked the housekeeper about the ringing, but the housekeeper began walking away. The RNS followed the housekeeper and demanded to give the phone back. The housekeeper gave the phone to the RNS, and the phone was returned to the resident. A review of the housekeeper ' s time card revealed that he worked in the facility on 11/14/2013, 11/15/2013, 11/18/2013, 11/19/2013, and 11/20/2013. The facility ' s policy and procedures on abuse prevention and reporting dated 12/8/2010 did not indicate the time frame for reporting alleged violations of abuse, mistreatment, neglect or misappropriation of property to the DOH. On 12/20/2013 at 9:39AM an interview was conducted with the RNS. The RNS stated that on 11/14/2013 she reported the alleged incident to the housekeeper ' s supervisor. The RNS stated that she also reported the incident to the Director of Nursing (DON), but only " in passing " because they were very busy attending to the DOH recertification survey on the day of the incident. On 12/20/2013 at 10:30AM an interview was conducted with the Housekeeping Supervisor (HS). The HS stated that he received a call from the RNS informing him that a resident ' s cellphone was found in the housekeeper ' s possession. The HS stated that he reprimanded the housekeeper by a verbal warning and sent him back to work. The HS stated that he reported the incident to the Administrator 5 days after it occurred. The HS stated that he did not report to the Administrator right away because he had already reprimanded the housekeeper. The HS stated that he was not aware that a misappropriation of property incident had to be reported to the DOH. On 05/06/2014 at 10:45AM an interview was conducted with the DON. The DON stated that the incident occurred in the middle of a recertification survey, but she did not state exactly when she was notified of the incident. The DON stated that she was aware that this incident should have been reported to the DOH within 24 hours. The DON stated " it was an honest mistake. " On 12/20/2013 at 11:00AM an interview was conducted with the Administrator. The Administrator stated that the incident was not reported to him on the day it occurred. When he was notified of the incident on 11/20/2013, he reported to the DOH. He stated that he terminated the housekeeper when he was notified of the incident. 415.4 (b)(l)(ii)

Based on staff interviews and record review during an abbreviated survey, the facility did not develop policy and procedures specific to reporting of any reasonable suspicion of crime in accordance with the Elder Justice Act. This was evident for 1 of 3 sampled residents (Resident #1). Resident #1 reported that his cellphone was missing. The facility had a reasonable cause to believe that a housekeeper on the unit deliberately took the resident ' s phone. The allegation was not reported to the local law enforcement. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint # NY 809 The findings include: Resident #1 was an [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 09/21/2013 Minimum Data Set (MDS) 3.0 assessed that the resident was moderately impaired in cognition. The facility ' s investigation revealed that on 11/14/2013 at approximately 10:00AM, Resident #1 informed his Certified Nursing Assistant (CNA) that his cellphone was missing. The CNA reported it to the Registered Nurse Supervisor (RNS) and began searching for the phone throughout the unit. The housekeeper on the unit denied seeing the cellphone. When the RNS called the cellphone she heard a ringing nearby and followed the ring. The RNS and other staff members heard the ringing from the housekeeper who was mopping the floor at the nurse ' s station. The RNS asked the housekeeper about the ringing, but the housekeeper began walking away. The RNS followed the housekeeper and demanded to give the phone back. The housekeeper gave the phone to the RNS, and the phone was returned to the resident. The facility ' s policy and procedures on abuse prevention and reporting dated 12/8/2010 did not include the reporting requirements to the law enforcement in accordance with the Elder Justice Act. On 12/20/2013 at 9:39AM an interview was conducted with the RNS. The RNS stated that she reported the alleged incident to the housekeeper ' s supervisor and the Director of Nursing (DON). The RNS stated that she was not aware that the facility needed to report the incident to the local law enforcement. On 12/20/2013 at 10:30AM an interview was conducted with the Housekeeping Supervisor (HS). The HS stated that he received a call from the RNS informing him that a resident ' s cellphone was found in the housekeeper ' s possession. The HS stated that he reprimanded the housekeeper by a verbal warning and sent him back to work. The HS stated that he was not aware that the facility was required to report the incident to the law enforcement. On 05/06/2014 at 10:45AM an interview was conducted with the DON. The DON stated that the facility should have called the law enforcement when the incident occurred. The DON stated " it was an honest mistake. " On 12/20/2013 at 11:00AM an interview was conducted with the Administrator. The Administrator stated that the incident was not reported to him on the day it occurred. He stated that he terminated the housekeeper when he was notified of the incident on 11/20/2013. He stated that the incident was not reported to the local law enforcement because " it is not reportable if the amount is less than $50.00 and there should be intent before it can be reported. " 415.4 (b)

Based on observation, record review, resident and staff interviews, the facility did not provide interventions to meet the resident's need for relief of pain in order to achieve and maintain the highest practicable level of functioning and well being. Specifically, the facility did not ensure that a resident experiencing pain during physical therapy sessions was medicated for pain prior to therapy and the pain medication re-evaluated for effectiveness. This was evident for 1 (one) out of 30 (thirty) residents in the sample. (Resident #5). This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set 2.0 (MDS) assessment dated [DATE] documented that the resident had short and long term memory impairments and moderately impaired cognition, usually understands and is usually understood, and displayed no pain symptoms. On 11/17/2010 at 11AM, the resident was observed in her room, seated in a wheelchair with gel cushion and bilateral leg rests, with a facial expression of pain. The resident's right leg was observed flexed at the knee, approximately 2 inches above the surface of the gel cushion, while the lower part of the right leg was partially stuck between the two leg panels. The resident exclaimed "My knee hurts." When questioned about the pain, the resident stated "it is the worst when they pull my legs in therapy and ask me to stand up, because it hurts too much. I cannot do it." The resident stated she never told the nurse or the physician about her pain during the therapy. On question what does she do when her leg hurts during the therapy, the resident replied, " I cry. I tell them to leave me alone. They stop." This morning she complained to the nurse about the pain and got "some pills," but was not sure for what. The Certified Nursing Assistant (CNA), who previously assisted the resident with morning care came in the room and stated she was a floater. " She would not allow me to touch her knee ...Wants to keep it bent ...would not stand on her right leg." The CNA stated she did not have a chance yet to report this to the nurse. The Occupational Therapist and Physical Therapist came to see the resident, who was crying out in pain every time her leg was touched and her facial expressions demonstrated pain. When question to quantify the pain and to describe the type of pain, the resident became irritable and stated "I don't know ...my knee hurts. " The resident was provided with a full lower leg panel and after much counseling and emotional support agreed to have her leg placed on the foot rest. The comprehensive care plan for pain management dated 3/11/2010 documented that the resident was at risk for alteration in comfort R/T (related to) OA ([MEDICAL CONDITION]) and included interventions to "...assess pain quality, intensity, location, duration and relief and notify MD (Medical Doctor) of abnormal findings, administer pain medication, monitor effectiveness of pain medication, anticipate need for pain medication ... " The Pain Assessment Tool dated 11/10 documented that "negative vocalizations, moaning, crying, facial grimacing, constant fidgeting and tense appearance ...intermittent daily pain in R (right) foot due to presence of dry scab ...Tylenol administered and effective. " The Physician's monthly order dated 10/1/2010 and 10/28/2010 documented "[MEDICATION NAME] Oral tablet 325mg (milligrams) 2 tablet(s) (650MG) ...By Mouth every 6 hours as needed. " The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no documented evidence that the resident received Tylenol prior to attending physical therapy sessions. The physical therapy progress individual and group treatment records documented that the resident received therapy on 10/1/10, 10/4/10, 10/5/10, 10/6/10, 10/7/10, 10/8/10, 10/11/10, 10/12/10, 10/13/10, 10/14/10, 10/15/10, 10/18/10, 10/19/10, 10/20/10, 10/21/10, 10/22/10, 10/25/10, 10/26/10, 10/27/10, 10/28/10, 10/29/10, 11/1/10, 11/2/10, 11/3/10, 11/4/10, 11/5/10, 11/8/10, 11/9/10, 11/10/10, 11/11/10, 11/12/10, 11/15/10, 11/16/10 and 11/17/10. The Rehabilitation Communication Form Dated 10/1/2010 documented " Resident is seen for screening 2 ( secondary) to nursing referral due to resident refusing FAP (Floor Ambulation program) ... Pt. (patient) reports (B)LE (bilateral lower extremity) pain, PS (pain scale) 8/10 upon standing and increases by walking that is limiting pt. ability to ambulate longer. Nurse is informed. " The physician's orders [REDACTED]. " The Physical Therapy Progress Notes dated 10/14/2010 documented "Pt. (patient) in mod. (moderate) pain ...minimal improvement within past 2 week period & (and) c/o (complaint of) R. (right) leg pain agg (aggravated) by stretching ...nurse aware & (and) is addressing by pain meds before tx (treatment) session ... " The Physical Therapy Progress Notes dated 10/15 to 10/28/2010 document "Ambulates (up to) 12 ft (feet) c (with) RW (rolling walker) & W/C to follow that require min (minimal) A X 1 ( assistance of 1) ...Resident c/o constant B (bilateral) knees pain & (and) nursing was informed about pain meds before coming to rehab. Resident has not shown any improvement this week 2 to the pain mentioned above. " The Physical Therapy Progress Notes dated 10/29/2010 to 11/11/2010 documented "Resident requires a lot of encouragement to start therapy 2 c/o B (bilateral) knees pain. Nursing staff was always reminded about pain meds taken before starting therapy. Resident knees (with) mild contractures & (and) having difficulty extending while in standing position ... " The Physical Therapy Progress Notes dated 11/12/2010 to 11/17/2010 documented " ...able to ambulate for about 2 feet ...still c/o constant pain on B (bilateral) knees R (right) > (more than) L (left), when asked how resident would rate the pain scale, it ' s almost " like 10/10. " Resident was very bothered c (with) pain at stretching BLE's (bilateral lower extremities) would be difficult sometimes 2 to pain. Pain meds " were administered " according to nursing staff ... " On 11/17/2010 at 11:30 AM and 1:40 PM, the Physical Therapist (PT) was interviewed and stated she was providing therapy since 10/15/2010 to this resident, sessions routinely starting between 10:30 AM to 12 noon. The PT stated she initially informed the regular medication nurse and the Nurse Manager that the resident experienced pain during therapy. The PT stated she always called before therapy to remind the nurses to give the resident pain medication. She stated that she was assured that the resident was receiving her meds. She further stated that she reported a few times initially that the meds " don't seem to be working " to the Nurse Manager and the regular medication nurse. The PT stated that last week she informed the medication nurse that pain medication was not effective and the resident was in pain during the therapy. The therapist stated she did not use written communication form, because she was on the unit daily. " How many times should I tell them that the resident is in pain? " The PT stated that she did not call the Medical Doctor because she expected the nurses to do so. The PT concluded that when the resident experienced pain, she would change the type of activity to one that would not cause any discomfort. "Our biggest obstacle to progress in therapy was always the pain. " The PT was providing therapy on the unit in the last three days to see if the resident would be more comfortable in her room, but was considering discontinuation of therapy due to lack of progress and the pain resident was experiencing. On 11/17/2010 at 12:10 PM the Registered Nurse was interviewed and stated the resident complained of pain in her right leg this morning (approximately 6/10) and she gave her Tylenol per PRN order. The RN stated she did not have a chance yet to check the effect of pain medication on the resident. The RN continued stating she covers the unit for the last three days as the regular medication nurse was on vacation. She observed the resident with the Physical Therapist on the unit since Monday, but did not realize that the resident was in therapy or had any complaints of pain. The first time the resident demonstrated pain was this morning and she gave her pain medication. On 11/17/2010 at 12:30 PM and on 11/18/2010 at 10:15 PM the Registered Nurse (RN) Manager was interviewed and stated that the PT reported to her initially about the resident's refusal to participate. " We presumed she might be in pain." The RN Manager stated she immediately instructed the regular medication nurse to give pain medication to the resident prior to therapy and she assumed this was done. " The nurses know that. They would administer meds prior to therapy. They should be charting. " She also assumed that the medication was effective as she did not hear again from the Physical Therapist. The RN Manager stated she assessed the resident once, initially, upon the resident's return from physical therapy and the resident did not complain of pain. The RN Manager continued stating she did not ask the PT if the pain medication was effective. She also did not check the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The RN Manager stated she routinely checks the MAR indicated [REDACTED]. She explained that routinely the nurse would obtain a standing order for pain medication prior to PT sessions. This resident did not have a standing order, because nursing was not sure of the time the resident would PT. She stated that she does not recall receiving a call from PT before the resident went to therapy. The RN Manager stated she does not routinely read PT notes or assessments in the medical record, however, if she received a written communication form from the PT reporting resident's pain during therapy, she would have the issue immediately addressed - assess the resident, check for the administration of medication and notify the physician if meds ineffective. " She (Physical Therapist) never followed up with me. I don't know if medication nurse knew. I was not aware that the resident had pain in PT ... " On 11/17/2010 at 4:20PM the Physician was interviewed by phone and stated that he never observed the resident in pain during monthly exams. If the resident presented with pain during physical therapy, the physician stated, he would expect the PT to notify him so that he could adjust pain medication. He was never told that the resident experienced pain or that her PRN Tylenol was ineffective. On 11/18/2010 at 9:15 AM the Rehabilitation Nurse was interviewed and stated that the resident was ambulating about 60 feet in 7/2010 with R/W and W/C to follow. Gradually the resident started refusing the Floor Ambulation Program and her performance has drastically deteriorated. In September, the resident mostly refused to participate or walked up to 10 feet and at that time she was referred to PT. The Rehab nurse stated that the resident complained sporadically about the pain in her right foot only, but often did not provide explanation for her refusal of FAP. On 11/18/2010 at 2:15PM the Director of Nursing was interviewed and stated that routinely, when the resident has the pain during PT session, a nurse would obtain a standing order for pain medication prior to therapy. She would afterwards check the administration of medication on MAR. If pain medication is ineffective, the therapist should notify nursing to follow up with the physician. The DON stated " We have to work on improving staff communication. " On 11/18/2010 at 3:40 PM the Director of Rehabilitation was interviewed and stated that routinely the PT would notify nursing in person or by phone about the resident experiencing the pain during therapy. If the resident continues to experience pain in spite of medication administration, the PT would bring that to attention of RN Manager. " In this case, we should have better communicated with nursing staff ... We should have notified higher level nursing staff to make sure the pain was addressed. " 415.12