Every finding on record at Degraff Memorial Hospital-Skilled Nursing Facility

Based on observation, interview, and record review conducted during a survey, the facility failed to follow the manufacturers' recommendations and specifications for installing and maintaining bed rails for two (2) (Resident #2 and Resident #74) of two (2) residents reviewed. Specifically, Resident #2 and Resident #74 had a bed assist rail that was not secured to its bed frame. The findings include: The facility policy and procedure titled Transfer/Bed Mobility Bar, revised 02/24/2026, documented when installing transfer bars, the facility would follow manufacturer recommendations to ensure that the transfer bars were compatible with the bed frame and mattress and follow manufacturer instructions to ensure bed rails did not pose a risk for entrapment. Transfer bars would be inspected on a quarterly basis to ensure proper operation. Review of bed type A's manual revealed the Operating Instructions section included the following warning: Test the Pivot Assist to ensure that it was properly latched before leaving the patient. Review of bed type B's manual revealed the Safety Precautions section included the following warning: Test the side/assist rails to ensure that they were properly latched before leaving the patient. Review of bed type C's manual revealed the Operating Instructions section included the following warning: Test the assist rail to ensure that it was properly latched before leaving the patient. Review of the facility's Monthly Bed Inspection logs revealed the following information was recorded: room/bed, bed rails properly (yes/no), bed rail attached properly to frame (yes/no), black handle, and closet care plan. Further review revealed there was no documented evidence of the asset tag number (unique identifier applied to an item) for each bed assessed for bed assist rails. Review of the most recent Bed Entrapment Audit dated 03/23, revealed the following information was recorded: Room/Bed, Mattress Size, Zone 1 (space within the rail), Zone 3 (space between the rail and mattress), Zone 6 (space between rail and head/foot board), and Zone 7 (space between mattress and head/foot board). Further review revealed there was no documented evidence of the asset tag number for each bed assessed for entrapment. Review of the facility's QAPI (Quality Assurance and Performance Improvement) Report, dated April 2026, revealed one (1) bed assist rail was not latched properly and was subsequently corrected. Further review revealed there was no documented evidence of which specific bed had the noncompliant bed assist rail. 1. Resident #2 had diagnoses that included multiple sclerosis (a chronic, autoimmune disease of the central nervous system) and quadriplegia (paralysis affecting all four limbs and the torso). The Minimum Data Set (a resident assessment tool) dated 04/12/2026, documented the resident had an intact cognition level, made themselves understood and had the ability to understand others with clear comprehension, and did not use a bed rail. The Kardex Report (a guide used by staff to provide care) dated 06/02/2026, documented the resident required extensive staff assistance using bilateral transfer bars for bed mobility and required a full mechanical lift with assistance of two (2) persons using a large sling for transferring. The comprehensive care plan initiated 10/23/2025, documented the resident had limited physical mobility related to multiple sclerosis with bilateral lower extremity paralysis and spasticity. Interventions initiated on 10/23/2025 documented the resident was non ambulatory, required extensive staff assistance using bilateral transfer bars, and required a full mechanical lift with assistance of two (2) persons using a large sling. The Physical Therapy Evaluation and Plan of Treatment, dated 10/24/2025, documented the Functional Mobility Assessment indicated the resident used bilateral bedrails for bed mobility. The Occupational Therapy Evaluation and Plan of Treatment, dated 10/24/2025, documented the Functional Skills Assessment - Functional Mobility indicated the resident had a Mobility Function Score of zero (0) (ranges from zero (0) - 12; 12 being the highest function). Review of Progress Notes dated 04/08/2026, documented the resident was evaluated by the Lead Physical Therapist for an annual review and functional mobility assessment. Resident #2 mobility level was unchanged and they continued to require extensive assistance with bilateral transfer bars and a full mechanical lift with two (2) person assistance using a large sling. During an observation on 05/27/2026 at 9:51 AM, Resident #2 was awake and lying in bed. The resident's bed was positioned parallel to the room's windows and had bilateral assist rails installed at the head end of their bed. The bed assist rail located to the right side of the resident's body, closer to the room's entryway door was loose and not secured/latched within the bracket. The affected bed assist rail was made of plastic material and had one (1) manufacturer's label which read R9959. Further observations revealed the bed had two (2) labels located on the head end caster backet assembly: one (1) facility asset tag labeled 99948 and one (1) contractor's semi-annual inspection tag dated 1/26, with the technician's initials and the next inspection due date of 7/26. Review of the facility's Monthly Bed Inspection log, dated 03/23/2026 through 03/27/2026, revealed Resident #2's bed did not have an appropriately latched bed assist bar and was subsequently corrected at the time of inspection. During an interview and observation on 05/27/2026 at 2:15 PM, Certified Nurses' Aide #1 stated one (1) of Resident #2's bed assist rails was loose and not latched and secured in the bracket. Certified Nurse Aide #1 was able to securely place the affected bed assist rail back in the correlating bed bracket. Certified Nurse Aide #1 stated a certified nurse aide, or a licensed practical nurse, most likely removed the bed assist rail when the resident was transferred to a shower bed, either by using a sheet to slide the resident or by using a Hoyer lift (mechanical lift), but it was not a shower day for Resident #2. Certified Nurses' Aide #1 stated it was unknown how long the bed assist bar had been loose, and they were unsure which department was responsible for maintaining and inspecting bed assist bars. During a telephone interview on 06/02/2026 at 10:11 AM, Certified Nurse Aide #2 stated they usually assisted Resident #2 with showers on Monday mornings, and when they transferred the resident from their regular bed to the bath bed, they kept one (1) bed assist rail up and took the other bed assist rail completely off the regular bed. Certified Nurse Aide #2 stated once the resident was transferred onto the bath bed, they placed the bed assist rail back in the bracket of the resident's regular bed because the resident preferred to be transferred directly into their motorized wheelchair after their shower. Furthermore, Certified Nurse Aide #2 stated if the bed assist rail was not appropriately latched into place, it immediately would come out of the bed's bracket. Additionally, Certified Nurse Aide #2 stated it was possible nursing staff may have readjusted the resident's bed assist rail, causing it to come loose, as the resident was known to get a lot of wires tangled in the bed assist rail. Certified Nurse Aide #2 stated it was important to ensure bed assist rails were safely in place to prevent falls and maintain the general safety of the resident. 2. During an observation on 05/27/2026 at 10:26 AM, Resident #74's bed was positioned parallel to the room's windows and had bilateral assist rails installed at the head end of their bed. The bed assist rail located to the right side of the head of the bed, closer to the room's windows was loose and not secured/latched within the bracket. Additional observations at that time revealed the affected bed assist rail was made of metal material and the bed had two (2) labels located on the caster backet assembly: one (1) contractor asset tag labeled 61283 and one (1) contractor's semi-annual inspection tag dated 1/26, with the technician's initials and the next inspection due date of 7/26. Review of the contractor's most recent biannual bed inspection reports, dated 01/16/2026 through 01/28/2026, revealed the inspection report for contractor asset tag 61283 indicated the bed was located in a different resident room at the time of inspection. During an interview and observation on 05/27/2026 at 2:20 PM, Certified Nurse Aide #1 stated one (1) of Resident #74's bed assist rails easily came out of its bracket. Certified Nurses' Aide #1 was able to securely place the affected bed assist rail back in the correlating bed bracket. During an interview on 05/27/2026 at 2:24 PM, the Lead Physical Therapist stated the therapy department performed monthly inspections, rather than quarterly, to ensure bed assist rails were latched into place. The Lead Physical Therapist further stated the monthly inspections were recorded on a form and resident care plans were reviewed for accuracy related to bed assist rail use. Additionally, the Lead Physical Therapist stated that while nursing staff knew how to latch bed assist rails into place, they did not know if nursing staff checked the bed assist rails on a consistent basis nor were they aware if nursing staff received education and in-services on bed assist rail inspection and safety. During an interview on 06/02/2026 at 7:23 AM, Licensed Practical Nurse #1 stated it was possible for licensed practical nurses to help with resident transfers to stretchers or bath beds, but a Hoyer lift would be used to transfer a resident and there should be no need to remove the bed assist rail from the bed's bracket. During an interview on 06/02/2026 at 8:17 AM, the Director of Nursing stated they were unsure if nursing staff received an in-service on bed assist rail safety. During an interview on 06/02/2026 at 10:56 AM, the Director of Long Term Care (Administrator) stated the bed inspection contractor placed a sticker on each bed, which included the following information: the technician's initials, the date of the inspection, and the date the next inspection was due. The Director of Long Term Care (Administrator) stated based on the contractor's inspection documentation, it was not certain where each bed was currently located, as most inspection sheets only identified the bed's asset tag and not the room and bed location. The Director of Long Term Care (Administrator) further stated sometimes certified nurse aides and licensed practical nurses removed bed assist rails when using a Hoyer lift during resident transfers. Additionally, the Director of Long Term Care (Administrator) stated nursing staff had not received bed assist rail training recently, and it would be important to safely maintain bed assist rails to mitigate injury to staff and residents. During an interview on 06/02/2026 at 11:13 AM, the Physical Environment Compliance Manager stated the maintenance department, both corporate and facility-specific, did not provide inspection, maintenance, and testing for beds and bed rails at the long-term care facility. The Physical Environment Compliance Manager stated it was the Director of Long Term Care's (Administrator) responsibility to arrange a preventative maintenance program for the facility's beds and bed rails, and the expectation would be that the Director of Long Term Care (Administrator) would be aware of any issues related to the beds and bed rails. During an interview on 06/02/2026 at 11:57 AM, the President/Owner of the contracted bed inspection company stated they provided biannual bed inspections for the long-term care facility, conducted every January and July. The President/Owner further stated the beds were frequently relocated by facility staff, and the contractor's inspection documentation primarily identified each bed by asset number, not usually by location (i.e., a specific room number and for shared rooms: Bed A or Bed B). The President/Owner stated the beds were inspected per manufacturer's specifications and preventative maintenance procedures did not include inspection of bed assist rails. During an interview on 06/02/2026 at 2:15 PM, the Director of Nursing stated the nursing department had no part in the assessment process of bed rails, and if nursing staff had a concern that a resident may need bed rails or assist bars, nursing staff would tell the unit manager and/or the therapy department. The Director of Nursing stated the bed rail or assist bar could be removed if it was in the way; however, it would be immediately reattached and secured. The Director of Nursing stated facility staff have swapped a bed from room-to-room before; an example may be that a current resident had a large bed they did not need and a new admission needed that large bed. 10 New York Code Rules Regulations 415.12(h)(1)

Based on interview and record review during a survey, the facility failed to implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property. Specifically, an employee that worked in the facility and was subject to the New York State Nurse Aide Registry Verification, was not reviewed through the New York State Nurse Aide Registry prior to their employment as required. This affected one (1) (Environmental service Aide #1) of five (5) employees that worked in the facility and were subject to being reviewed through the New York State Nurse Aide Registry prior to their employment as required. The findings include: The facility's policy and procedure titled LTC Criminal History Record Check (CHRC) and NYS Nurse Aide Registry, revised 05/06/2025, documented:- the policy was established to ensure candidates for employment (New Hires, Re-Hires, Agency) and current employees (Internal Transfers) complete a Criminal History Background Check and a New York State (NYS) Nurse Aide registry check in accordance with Federal and State requirements and regulations regarding criminal convictions, documented findings, and program exclusions prior to commencement of new job responsibilities.- the policy applied to all employees, candidates for employment, and agency staff in a Long Term Care (LTC) facility providing service in areas of the organization specified by the New York State Department of Health (NYSDOH) and other government or regulatory authorities.- all candidates for employment, including agency staff, would be checked through the New York State Nurse Aide Registry to assure there were no findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. During an interview on 06/01/2026 at 3:33 PM, the Senior Human Resources Business Partner stated Environmental Service Aide #1 was hired on 04/20/2026. The Senior Human Resources Business Partner stated there had been a change in the Recruiter at that time, the Recruiter had missed Environmental Service Aide #1, and the New York State Nurse Aide Registry Verification for Environmental Service Aide #1 was not completed until 05/29/2026. The Senior Human Resources Business Partner further stated this Recruiter no longer worked at the facility. During an interview on 06/01/2026 at 3:51 PM, the Environmental Services Director stated Environmental Service Aide #1 worked on projects and in the corridors in the Medical Park, and worked in the skilled nursing facility on 05/14, 05/15, 05/17, 05/18, 05/20, 05/22, and 05/25/2026. The Environmental Services Director further stated Environmental Service Aide #1 worked alone in resident rooms in the skilled nursing facility on the Second Floor. Review of Environmental Service Aide #1 personnel file revealed they were hired on 04/20/2026. Review of the New York State Nurse Aide Registry Verification Report for Environmental Service Aide #1 revealed the verification date on the report was 05/29/2026. Review of the electronic timecard information for Environmental Service Aide #1 revealed the employee was in General Orientation on 04/20/2026, worked from 04/21/2026 through 05/31/2026, and the timecards did not document any information that showed where the employee worked. Review of Environmental Services Sign-in Sheets revealed Environmental Service Aide #1 worked:- in the Medical Park starting on 04/29/2026; and - in the skilled nursing facility on the Second Floor from 7:00 AM to 3:00 PM on 05/14, 05/15, 05/17, 05/18, 05/20, 05/22, and 05/25/2026. 10 New York Codes, Rules, and Regulations (NYCRR): 415.4(b)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #2678647), the facility did not ensure that all alleged abuse violations were reported immediately but not later than two (2) hours after the allegation was made to the Administrator of the facility and to the State Survey Agency for one (1) (Resident #1) of three (3) residents reviewed. Specifically, staff did not report an allegation of physical abuse to the Administrator immediately which resulted in delayed reporting to the New York State Department of Health within the required time frames. The finding is:The policy titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d last revised on 10/22/24 documented any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report their concerns to the Nursing Home Administrator or designee. The Long-Term Care Administrator will report abuse to the state agency per State and Federal requirements. The Patient Abuse Reporting Law Section 2803-d requires every nursing home employee and all licensed professionals to report to the New York State Department of Health when there is reasonable cause to believe that a resident has been physically abused, mistreated or neglected. Immediately means as soon as possible but not to exceed two hours after the discovery of the incident.The policy titled Incident Escalation dated 1/7/25 documented all staff are responsible for ensuring the safety and welfare of residents through appropriate notification, response, and follow up. Staff are required to inform their supervisor as soon as they have knowledge of an incident. If their supervisor is unavailable, then the employee is expected to follow the chain in command. Every effort should be made to resolve the incident at the lowest level on the chain of command, however, based on the seriousness of the event, i.e. suspicion of abuse, then the notification of the chain of command may be escalated to the director level.Resident #1 had diagnoses which included diabetes, obesity, and mood disorder. The Minimum Data Set (a resident assessment tool) dated 11/23/2025 documented Resident #1 had intact cognition, was understood and understands. The Minimum Data Set further documented Resident #1 was dependent on staff for toileting needs and required supervision for rolling from left to right in bed. Resident #1 had no documented behaviors.The comprehensive care plan revised on 08/26/2025 documented that Resident #1 had physical limitations related to weakness, declined to get out of bed daily, and was a limited assist of one staff member for bed mobility. The comprehensive care plan further documented Resident #1 was alert and oriented to person, place, time, and made their needs known with some mild memory issues.Review of the New York State Department of Health Complaint Tracking System Complaint/Incident Investigation Report revealed the date/time of the alleged incident was 11/24/2025 at 1:00PM. The date/time the Administrator was first made aware of the incident was 11/26/2025 at 8:00AM. It was submitted by the facility to the New York State Department of Health on 11/26/2025 at 9:15AM.The facility investigation dated 11/26/2025 revealed that Nurse Aide Trainee's #1 and #2 reported to Certified Nurse Aide #2 on 11/26/2025 at 7:35AM that on 11/24/2025 at 1:00PM, they witnessed Certified Nurse Aide #1 slap Resident #1 across the face and was verbally abusive during care. There were no other witnesses to the incident. There were no injuries to Resident #1. Certified Nurse Aide #2 then reported the allegation to Registered Nurse #1 Unit Manager. Nurse Aide Trainee's #1 and #2 were scared, did not know the process for reporting and were fearful of losing their jobs.During an observation and interview on 12/08/20255 at 9:20AM Resident #1 was in bed. There were no indications of abuse. Resident #1 denied being abused physically or verbally by Certified Nurse Aide #1 and stated they just weren't nice, not abusive. During an interview on 12/08/2025 at 10:38AM, Nurse Aide Trainee #1 stated Certified Nurse Aide #1 openly expressed dismay about Resident #1 in common areas such as the hallway or nurses' station but had not said those words directly to the resident. They stated during incontinent care on 11/24/2025 at 1:00PM they witnessed Certified Nurse Aide #1 what they described as being physically and verbally abusive. Certified Nurse Aide #1 was not happy about providing care to Resident #1. Certified Nurse Aide #1 was close to the bed. Nurse Aide Trainees #1 and #2 stood by the closet. Certified Nurse Aide #1 told Resident #1 you are F. disgusting, you need to wake up and then they saw and heard Certified Nurse Aide #1 slap the resident on the left side of their face. The Nurse Aide Trainees #1 and #2 then started collecting the linen because they didn't know what to do and they didn't say anything to Certified Nurse Aide #1 or Resident #1. Nurse Aide Trainee #1 stated Resident #1 was not fazed by the slap as Resident #1 was asleep. Resident #1 opened their eyes and then closed their eyes and didn't say anything. During an interview on 12/08/2025 at 10:58AM, Nurse Aide Trainee #2 stated Resident #1 looked at Certified Nurse Aide #1 in shock and was alert during the incident. There was no redness or injuries to Resident #1's left side of their face. Nurse Aide Trainees #1 and #2 discussed it together on their break on 11/24/2025, worked on 11/25/2025, and then reported the alleged abuse on 11/26/2025 to Certified Nurse Aide #2. During an interview on 12/08/2025 at 12:24PM Social Worker #1 stated they visited Resident #1 in the afternoon on 11/24/2025 in their room. Resident #1 did not express concerns of mistreatment, physical or verbal abuse. Resident #1 was credible and would complain if they were mistreated. Nurse Aide Trainee's #1 and #2 should have told the nurse on the unit immediately after they witnessed the abuse.During an interview on 12/08/2025 at 12:41PM, Registered Nurse #1 Unit Manager stated Nurse Aide Trainees #1 and #2 and Certified Nurse Aide #1 reported the alleged abuse to them on 11/26/2025 at 7:35AM. Registered Nurse #1 Unit Manager then reported it immediately to the Administrator.During an interview on 12/08/2025 at 1:35PM, Licensed Practical Nurse #1, who worked on 11/24/25, stated they were unaware of the allegation with Resident #1. Nurse Aide Trainee's #1 & # 2 should have brought the concern to them as soon as it happened. During a telephone interview on 12/08/2025 at 1:13PM, Certified Nurse Aide #1 denied slapping or calling Resident #1 disgusting.During a telephone interview on 12/08/2025 at 3:13PM, Certified Nurse Aide #2 stated Nurse Aide Trainee's #1 and #2 told them about the incident that occurred with Certified Nurse Aide #1 and Resident #1 on the morning of 11/24/2025. They told them waiting (2) two days was too late and needed to protect other residents. Then together they informed Registered Nurse #1 Unit Manager. During an interview on 12/08/2025 at 3:49PM, the Director of Nursing stated that Nurse Aide Trainee's #1 and #2 had abuse training in general orientation. They should have reported the abuse allegation to Licensed Practical Nurse #1 or a supervisor to protect the residents from further abuse. It was a two (2) day delay in reporting to the State agency. During an interview on 12/08/25 at 4:04PM, the Administrator stated they were informed of the allegation on 11/26/2025 at 8:00AM. Registered Nurse #1 Unit Manager told them the slap occurred on 11/24/2025 at 1:00PM. The Administrator would have expected the Nurse Aide Trainee's #1 and #2 to have reported it immediately on 11/24/2025 and they would have reported it to the New York State Department of Health within two (2) hours. 10 NYCRR 415.4 (b)(2)

Based on interview and record review conducted during an extended survey completed on 10/3/24, the facility's quality assurance and performance improvement program did not perform improvement activities that tracked adverse resident events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the facility. Specifically, the facility did not ensure their WanderGuard policy was updated; that staff were educated about the wander guard system, and did not ensure preventive actions were implemented to ensure resident safety. The finding is: Refer to: F 689 - Free from Accident Hazards/Supervision and Devices to Prevent Accidents The 2024 Facility Assessment Review dated 2/6/2024 documented the facility assessment was used to determine gaps in service or expected outcomes, when identified, are reviewed and correction plans are discussed for implementation. The corrective activities are then review during subsequent meetings to assure changes are sustained and there is no recurrence of the issue. The policy and procedure titled LTC (long term care) Quality Assessment and Performance Improvement revised on 9/23/2021 documented the mission of the LTC Quality Assurance Performance Improvement Plan (QAPI) was to promote the delivery of resident care in keeping with the highest standards of outcomes and services valued by our customers, medical staff, employees, and payors; its institutional relationships and the community served. It documented the Facility QAPI (Quality Assessment and Performance Improvement) Plan includes the policies and procedures used to identify and use data to monitor facility performance: establish goals and thresholds for performance measurement using data from published sources; utilize resident, staff and family input through Resident Council minutes, discharge interviews, concerns, and other ad hoc (for this situation) committee forums; identify and prioritize problems and opportunities for improvement; analyze underlying causes of systemic problems and adverse events; and develop corrective action or performance improvement activities. The facility Quality Assessment and Performance Improvement Plan documented data from multiple sources (performance indicators, input from residents and families, audits) are utilized to monitor care and services. It documented the Quality Assessment and Performance Improvement focuses on a systematic approach to identify problems, their causes, and implications of change, and focuses on processes rather than addressing individual behaviors. An undated investigation completed by the Director of Nursing documented Resident #14 was on the sidewalk in their wheelchair and found by Registered Nurse Nursing Supervisor #4 on 6/23/2024 at 6:55 AM. Resident #14's wander guard device was intact but did not lock the doors to prevent them from leaving the building. It documented that the sales representative for the vendor for the security system thought the reason why the wander guard tag did not set off the alarm was due to a possible software update. It documented the batteries were changed for Resident #14 who's wander guard tags didn't work. On 6/28/2024 the sales representative for security system arrived at the facility to test the wander guard tags and they were found to be working. During an interview on 9/30/2024 at 11:52 AM, Registered Nurse Supervisor #4 stated they saw Resident #14 sitting outside of the building on the sidewalk on 6/23/2024 at 6:55 AM. They stated they checked Resident 14's wander guard, and the door did not lock or alarm. During an interview on 9/30/2024 at 3:00 PM, the Administrator stated they discussed the elopement that occurred on 6/23/2024 but did not discuss the any communication issues with their IT or security IT computer network related to the issues of software. During an interview on 10/1/2024 at 9:06 AM, Security Officer #1 stated they do not check the individual wander guard tags on residents or their wheelchairs. They stated they only check the alarms on the egress doors and if the front doors lock. They stated if they alarm does not go off or if the front doors do not lock, there was something wrong with the wander guard tag. During an interview on 10/1/2024 at 4:00 PM, the sales representative of the wander guard system stated they have not done an in-service on how the wander guard monitor works in at least two to three years. The sales representative stated, it sounds like the nurses need education on how the wander guard monitor works and even if it the system is offline; the tags should still work no matter what. During an interview on 10/2/2024 at 11:11 AM, Licensed Practical Nurse #3 stated they were not sure of the life span of the battery of the wander guard tags or when the batteries needed to be changed. They stated they were not sure if security tests each individual wander guard tag of each resident. During an interview on 10/2/2024 at 11:24 AM, Registered Nurse Unit Manager #1 stated if there was a feature in the system to check the battery life, they were not aware of it. During an interview on 10/2/2024 at 11:28 AM, Registered Nurse Unit Manager #2 stated they were not checking the individual wander guard tags of residents prior to 10/2/2024. During an interview on 10/2/2024 at 1:56 PM, the Director of Nursing stated they have never checked the batteries on the individual resident's wander guard tag. They stated they should have been checking the batteries of resident's wander guard tags. During an interview on 10/3/2024 at 8:15 AM, the Administrator stated they were not aware how the tag health function worked on the wander guard system prior to 10/2/24. They stated there was no wander guard tag battery audit log prior to 10/2/24. During an interview on 10/3/24 at 10:13 AM, the Director of Nursing stated they were using the tags that required batteries. In June 2024 when they looked at the tags they had, some were totally sealed and those went in the garbage. The Director of Nursing stated they couldn't confirm which residents had which type of tags on in June, they all just got new ones (that required batteries) at that point. The Director of Nursing stated they weren't checking the batteries and didn't know about their policy to check the batteries. The Director of Nursing stated maybe checking the batteries was something they should have been in tune with in June. During an interview on 10/3/2024 at 12:00 PM with the Director of Nursing and the Administrator, the Administrator stated the Quality Assurance and Performance Improvement committee meets monthly. No one knew the wander guard system was down or that there was a malfunction with the wander guard tags. The Administrator stated they would have to read the policy again and update the policy to reflect any changes. NYCRR 415.27(c)(3)(iv)(4)

Based on observations, interviews, and record reviews conducted during a complaint investigation (NY00346092) conducted during an extended standard survey from 9/26/2024 to 10/3/2024, the facility did not to ensure that each resident receives adequate supervision to prevent accidents for three (Residents #12, 14, and 29) of three reviewed. Specifically, the facility did not monitor the wander guard signaling device's (tag/bracelet) battery life/functionality of those that were assigned (#12, 14, 29) and Resident #14 exited the building unsupervised without staff's knowledge. In addition, the facility staff lacked education and training regarding the wander alert system and policy. The findings are: The policy and procedure titled WanderGuard dated 12/2022 documented all batteries of activated bracelet signaling devices are continuously monitored by the wander guard computer system and, if a battery is low, an alarm on the computer will be activated and identify the low battery; and nursing will be responsible to change the bracelet signaling device. The policy and procedure titled Elopement, Missing Person revised 10/27/2022 documented a resident elopement was defined as when a cognitively impaired resident leaves the facility without staff observation or knowledge of the resident's departure. The Quality Assurance functions after an elopement should include random test personal alarm systems. Resident #14 had diagnoses of dementia, depression, and borderline personality disorder (a mental disorder characterized by instability in mood, behavior, and functioning). The Minimum Data Set (a resident assessment tool) dated 4/28/2024 documented Resident #14 was cognitively intact. Resident #14 could wheel their wheelchair up to 150 feet and make turns. The comprehensive care plan dated 12/22/2022 (current) documented Resident #14 was alert and oriented but has fluctuating memory issues due to dementia and was high risk for falls due to confusion. The comprehensive care plan dated 1/5/2023 documented Resident #14 was an elopement risk due to impaired safety awareness, wandered aimlessly, and stated they need to go home. The comprehensive care plan dated 4/23/2023 documented the resident had poor impulse control, ineffective coping skills, and aggression towards others due to dementia. The physician orders dated 3/8/2024 documented Resident #14 was to have a wander guard on the back of their wheelchair, to check the wander guard once a shift, and to notify security if the wander guard was missing or broken. The Kardex care plan (guide used by staff to provide care) dated 6/1/2024 documented Resident #14 was a risk for elopement, check whereabouts after meals, at change of shift, and may not leave the facility unaccompanied. The undated (the manufacturer of the wander guard system) Skilled Nurse Facility Wandering System instructions documented each resident is assigned a wander guard tag that actively monitors a resident when they are near a door controller. It documented the battery life can be checked by bringing the wander guard tag to a door controller, holding it there for a few seconds then going back to the wander guard monitor to look for the tag in the tag health field that would indicate if the battery was good or if the battery needed to be replaced. Resident #14's progress notes dated 2/1/2024 to 6/30/2024 documented the resident had exit seeking behaviors on the following dates: 2/9/2024, 2/15/2024, 2/29/2024, 3/7/2024, 3/10/2024, 3/24/2024, 4/8/2024, 4/11/2024, 4/18/2024, 4/25/2024, 5/13/2024, and 5/14/2024. On 6/23/2024 at 6:55 AM Resident #14 was found outside of building on the sidewalk and stated they were waiting for a ride. An undated investigation completed by the Director of Nursing documented Resident #14 was on the sidewalk in their wheelchair and found by Registered Nurse Nursing Supervisor #4 on 6/23/2024 at 6:55 AM. Resident #14's wander guard device was intact but did not lock the doors to prevent them from leaving the building. The investigation documented the batteries were changed for Resident #14's wander guard bracelet that didn't work. An observation and interview on 10/2/2024 at 8:11 AM, Resident #14's wander guard was tested at the front doors. The front doors locked, and the alarm sounded at the wander guard monitor. A red icon appeared on the screen with Resident 14's name and the location of the alarm. During this observation of the wander guard monitor, Registered Nurse Unit Manager #2 stated they did not know how to find out the battery life of the wander guard tag through the tag health field. During an interview on 9/30/2024 at 11:52 AM, Registered Nurse Supervisor #4 stated they saw Resident #14 sitting outside of the building on the sidewalk on 6/23/2024 at 6:55 AM. They stated they checked Resident 14's wander guard, and the door did not lock or alarm. During an interview on 10/1/2024 at 9:03 AM, the Plant Operations Manager stated the maintenance department does not do anything with the wander guard system, and the nursing department was responsible for checking the functionality of the wander guards. During an interview and observation on 10/1/2024 at 9:06 AM, Security Officer #1 stated they only check the alarms on the egress doors and if the front doors lock; they do not check the individual wander guard bracelets that were assigned to the residents. Security Officer #1 demonstrated the egress doors alarmed with a wander guard, and the front doors locked when the wander guard bracelet was nearby, and if the front doors were wide open the alarm would sound. They stated if the alarm does not go off or the front doors do not lock, there was something wrong with the wander guard bracelet. During a telephone interview on 10/1/2024 at 9:28 AM, the sales representative of the wander guard system stated the wander guard system will not work if there was a power outage. They stated metal from a wheelchair could interfere with the alarm system if it was placed on the chair where the metal could block the frequency. They stated there was an issue with a firewall which could have caused the wander guard not working. They stated the wander guard system could still work even if the network was offline. During an interview on 10/1/2024 at 10:14 AM with the technical support customer service representative of the manufacturer of the wander guard system, stated the wander guard tags might not work if the Wi-Fi was not working, if the power was out, if the battery of the wander guard tag was dead, and there was a small possibility the wander guard tag would not work if there was a lot of metal surrounding the tag. They stated there is no device to check the battery life of the individual tag. However, the tag batteries life could be found on the tag health on the wander guard monitor. During an interview on 10/1/2024 at 10:50 AM, Licensed Practical Nurse #1 stated they were working on the morning of 6/23/2024 and did not hear an alarm going off from the front door. They stated they do not check the individual resident's wander guard's functionality; they only check for the placement of the wander guard tag on the resident's person or their wheelchair. During an interview on 10/1/2024 at 11:02 PM, Certified Nurse Aide #1 stated they worked on 6/23/2024. They stated they were on their way to do rounds at approximately 6:45 AM that day and saw Resident #14 in the front foyer. They stated they did not hear an alarm sounding. They stated the resident had tried to elope before. During an interview on 10/2/2024 at 11:11 AM, Licensed Practical Nurse #3 stated they were not sure of the lifespan of the battery of the wander guard tag/bracelet or when the batteries needed to be changed. They stated they were not sure if security tests each individual wander guard tag of each resident. During an interview on 10/2/2024 at 11:24 AM, Registered Nurse Unit Manager #1 stated when someone's wander guard was removed, they had to discontinue it from the system. To reactivate it, they'd go to the front door and hold it up, then it would come up on the monitor and staff would put in the resident's name it was assigned to. The Registered Nurse Unit Manager #1 stated if there was a feature in the system to check the battery life, they were not aware of it. During an interview on 10/2/2024 at 11:28 AM, Registered Nurse Unit Manager #2 stated they check for physical placement of the wander guard tag/bracelet but not batteries. During an interview on 10/2/2024 at 1:56 PM, the Director of Nursing stated they never checked the batteries on the individual resident's wander guard tag but should have been. During an interview on 10/2/24 at 3:00 PM, Licensed Practical Nurse #4 stated they never checked the battery life of the wander guard tags. They stated they only checked the placement of the wander guard tag and check it off on the treatment administration record. During an interview on 10/3/2024 at 8:15 AM, the Administrator stated they attempted to find out how the battery life was shown on the wander guard monitor. They stated they found the tag health field to determine the battery life. They stated they were not aware how the tag health function worked prior to 10/2/24. During a telephone interview on 10/3/24 at 8:41 AM, Licensed Practical Nurse #5 stated Resident #14 tried to leave at times, they were on the wanderer list and have a wander alert band. Nurses checked for placement of the wander guard. They were not responsible for checking the functionality and how long the band had been in use. The nursing supervisors checked the functionality. During a telephone interview on 10/3/2024 at 9:04 AM, Registered Nurse Supervisor #3 stated they have never checked individual wander guard tags. They stated they do recall a device to check the wander guard tag's batteries, but they stated, It didn't work that well. During an interview on 10/3/24 at 10:13 AM, the Director of Nursing stated they were using the tags that required batteries. In June when they looked at the tags they had, some were totally sealed and those went in the garbage. The Director of Nursing stated they couldn't confirm which residents had which type of tags on in June, they all just got new ones (that required batteries) at that point. The Director of Nursing stated when staff go to activate or reactivate the tags, if it wasn't working, it won't show up on the monitor, and they would throw the tag out. The Director of Nursing stated they weren't checking the batteries and didn't know about their policy to check the batteries. The Director of Nursing stated maybe checking the batteries was something they should have been in tune with in June. The Director of Nursing stated they worked at the facility for 2.5 years and there wasn't a record of doing any checks when they first got there or since they've worked there. During an interview on 10/3/2024 at 12:00 PM, the Administrator stated that no one knew the wander guard system was down or that there was a malfunction with the wander guard tags. The Administrator stated they would have to read the policy again and update the policy to reflect any changes. 2. Resident #12 had diagnoses of Alzheimer's disease and depression. Review of Resident #12's Minimum Data Set, dated dated dated [DATE] documented Resident #12 was cognitively impaired, needed supervision or touching assistance (help provides verbal cues or steadying assistance as resident completes the task) to wheel 150 feet, and rejected care from staff. The comprehensive care plan dated 1/20/2020 (current) documented Resident #12 was an elopement risk and wanderer related to impaired safety awareness and the resident's wandering is not purposeful. It documented staff were to check the resident's wander guard placement every shift, an elopement tool to be completed, and all staff are to be notified of wandering risk. The physician orders dated 7/18/23 documented Resident #12's wander guard tag every shift and to notify the supervisor or security if the wander guard tag is missing or broken. The treatment administration records dated February 2024 to September 2024 documented nursing staff were to check wander guard placement on the back of Resident #12's wheelchair once a shift. The Elopement Risk Scale dated 2/21/24 documented Resident #12 the resident ambulated with their wheelchair, cognitively impaired with poor decision-making skills, and displays body language or behavior that indicates an elopement may be forthcoming. A plan of care progress note dated 2/21/2024 documented Resident #12 was an elopement risk and made comments about leaving the facility. A social work progress note dated 3/20/24 documented the resident was upset and wanted to leave the facility to go home. A plan of care note dated 6/24/2024 documented Resident #12 asked to return to the community and their home. The undated investigation completed by the Director of Nursing documented Resident #12's wander guard tag was not setting off the alarm or locking the front doors as it should have been. During an interview on 10/2/2024 at 11:28 AM, Registered Nurse Unit Manager #2 stated checking the individual wander guard tags for residents, including Resident #12's was not implemented until today 10/2/2024. During an interview on 10/3/24 at 12:00 PM, the Director of Nursing stated they would expect security to notify them the internet system or the wander guard system was down or not working. 3. Resident #29 had diagnoses of anxiety and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident was #29 cognitively impaired, would reject hands on care, and required assistance to wheel their wheelchair 150 feet. The comprehensive care plan dated 4/2/2024 documented Resident #29 had a wander guard tag placed on their wheelchair. It was documented the resident repeatedly asks when they can go home. The physician's orders dated 4/2/2024 documented the wander guard tag placement on the back of Resident 29's wheelchair was to be checked every shift by nursing staff. The treatment administration record dated 4/1/2024 to 7/31/2024 documented nursing staff checked Resident 29's wander guard tag for placement every shift. The elopement risk scale dated 4/29/2024 documented Resident #29 was an elopement risk related to the resident statements of leaving, cognitively impaired with poor decision-making skills, and the resident had a history of wandering. A review of the interdisciplinary progress notes dated 4/1/2024 to 7/31/2024 documented the resident had exit seeking behaviors 4/2/24, 4/29/2024, and 5/31/2024. The undated investigation completed by the Director of Nursing documented Resident 29's wander guard tag was intact and working when tested by security. During an interview on 10/2/2024 at 1:56 PM, the Director of Nursing stated they should be following the wander guard policy about checking battery life. NYCRR 10 415.12(h)(1)

Based on observation, interview, and record review conducted during an Extended Recertification survey completed on 10/3/24, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of four residents reviewed for infection control processes during care. Specifically, staff did not wear proper personal protective equipment during hands on care and transfer of the resident, who required enhanced barrier precautions. The finding is: The policy and procedure titled Enhanced Barrier Precautions dated 6/18/24 documented personal protective equipment is used to prevent the spread of multi-drug resistant organism transmission. The recommendations include the use of enhanced barrier precautions during high-contact activities for residents with chronic wounds (open wounds that typically require a dressing change such as pressure injuries, venous and vascular ulcers, diabetic ulcers, and open surgical wounds) or indwelling medical devices (any devices that are inserted into the resident and have contact with external environment) regardless of [NAME]-drug resistant organism status. High contact activities include dressing, bathing/showering, providing hygiene, and transferring. The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism. Examples of chronic wounds include, but are not limited to, pressure ulcers and examples of indwelling medical devices included urinary catheters. The memo documented enhanced barrier precautions are employed for high contact resident care activities. Resident #2 had diagnoses that included multiple sclerosis (an autoimmune disorder that affects the brain, spinal cord, and other nerves), pressure ulcer of sacral region and neuromuscular dysfunction of bladder (a condition where the bladder function is impaired due to a brain, spinal cord or nerve problem). The Minimum Data Set (a resident assessment tool) dated 9/8/24 documented Resident #2 was cognitively intact, understands others, and was understood by others. Resident #2 required substantial assistance for personal hygiene and was dependent on staff for toileting hygiene and transfers. Additionally, they had a urinary catheter (a thin tube inserted into the bladder to drain urine) and a stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. The comprehensive care plan dated 7/12/23 documented that Resident #2 required extensive assist for bathing/showering and was dependent for toilet hygiene/clothing management. They required a full mechanical lift with 2 person assist for transfers. The comprehensive care plan initiated 8/23/23 documented the resident had a neurogenic bladder that required a suprapubic catheter and had a stage 4 pressure ulcer on their sacrum. The comprehensive care plan did not document evidence that Resident #2 was on enhanced barrier precautions. Review of the Kardex (a guide for resident care) dated 10/2/24 documented that Resident#2 had a urinary catheter. There was no documented evidence that Resident #2 was on enhanced barrier precautions. During an observation on 9/26/24 at 9:43 AM, an orange-colored Enhanced Barrier Precaution sign was observed on Resident #2's room door. During an observation on 10/1/24 at 10:22 AM-11:00 AM, Certified Nurse Aide #3 was observed providing hands on morning care for Resident #2 that included bathing, hygiene, and dressing wearing only gloves. The Certified Nurse Aide #3 was not wearing a gown. Registered Nurse #2 Unit Manager assisted Certified Nurse Aide #3 with positioning Resident #2's transfer sling, adjustment of their clothing and transfer out of bed while wearing gloves and no gown. Registered Nurse #2 Unit Manager and Certified Nurse Aide #3's clothing was observed in direct contact with the resident's bedding during care. During an observation and interview on 10/2/24 at 10:53 AM, Certified Nurse Aide #3 was providing hands on care, wearing only gloves, to Resident #2 while they were in their bed without wearing a gown. Certified Nurse Aide #3 stated they didn't know they had to gown up during hands on care of residents with urinary catheters. They stated they identified what residents were on precautions by the signs posted on their hallway door, or by the resident's care plan. Certified Nurse Aide #3 stated they did not gown up during hands on care with Resident #2 on 10/1/24 or 10/2/24 and they should have because something could have splashed on them, or they could have had contact with the resident's wound. Certified Nurse Aide #3 stated they did not see the enhanced barrier precaution sign posted on Resident #2's door. During an interview on 10/2/24 at 11:11 AM, Licensed Practical Nurse #3 stated they can identify what residents are on enhanced barrier precautions by the signs posted on the residents' doors. They stated the precaution sign told them what personal protective equipment was to be worn with catheter and wound care. During an interview on 10/2/24 at 11:28 AM, Registered Nurse #2 Unit Manager stated enhanced barrier precautions were for residents that had a urinary catheter or were receiving active wound care. They stated that personal protective equipment was required when emptying, providing urinary catheter care and when performing wound care such as dressing changes. Registered Nurse #2 Unit Manager stated a gown was not required during care if care didn't involve managing a urinary catheter or wound. They stated they didn't believe they needed to wear gown prior to assisting with Resident #2's care on 10/1/24 because they weren't managing their catheter or pressure wound at that time. During an interview on 10/2/24 at 3:37 PM, the Director of Nursing stated nursing staff should be wearing gowns when they were performing high contact activities on residents who were on enhanced barrier precautions. The Director of Nursing expected nurses, aides, whoever was performing care to follow the precaution signs posted for the resident's protection and safety. During an interview on 10/3/24 at 10:48 AM, the Registered Nurse #1 Unit Manager/Infection Preventionist stated staff were supposed to wear personal protective equipment that included gowns and gloves while they provided hands on care, bathing and any personal hygiene to residents who were on enhanced barrier precautions. Residents who were on enhanced barrier precautions included anyone with central lines, urinary catheters, or open wounds. It was important for staff to wear the gown and gloves to reduce the risk of spreading multi drug resistant organisms. The Registered Nurse Unit Manager #1/Infection Preventionist stated they would need to work on more education with the staff. 10 NYCRR 415.19(a)(2)

Based on observation, record review, and interviews conducted during the Extended survey completed on 10/3/24, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft for one (Resident #51) of three residents reviewed for personal property. Specifically, Resident #51 had no pants available to wear in their closet and their inventory sheets documented the resident had 17 pairs of pants. The finding is: Resident #51 had diagnoses including dementia, age related physical debility, and high blood pressure. The Minimum Data Set (a resident assessment tool) dated 8/11/24 documented the resident had moderately impaired cognition. The comprehensive care plan dated 8/21/24 documented the resident required extensive assistance with dressing, was non ambulatory, and was not able to make their needs known. During a telephone interview on 9/27/24 at 9:54 AM, the resident's family member stated when they came to visit, the resident would be wearing clothes that were too small for them, like they weren't the clothes they had brought in for the resident. The family member stated the resident's clothes were always missing, they get labeled with the resident's name but that didn't mean anything. When asked if the resident owned a red (name of video character) t shirt that they were observed wearing that morning, the family member stated, no that was not something they brought in for the resident. During an observation and interview on 9/30/24 at 1:29 PM, Certified Nurse Aide #1 exited Resident #51's room and stated they needed pants for the resident and the resident didn't have any in their room. Certified Nurse Aide #1 then went into the resident's room. The resident was observed sitting in their chair with an incontinence brief on and no pants. Observation of the resident's closet revealed there were t shirts and long-sleeved shirts on hangers, but there were no pants available. Certified Nurse Aide #1 stated the resident used to have a bunch and that new staff might put them in a wrong bag or maybe laundry didn't bring them up yet. The Unit Secretary brought a pair of maroon-colored pants for the resident, the Certified Nurse Aide #1 stated they were not the resident's pants, they were extra. During an observation and interview on 10/1/24 at 8:56 AM, Registered Nurse Unit Manager #1 went to the laundry area to look for pants for Resident #51. They looked around the laundry area where there were clean clothes on hangers and another pile of clothes that were unlabeled and stated they could have been the resident's pants, but they were not labeled. The Laundry Attendant #1 arrived and stated they brought up a pair of pants for Resident #51 last night and hasn't seen any pants for that resident. Registered Nurse Unit Manager #1 stated that the resident was wearing those pair of pants right now. Observation on 10/1/24 at 9:56 AM, the Laundry Attendant #1 passed out laundry on the unit. At 10:03 AM, observation of Resident #51's closet revealed there were no pants. Review of Resident #51's Resident Inventory Personal Linen/Appliances dated 3/22/23 and 1/11/24 documented the resident had 17 pairs of pants. They were described as joggers, lounge, or sweatpants in assorted colors. During an interview on 10/1/24 at 10:18 AM, Registered Nurse Unit Manager #1 reviewed the inventory lists and stated the resident should have like 30 pairs of pants. The Registered Nurse Unit Manager #1 stated they were not sure where the pants were, they would wait for laundry to get through what they had, but she hopes there weren't 30 pairs of the resident's pants in laundry. The Certified Nurse Aides were supposed to put resident's personal clothing in purple bags that were then taken down to laundry. Maybe more re-education was needed for staff on which bags staff were to use for personal clothing. During an interview on 10/1/24 at 12:41 PM, Social Worker #1 stated they bought four pairs of new pants for Resident #51, and they would let the family member know about them. During an interview on 10/1/24 at 1:06 PM, Social Worker #1 stated they were aware the resident was getting low on pants in the last couple of days. At times there might be more of a lag with laundry. Social Worker #1 stated they didn't know if they would find all the resident's pants but was hopeful for finding at least 6 pairs. When families bring clothing in, they are inventoried and sent down to laundry to be labeled. Social Worker #1 stated they were not exactly sure why so many of this resident's pants were missing, but they use an offsite laundry service for facility linens so maybe the personal items were getting put into the wrong-colored bags. Social Worker #1 stated when items went missing the business office needed receipts for reimbursement, so they asked families to buy replacements and submit the receipts. Social Worker #1 stated the resident's family had been reimbursed for clothing items in May 2023 but don't have any further reimbursements or grievance/customer service forms since then. During an interview on 10/3/24 at 11:06 AM, Registered Nurse Unit Manager #1 stated they tried to ensure resident's personal property was kept safe from loss by using the different color bags to keep personal clothing separate from facility linens. If staff weren't using this process, things could get lost. When asked if this process worked, the Registered Nurse Unit Manager #1 stated yes and no. During an interview on 10/3/24 at 11:29 AM, the Director of Nursing stated the facility ensured resident's personal items were safe from loss by having the items logged when they come in. If clothing goes missing, they have social work fill out a customer service form or sometimes they could be in laundry as the resident can go through a few pairs per day. The Director of Nursing stated staff were supposed to know that personal clothes go into the purple bags, and they had not witnessed any staff placing personal clothing in the wrong bags. During an interview on 10/3/24 at 12:05 PM, the Administrator stated they had no policies about providing a homelike environment or safeguarding of personal belongings. At 1:56 PM, the Administrator stated they didn't have any policies on laundry either and that resident clothing inventory sheets were part of the admission packet that staff completed. NYCRR10 415.5(h)(1)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint # NY00305155) completed on 12/9/22, the facility did not ensure that the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents for two (Resident #1 and #2) of three residents reviewed. Specifically, every shift (Q shift) safety checks of Resident #1's wander guard device did not occur after the device was assigned, and every 15-minute checks were not performed while the wander guard system was not functional (#1 and #2). Additionally, the facility did not complete regular safety checks of the wander guard (electronic wander management) system at the Skilled Nursing Facility (SNF) exit into the attached hospital's service corridor. The facility did not have a policy and procedure in place, or the manufacturer's manual related to the operation and maintenance of the wander guard system. The findings are: 1. Resident #1 had diagnoses that included chronic obstructive pulmonary disease (a chronic inflammatory lung disease) and dementia. Review of the Minimum Data Set (MDS, resident assessment tool) dated 10/11/22 revealed Resident #1 had severe cognitive impairment and had no wandering behaviors. The Certified Nurse Aide (CNA) care plan (guide used by staff to provide care) dated 11/5/22 documented Resident #1 was non-ambulatory and needed extensive assist in a manual wheelchair for mobility. A Progress Note, written by the Registered Nurse (RN #1), dated 11/5/22, documented Resident #1 was found in the main hospital corridor heading toward the hospital kitchen in their wheelchair. Resident #1 was returned to the facility and was placed on Q 15-minute checks. An undated summary of events, signed by the Director of Nursing (DON), documented the following plan: -Resident #1 was placed on Q 15-minute checks as the Nursing Supervisor were unable to activate a wander guard monitor device. -A wander guard monitor device was placed on Resident #1's left ankle for safety on 11/7/22. Review of the Treatment Administration Record (TAR) for Resident #1 revealed the following: Wander guard Placement Check - staff to check placement Q shift. Notify Security immediately if missing or broken. Every shift for Wander guard placement left ankle. Start date 12/9/22. During an observation on 12/9/22 at 11:00 AM revealed the door to the Wet Room in the hospital was unlocked and contained floor machines and housekeeping supplies. The distance between the SNF exit doors and the Wet Room door was approximately 226 feet. During an observation of Resident #1 in the Main Dining Room on 12/9/22 at 11:20 AM revealed Resident #1 had a wander guard monitor device on their left ankle. During an interview on 12/9/22 at 3:30 PM, the First Floor RN Unit Manager #1 stated Resident #1's wander guard monitor checks were started today (12/9). The First Floor RN UM #1 stated the nurse who initially placed the wander guard monitor device on the resident should have added the Q shift checks to the TAR at that time. In the case of Resident #1, that was missed, and it was noticed today the Q shift wander guard monitor checks had not started. Resident #1 initially received their wander guard monitor device about a month ago and the checks should have been performed Q shift since then. During an interview on 12/9/22 at 3:45 PM, the DON stated Resident #1's wander guard monitor Q shift placement checks were not entered into the TAR until today (12/9), and it should have been added to the TAR on the day the monitor device was assigned to Resident #1 (11/7). The supervisor or nurse who placed the monitor device on Resident #1 should have put the order in the TAR at that time. The facility's policy and procedure titled, Elopement Long Term Care/ Missing Person, revised 10/27/22, documented the facility will properly assess residents and plan their care to prevent accidents related to unsafe behavior and/ or elopement. Once a resident has been identified as being at risk for elopement and preventative interventions have been implemented, everything needs to be documented in the resident's chart and communicated to everyone involved with the resident's care. 2. Resident #1 had diagnoses that included chronic obstructive pulmonary disease (a chronic inflammatory lung disease) and dementia. The MDS dated [DATE] revealed Resident #1 had severe cognitive impairment and had no wandering behaviors. The Treatment Administration Record (TAR) for Resident #1 revealed the following: Wander guard Placement Check - staff to check placement Q shift. Notify Security immediately if missing or broken. Every shift for Wander guard placement left ankle. Start date 12/9/22. Resident #2 had diagnoses of dementia, cerebrovascular accident (CVA, stroke), diabetes. The MDS dated [DATE] revealed Resident #2 was cognitively intact and had no wandering behaviors and required extensive assist of one person for ambulation and independent with wheelchair mobility. The TAR dated 11/1/22-12/30/22 documented Resident #2 had a wander guard on their wheelchair that was to be checked for placement every shift. During an interview on 12/9/22 at 8:20 AM, the Manager of Facilities and Environmental Services stated the double doors that lead from the SNF to the hospital service corridor were normally unlocked to allow free access, but when a wander guard monitor device was nearby, the double doors would lock down and an alarm would sound. The Manager of Facilities and Environmental Services further stated the doors would remain locked for 15 seconds. They stated Maintenance staff checked the doors for operation but did not check the wander guard system function. During an observation on 12/9/22 at 8:30 AM revealed the Manager of Facilities and Environmental Services held a wander guard testing device in their hand to test the double doors between the SNF and the hospital service corridor. At this time, the Manager of Facilities and Environmental Services proceeded to open the double doors with no audible alarm and the doors did not lock. At this same time, the DON tested the same double doors with a different wander guard testing device and the doors did not lock and there was no audible alarm. During an interview on 12/9/22 at the time of the observation, the Manager of Facilities and Environmental Services stated the doors should have alarmed, maglocked (held closed by a magnet), and the maglock should have held for 15 seconds, and they were unaware that the system was not working as designed. During an observation on 12/9/22 at 8:40 AM, revealed the Second Floor Registered Nurse Unit Manager (RN UM #2) approached the double doors between the SNF and the hospital service corridor with an activated wander guard. At this time, the Second Floor RN Unit Manager #2 proceeded to test the double doors with the same outcome. During an interview at the time of the observation, the Second Floor RN UM #2 stated the door should have alarmed, locked, and should have stayed locked for 15 seconds. During an additional interview at 12:34 PM, the Second Floor RN UM #2 stated they were not aware that the wander guard system on the double doors between the SNF and the hospital service corridor was not working. During an interview on 12/9/22 at 10:20 AM, CNA #1 stated they did not know if the facility's wander guard system was working today (12/9). During an interview on 12/9/22 at 11:13 AM, CNA #2 stated they stated they did not know if the wander guard system was working at this time. During an interview on 12/9/22 at 11:17 AM, CNA #3 they started their shift today at 10 AM and were not sure if the system was working at this time. During an interview on 12/9/22 at 12:34 PM, the Second Floor RN UM #2 stated when there is a malfunction of the wander guard system, the procedure was to call the outside vendor for service immediately and to place all residents with wander guard monitor devices on Q 15-minute checks. During an interview on 12/9/22 at 12:22 PM, the First Floor RN UM #1 stated Licensed Practical Nurses (LPNs) checked the wander guard monitor for each resident that was assigned one Q shift. The LPNs' checks included observing that the monitor was present on the resident and checking that the monitor was activated by using a hand-held testing device. The information was entered into each resident's treatment administration record (TAR). The RN UM #1 stated nursing staff did not perform any checks of the wander guard monitors near the door sensors to test for activation. Review of an internal email dated 12/1/22 from the Administrator to the Manager of Facilities and Environmental Services documented, I tested the double doors with the wander guard. The door locked when the wander guard was in range. It released after 15 seconds, and the alarm sounded. During an interview on 12/9/22 at 2:04 PM, the DON stated the Administrator did not normally check the doors, it was only a one-time check on 12/1/22. The DON stated they did not know why the Administrator checked the doors on 12/1/22 and the Administrator was not available to provide further information. The DON also stated Security did check doors routinely. During an interview on 12/9/22 at 3:55 PM, the Security Officer stated the double doors between the SNF, and the hospital service corridor were always open, therefore Security did not check them. During an interview on 12/9/22 at 3:20 PM, LPN #1 stated the wander guard system should be working at this time, they came into the facility today at 2:00 PM, and they did not hear anything about a malfunction of the wander guard system. If the wander guard system is not working properly, we perform Q 15-minute checks on those residents with wander guard monitor devices. LPN #1 further stated they were not performing any Q 15-minute checks of any residents today. During an interview on 12/9/22 at 3:30 PM, the First Floor RN UM #1 stated when the wander guard system is not working properly, Q 15-minute checks are done on residents with wander guard monitor devices. They stated there were two residents currently with wander guard monitor devices (#1 and #2) and Q 15-minute checks were not performed on either of those residents today and there was no official documentation. During an interview on 12/9/22 at 3:45 PM, the DON stated when the wander guard system is malfunctioning, staff is supposed to keep an eye on the door and keep the medicine cart close by on the affected side of the building, and if that wasn't possible, staff would do Q 15-minute checks of the residents with wander guard monitor devices. The Q 15-minute checks should be documented. The DON stated there was a nurse on a nearby medicine cart during the day shift today, but that nurse's shift has ended, and they did not assign that nurse to perform Q 15-minute checks or fill out Q 15-minute check logs for Resident #1 or Resident #2. During an interview on 12/9/22 at 12:43 PM, the Manager of Facilities and Environmental Services stated they did not have an owner's manual for the operation and maintenance of the wander guard system. Additionally, on 12/9/22 at 1:15 PM, they stated the Security department also did not have an owner's manual for the wander guard system. During an interview on 12/9/22 at 3:45 PM, the DON stated they could not locate any policies and procedures related to the operation or maintenance of the wander guard system that would be applicable to this facility. 415.12(h)(1)(2)

Based on observation, interview and record review conducted during a Standard Survey completed on 5/14/21, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown origin are thoroughly investigated for one (Resident #24) of three residents reviewed for abuse. Specifically, the facility did not complete an investigation of bruising to the resident's left forehead and left periorbital (area around the eye) area. The finding is: The facility Policy and Procedure (P&P) titled Identification and Reporting of Abuse, Neglect or Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, an investigation of injuries of unknown origin must be immediately investigated to rule out abuse. Injuries included in injuries of unknown origin are, but not limited to, bruising of the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruises in an area not typically vulnerable trauma. When a verbal report or written incident report is received, the principal manager of the department shall initiate the investigative process and notify the Administrator/designee. The P&P titled Long Term Care Incident Reporting Policy revised 11/11 documented where there is possible injury or harm to a resident, the supervisor or person in charge must initiate an Incident Report and the resident is evaluated by a RN and a determination is made if the resident requires emergency care or care can be provided in the facility. Medical provider is consulted. Incident report is completed immediately or as soon as possible after the incident. The incident report must reflect the category of the incident and any descriptive natures. Resident representative is notified, as appropriate. 1. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/14/21 documented the resident sometimes was able to understand and sometimes was able to make self-understood and had severely impaired cognitive skills for daily decision making. The Comprehensive Care Plan initiated 2/10/21 documented Resident #24 had a high risk for falls related to deconditioning, history of fracture and was restless at times, attempted to self-transfer and frequently lowered self onto the floor. Review of Resident #24's Visual/Bedside Kardex Report (guide used by staff to direct care) dated 5/14/21 revealed that skin was to be monitored and to report PRN (as needed) any changes in skin status. Intermittent observations from 5/10/21 to 5/14/21 between 8:58 AM and 4:44 PM revealed Resident #24 had various shades of yellow, and green to light purple bruising to the left side of their forehead and left inner periorbital area that spread under their left eye. Review of the Accident and Incident Work Sheet (A&I) reports from 4/1/21 through 5/12/21 revealed no investigation or documentation of Resident #24's facial bruising. The Progress Notes dated 4/1/21 to 5/12/21 revealed no documentation of bruising to Resident #24's face. Review of the 24-Hour Nursing Report from 4/1/21 through 5/12/21 revealed no documentation of facial bruising for Resident #24. During an interview on 5/13/21 at 4:23 PM, CNA #7 stated that the first time they noted bruising to Resident #24's forehead was on 5/12/21 and that it was reported to LPN #2. During an interview on 5/13/21 at 4:44 PM, LPN #2 stated he was unaware of any skin issue on Resident #24's face. After observation of Resident #24, LPN #2 stated the area on the forehead and eye appeared to be an old bruise and he had not noticed the area until now. LPN #2 stated they would report any new skin areas to their supervisor and the supervisor would do an assessment and notify the medical doctor on call. During an interview on 5/13/21 at 4:31 PM, RN #6 (3:00 PM-11:00 PM shift supervisor) observed the area to Resident #24's face and stated it appeared the resident had bruising on their eye and forehead. RN #6 stated they did not know how the bruise happened and they did not see the bruise until now. RN #6 stated that if a bruise was noted on a resident or if staff reported a bruise, the process was to start an investigation, do a head to toe assessment of the resident, the supervisor would start an A&I form, and the bruise would get documented on shift report and in the medical record. During an interview on 5/14/21 at 8:12 AM, CNA #6 stated that they could not recall the date they noticed Resident #24's bruise, but at that time the bruise was darker in color and they reported it to LPN #3. During an interview on 5/14/21 at 8:58 AM, RN #7 Unit Manager observed Resident #24's face and stated that the areas to the resident's forehead and eye were fading ecchymosis (bruising). RN #7 stated they did not recall seeing the bruising until today. RN #7 stated that if a resident had a bruise, an investigation should be started. RN #7 also stated if the bruise could be contributed to another A&I it would be added to that A&I report and a nursing note should be written in the medical record. During a telephone interview on 5/14/21 at 10:23 AM, RN #5 (11:00 PM-7:00 AM part-time supervisor) stated the first time they noted bruising to the resident's face was on 5/13/21 when RN #6 wrote an A&I report. RN #5 stated no staff reported the resident had bruises on their face. RN #5 stated the process would be to start an A&I, start an investigation and question the staff. RN #5 also stated that if the bruising appeared old, they would not start an A&I, but write a nursing note and report it to the nurse manager. During a telephone interview on 5/14/21 at 10:30 AM, LPN #3 stated that on 5/8/21 they noticed Resident #24 had yellow bruising to their left eye and forehead and that it was reported to RN #5. LPN #3 stated they did not document the bruise in the nursing notes because they assumed it was from when the resident fell a few days prior, but that they should have documented it. During an interview on 5/14/21 at 10:58 AM, the Director of Nursing (DON) stated that it was brought to her attention on 5/13/21 that Resident #24 had yellowing bruising on their forehead that extended into the periorbital area. The DON stated they expected the supervisor would assess the area of concern, start an A&I, continue to report on it for three days on the report sheet, and document the assessment in the medical record. The DON stated they expected that the bruise would have been investigated even if it was believed to be from a fall. During an interview on 5/14/21 at 11:18 AM, the Administer stated that they expected an investigation would be started by the supervisor or unit manager when bruising was noted on a resident. The investigation would include getting statement from staff members from the previous shifts and that this could lead to writing an A&I if the injury could not be contributed to another cause. The administrator stated that the bruising should be documented in the medical record. 415.4(b)(3)

Based on observation, interview, and record review completed during the Standard survey completed on 5/14/21, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #6) of two residents observed for pressure ulcers. Specifically, infection control practices were not maintained during a pressure ulcer treatment application and the treatment was not completed as ordered by the physician. The finding is: Review of facility policy titled Physician Orders- Long Term Care (LTC) dated 7/21/14 documented telephone or other verbal orders shall be accepted only by a license nurse, pharmacist or such other licensed practitioner as permitted by law. Telephone and verbal orders that follow this policy are considered to be valid orders and will be executed as if the authorized prescriber wrote them. Review of the facility policy titled Pressure Ulcers-LTC revised 11/17 documented the resident's Comprehensive Interdisciplinary Care Plan will be reviewed and/or revised by the members of the interdisciplinary team within 72 hours following a change in any pressure ulcer monitoring point. Review of the facility's policy entitled Hand Washing revised 10/14/19 documented hand hygiene is considered the most important measure for reducing the transmission of microorganisms in healthcare facilities. Hand hygiene is a general term that applies to either handwashing, antiseptic hand wash/alcohol-based hand rub (ABHR), or surgical hand hygiene/antisepsis. Hand hygiene is a practice that must be done faithfully by all personnel without exception. Hand hygiene will be performed by personnel that perform procedures on patients, even though gloves are worn. 1. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/7/21 revealed the resident had severe cognitive impairment and had one unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. Review of the comprehensive care plan revised on 5/9/21 documented Resident #6 had an unstageable chronic ulcer on the right posterior thigh. Interventions included to administer treatments as ordered and monitor effectiveness. Review of a nursing Progress Note dated 4/8/21 at 12:42 AM documented the Nurse Practitioner (NP) saw Resident #6 and new orders were received for a wound culture (test to find and identify a microorganism causing an infection in a wound) of the right thigh area and the treatment was changed. Review of SNF (Skilled Nursing Facility) Physician Telephone Orders dated 4/8/21, signed by the provider, documented the following: -Discontinue current right posterior thigh treatment; irrigate with normal saline (NS-solution used for wound cleansing) and apply Santyl ointment (promotes the removal of necrotic (dead) tissue and advances wound healing) and pack with gauze every day -Also apply [MEDICATION(S)] powder (medication used to treat bacterial infection and reduce odor) Review of the Bacteriology report dated 4/11/21 documented the right thigh wound culture was positive for Proteus Mirabilis and Staphylococcus Aureus (bacteria that indicated infection). Review of the Wound-Weekly Observation Tool dated 5/7/21 documented Resident #6's right posterior thigh pressure ulcer measured 3.6 centimeters (cm) length (L) x 3.4 cm width (W) x 2.4 cm depth (D). During an observation on 5/13/21 at 9:49 AM, Licensed Practical Nurse (LPN) #1 washed their hands, applied clean gloves, and assisted Resident #6 to lay on their left side. LPN #1 removed the moderately soiled dressing from the resident's right posterior thigh wound and removed moderately soiled gauze packing from the ulcer. With the same gloved hands, LPN #1 irrigated the wound with NS then patted the wound dry with gauze. LPN #1 removed their gloves, did not perform hand hygiene, and put on a new pair of clean gloves. LPN #1 picked up the [MEDICATION(S)] container, poured the powder onto a 3x3 gauze pad, and patted the powder into the wound. LPN #1 poured more [MEDICATION(S)] powder onto the same gauze and packed the gauze into the wound. Wearing the same gloves, LPN #1 then squeezed santyl ointment from the tube onto to their gloved finger and applied it on the skin edges surrounding the wound. The santyl was not applied to the wound bed. Wearing the same gloves, LPN #1 placed dry clean gauze over the packing in the wound. During an interview on 5/13/21 at 10:04 AM, LPN #1 stated they reviewed the physician's order prior to completing the treatment, that they should have put Santyl on the gauze before the [MEDICATION(S)] powder, because it should have been placed on the wound, and should have used an applicator to apply the ointment, not their gloved finger. LPN #1 also stated they should have washed their hands after removing the previous soiled treatment and before applying a new treatment, for proper infection control. During an interview on 5/14/21 at 9:12 AM, Registered Nurse (RN) #7 Unit Manager stated they expected staff to apply Santyl and [MEDICATION(S)] powder to a wound bed after the wound was irrigated with NS. RN #7 stated they would also expect hand hygiene to be performed after removing the old treatment, prior to completed the new treatment due to infection control purposes and cross contamination. During an interview on 5/14/21 at 11:04 AM, the Director of Nurses (DON) stated they expected the staff to follow the treatment orders and complete treatments as ordered by the physician. The DON stated they expected hand hygiene be performed after removing soiled dressings and gloves, prior to application of a new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 415.12(c)(2)

Based on observation, record review, and interview completed during the Standard survey completed 5/14/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion for one (Resident #7) of two residents observed for range of motion (ROM-normal range of motion of a joint) services. Specifically, Resident #7 did not have rolled washcloths to the right and left hands as recommended by OT (Occupational Therapy), and lacked comprehensive assessments, including measurements of joint mobility. Additionally, there was no documented evidence to support range of motion services were provided as recommended. The finding is: The facility policy and procedure (P&P) entitled Physical / Occupational Therapy- SNF-Range of Motion (Preventative routine) dated 7/23/19 documented ROM programs are implemented by the rehabilitation department to prevent and manage contractures, maintain joint mobility, and for stretching of upper extremities and lower extremities muscles for functional benefits. ROM Programs are completed by ROM CNAs (Certified Nursing Assistants) per therapists' recommendations. The ROM program is documented in the computer system by the therapy department, exercises are provided by ROM CNAs per resident's schedule and documentation is completed in the computer system. The range of motion program is reviewed on quarterly basis and as requested by nursing. 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/2/21 revealed the resident was rarely/never understood, and had long term and short-term memory problems. The MDS documented the resident had functional limitations on both sides of upper and lower extremities. Review of the comprehensive care plan initiated on 7/22/16 revealed Resident #7 had limited ROM related to limited mobility with a revised intervention dated 11/17/20 to include PROM (passive range of motion - someone physically moves or stretches a part of the body) to bilateral upper and lower extremities 3 times per week. In addition, the resident had an ADL (activities of daily living) self-care performance deficit related to impaired cognition with revised interventions dated 6/25/19 to include B (bilateral) wash cloth roll during the day as tolerated 3 days per week. Review of the Kardex Report (a guide used by staff to provide care) dated 5/12/21 revealed interventions included PROM to bilateral upper and lower extremities 3 times per week and B (bilateral) wash cloth rolls during the day as tolerated 3 days per week. Review of the POC Response History report from April 13, 2021 through 5/12/21 revealed the resident was to receive PROM 3 times per week to their bilateral upper extremities (BUE) and bilateral lower extremities (BLE). There was no documented evidence that PROM was provided to the resident as recommended and per the care plan. Review of the Occupational Therapy Plan of Care dated 3/27/19 through 5/11/21 revealed there were no documented measurements of the resident's BUE ROM. In addition, the Occupational Therapy Plan of Care documented PROM 3 times per week to BUE. The Progress Notes dated 5/10/21 at 7:33 AM, written by Occupational Therapist (OT) #3 documented B wash cloth roll during the day as tolerated 3 days per week, BUE PROM 3 times per week with the ROM aide. Intermittent observation from 5/10/21 to 5/12/21 between 8:00 AM to 4:00 PM revealed Resident #7 did not have rolled wash cloths in either hand. The resident's fingers on bilateral hands were curled in toward their palms. During an interview on 5/12/21 at 11:50 AM, the Lead Physical Therapist stated Resident #7's contractures should have been measured at least annually and the last documented measurements available in the medical record were from July 2018. The Lead Physical Therapist stated the resident was on a therapy program in 2019, 2020, and 2021 and there was no documented evidence the upper extremity contractures were measured. During an interview on 5/12/21 at 12:35 PM, CNA #2 stated she was the ROM aide for the facility, but had worked frequently as a CNA, therefore the CNAs were responsible to complete the ROM for their assigned residents. CNA #2 stated the ROM task gets documented in the computer system. During an interview on 5/12/21 at 12:55 PM, CNA #1 stated she performed ROM to the Resident #7's elbows only, and didn't do the resident's wrists and fingers because they were too contracted. CNA #1 stated she didn't look at the Kardex to know what ROM was recommended for Resident #7 and she was not educated on how to perform ROM. Observation and interview on 5/12/21 at 1:36 PM, revealed OT #1 completed the measurements of Resident #7's BUE including shoulders, elbows, wrists and fingers. OT #1 stated the measurements should have been completed at least annually and the resident was care planned for rolled wash cloths to both hands 3 times per week which were not in the resident's hands at this time. During an interview on 5/12/21 at 3:30 PM, OT #1 stated she compared Resident #7's previously documented measurements from 2018 and stated the resident had decreased ROM in both elbows and shoulders and due to the lack of yearly measurements was unable to determine when the resident had the decline. OT #1 stated the CNAs were to supposed document the completion of ROM in the computer system. Upon review of the POC Response History from April 13, 2021 through 5/12/21, OT #1 stated there was no documented evidence the resident had received ROM as recommended. Intermittent observations on 5/13/21 at 8:31 AM, 9:25 AM, and 10:10 AM revealed Resident #7 had no rolled wash cloths in bilateral hands. During an interview and observation on 5/13/21 at 10:10 AM, CNA #2 stated she completed Resident #7's AM care and that she didn't know the resident had recommendations for rolled washcloths in bilateral hands. CNA #2 reviewed the resident's Kardex, verified the recommendation and placed the rolled washcloths into both of the resident's hands. CNA #2 stated the recommendation was for 3 times a week, there were no set days of the week, and it was not a task that got documented. CNA #2 stated they were uncertain when the washcloths were to be placed into the resident's hands. During an interview on 5/13/21 at 10:42 AM, the Director of Nursing (DON) stated she expected the CNA's to document completion of ROM in the computer system, but there was a glitch in the computer system and not all the CNA's could see the ROM recommendations. The DON stated there was no documented evidence ROM was performed as recommended for Resident #7. In addition; the DON stated she expected the CNA's to apply the wash cloths to the resident's hands as recommended, 3 times per week. The DON stated there was no documented evidence the recommendation was completed, there were no scheduled set days the wash-cloths were to be applied, therefore, she did not know how the staff would know what days of the week to apply the wash cloths to the resident's hands. The DON also stated she expected the therapy department to measure the resident's upper extremity contractures annually and it was the Lead Physical Therapist's responsibility to ensure that contractures were measured annually. During an interview on 5/13/21 at 11:11 AM, the Lead Physical Therapist stated he expected the CNA's to complete the ROM and apply the wash cloths to the residents hands as recommended to prevent further contractures but there was no documentation that these interventions were completed as recommended. During an interview on 5/14/21 at 9:01 AM, the Administrator stated he expected the nursing staff to follow the recommendations from therapy. 415.12 (e)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 905) completed during the Standard Survey on 5/14/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, one (Resident #216) of two residents reviewed for quality of care lacked follow up to have staples removed, from left hip, that were in place greater than three weeks. The finding is: Review of the facility policy and procedure entitled Staple Removal dated 3/19/19 revealed this document outlines the responsibilities of the Registered Nurse (RN) to safely remove incision closures (staples) used to approximate edges of an incision after healing has occurred. Instructions included check the Medical Doctor (MD)/Nurse Practitioner (NP) order to determine the details for the procedure. Document in a progress note the procedure, condition of incision, pertinent observations, and resident tolerance to the procedure in the resident's electronic medical record (EMR). 1. Resident #216 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS- a resident assessment tool) dated 2/11/20 documented the resident had severe cognitive impairment, a surgical wound and surgical wound care. Review of the hospital Discharge Summary dated 2/4/2020 revealed under Hospital course: Patient admitted with the diagnose of mechanical fall induced left hip fracture. Orthopedic surgeon (doctor who specializes in bones, joints, tendons, and muscles) was asked to see the patient who did intramedullary nailing (surgery to repair a broken bone) of the left intertrochanteric fracture (broken hip). Review of the Skilled Nursing Facility Admission Data Sheet dated 2/4/20 under Skin Integrity: documented a left leg/thigh (inner) scar. There was no description of the site. Review of the left hip x-ray Final Report dated and initialed on 2/6/20 revealed under Findings: 3 views of the left hip joint demonstrated ORIF (open reduction internal fixation, a surgical repair of hip fracture) of intertrochanteric fracture left femur with a metallic screw and intramedullary rod. Skin staples seen along the lateral (side) aspect. Completed action list revealed x-ray was ordered by the Nurse Practitioner (NP) on 2/6/20. Review of the Comprehensive Care Plan (CCP) dated 2/6/20 revised on 3/2/20 revealed no documentation of the left hip surgical site, plans for surgical follow up, or staple removal. Review of the physician Order Listing Report dated 2/4/20 through 3/3/20 revealed the following orders: 2/4/20- monitor left hip incision for signs/symptoms of infection cover with gauze pad as needed for left hip fracture. 2/22/20- [MEDICATION(S)] Ointment (antibiotic) to left hip incision daily for incisional [CONDITION(S)] (reddening of skin) for 5 days. Keep open to air. 2/22/20 -[MEDICATION(S)] (broad spectrum antibiotic) 100mg BID for incisional [CONDITION(S)] and leukocytosis (increased of white cells in the blood, especially during an infection) for 5 days. Review of the February and March 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 24-Hour Nursing Reports dated 2/4/2020 through 3/3/2020 documented the following: 2/16/20- left hip incision [CONDITION(S)] noted. Staples in place. 2/19/20- left hip incision intact, staples in place. 2/22/20- signs& symptoms of infection to incision left hip, redness found. [MEDICATION(S)] and [MEDICATION(S)] left hip incision x 5 days. 2/23/20- treatment applied to staples, redness continues. 2/24/20- staples intact left hip. 2/28/20- left hip incision [CONDITION(S)] continues, staples in place. 2/29/20- left hip staples intact, [CONDITION(S)] around incision continues. 3/01/20- hip staples intact, [CONDITION(S)] continues. No documented evidence of plans for surgical follow up or staple removal. Review of the Physician History and Physical (Amended) dated 2/4/20 revealed under Physical Exam- Skin left hip surgical site is intact, without signs of dehiscence (splitting or breaking open), rash, new bruising or bleeding noted. No documented evidence of plans for surgical follow up or staple removal. Review of the nursing the Progress Notes dated 2/4/2020 through 3/2/20 revealed the following documentation: 2/4/20 at 8:52 PM admitting dx (diagnosis): S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] 2/6/20 at 6:46 PM reident given one time dose of [MEDICATION(S)] for pain before X-ray. Results from X-ray negative no displaced fragment is seen. 2/21/20 at 11:45 AM interdisciplinary team (IDT) met for a CCP review. Plan of care was reviewed/revised and was deemed appropriate. 2/22/20 at 10:55 AM during shift crusting and [CONDITION(S)] noted around patient's incision site on left hip. NP was updated, new orders for [MEDICATION(S)] 100 milligrams (mg) two times per day (BID) for 5 days, and [MEDICATION(S)] ointment to left hip incision for 5 days and keep open to air. 3/2/20 at 10:35 AM left hip incision intact with slight [CONDITION(S)] (redness). No further concerns at this time. Continue to monitor. 3/3/20 at 11:55 AM discharge instructions were reviewed with patient including follow up appointments. Patient was educated on importance of following up with primary care physician and orthopedic surgeon. Patient was discharged to home via private vehicle with spouse. No documented evidence of plans for surgical follow up or staple removal. Review of the Nurse Practitioner (NP) Progress Notes revealed the following documentation: -2/14/20, 2/17/20, 2/21/20, and 2/28/20 under Physical Exam- Skin: hip surgical incision unremarkable without signs or symptoms of infection. No documented evidence of plans for surgical follow up or staple removal. -2/24/20 under Chief Complaint/Nature of Presenting Problem included incisional [CONDITION(S)]. Additionally, patient started on antibiotic therapy for some incisional [CONDITION(S)]. Plan was reported [CONDITION(S)] ( bacterial infection under the skin) incisional [CONDITION(S)]- not noted today. Will finish antibiotic. Site unremarkable. Review of the NP Discharge Summary dated 3/2/20 documented patient fractured left hip, underwent ORIF, and transferred to facility for restorative therapy. Had some incisional [CONDITION(S)] and underwent short course of [MEDICATION(S)]. Physical Exam- Skin revealed hip surgical incision unremarkable without signs or symptoms of infection. Follow Up Appointments documented surgeon as scheduled. No documented evidence of staple removal. During an interview on 5/14/21 at 7:31 AM, RN #1 Unit Manager (UM) stated the process for a resident getting staples removed depends on the surgeon. Some will have us remove them, others prefer their patient to follow up in the office. The hospital discharge will usually have instructions for staple removal in 10 to 14 days. If there are no orders, we will attempt to call the surgeon. The expectation would be, if not on the hospital discharge instructions, the admitting nurse would document that resident has no follow up appointment and the surgeon would be called to schedule. The nurse who admitted the resident no longer works here and I don't really remember why it was not scheduled. RN #1 UM reviewed the residents EMR and stated the resident was here for a femur fracture and there should be follow up. Either me or the admitting nurse would call the surgeon for surgical follow up orders. RN #1 UM reviewed the residents CCP and stated there were no follow up instructions. That should have been done within the first couple days of a resident being in the facility because we have to do the 48-hour care plan. During an interview on 5/14/21 at 10:25 AM, the NP stated the expectation for staple removal depends on the type of surgery and direction from the surgeons. It should be on the hospital discharge summary orders. If not nursing should contact the surgeon to see when the staples should come out and that would go in the physician orders. While reviewing the residents EMR the NP stated they could not remember the incision, it was over a year ago. I would expect nursing to put it on report and my list to see the resident. They should ask why this incision is red, and why aren't these staples out and there should be follow up. They should have been removed before the resident was discharged and I cannot say why they weren't. During an interview on 5/14/21 at 11:06 AM, the Director of Nursing stated if a resident is admitted with staples and there are no instructions for removal, I would expect a call to the surgeon by the next day for follow up. Staples are usually only left in for 14 days. A month is a long time for staples to be left in. I would expect that a call would have been placed to the surgeon to see when they should be taken out. During an interview on 5/14/21 at 12:52 PM, the Medical Director stated the expectation for a resident with staples is to check with ortho, we would follow up with them and expect that they were removed. The expectation is to have them removed after 14 days. During a follow up interview on 5/14/21 at 1:13 PM, the NP reviewed the 24-Hour Nursing Report documentation of resident with staples. The NP stated there must have been a reason we did not take the staples out. 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 5/14/21, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, one (Resident #14) of one resident reviewed for activities revealed the resident was not asked to participate in activities and was not able to go outside of the facility. The finding is: The facility policy and procedure (P&P) titled Progress Notes - Activities effective date 3/29/16 revealed the Activities Department personnel will periodically, and at least quarterly, assess the resident's response to the activities plan of care and treatment provided. The progress note will be a composite of information obtained from an interview with the resident, the resident's attendance records, the resident's chart and dialogue with other disciplines. The facility P&P titled Long Term Care Activities Programming effective date 3/29/16 revealed the Activities Department will provide a planned activities program seven days a week to include individual, group and independent activities which are age appropriate to the needs, interests and capabilities of each resident and are based on former lifestyle; include a wide variety of activities and encourages the resident's voluntary choices of activity participation; and include a visitation program designed to reach residents who will not or cannot attend other activities. 1. Resident #14 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 2/26/21 documented the resident was cognitively intact. The MDS documented it was somewhat important to have books, newspapers, and magazines to read; do favorite activities; and very important to go outside to get fresh air when the weather is good; and do things with groups of people. During an observation and interview on 5/11/21 at 9:00 AM the resident was in bed, watching TV, no other activity supplies in the room. The resident stated they wanted to play BINGO but it is never offered, and Activities does not provide them with anything to do in their room. During intermittent observations on 5/11/21, 5/12/21, and 5/13/21 there were no available activity supplies in the resident's room except the TV. During an observation on 5/13/21 at 12:44 PM the Activity Department Director offered the resident word search books and room activity supplies. During an observation and interview on 5/14/21 at 7:45 AM a word search book and pencil were on the resident's bedside table. The resident stated they are pleased they have the word search puzzle book so they can do some activities in their room. Review of the Activities - Initial Review dated 2/20/21 revealed resident enjoys watching on television (TV) the news and specific television programs. Reads the newspaper, likes animals, plays BINGO, works jigsaw puzzles and word search puzzles, plays checkers and trouble board games. Resident is alert, oriented and wants to plan their own leisure time, often preferring the comfort of their room. Resident will be offered a variety of in room leisure time choices. Review of the Comprehensive Care Plan (CCP) initiated on 2/20/21 documented the resident is alert and oriented and able to choose their own leisure time with an intervention to provide supplies and/or materials upon request for room activities. Review of the Activity Participation log for Resident #14 dated 4/15/21 through 5/13/21 revealed the resident participated in coffee hours 6 times. No documentation provided with evidence showing the resident received 1 to 1 personal visits, games / trivia, or individual activities. Review of the Progress Note dated 3/10/21 at 8:13 AM documented by the Activities Department Director revealed, the resident is alert and oriented and able to choose their own leisure time. Activities will continue to offer activities of choice and interest. During an interview on 5/13/21 at 12:34 PM the Activities Department Director stated the resident chooses to watch TV and participates in coffee cart, but when BINGO is offered, they would need to sit at their doorway and the resident doesn't like to get out of bed, so they can't participate. The Activity Department Director stated she had not asked the resident if they wanted any activity supplies such as word search books, cross word puzzles, cards brought to the resident's room and thought if the resident wanted something at bedside the resident would have asked for it. During an interview on 5/14/21 at 9:05 AM the Administrator stated his expectation is the Activity Department, upon rounds on a daily basis, ask the residents what kind of activities they would like to participate in and the activity department provide some in-room activities of their choice such as books and puzzles. 415.5(f)(1)

Based on interview, and record review conducted during an Abbreviated survey (Complaint #NY 643) completed on 8/5/19, the facility did not ensure that each resident received treatment and care based on the comprehensive assessment of the resident that is in accordance with professional standards of practice, the comprehensive person-centered care plan for one (Resident #1) of three residents reviewed for quality of care. Specifically, there was lack of a care plan for a resident with a [DIAGNOSES REDACTED]. The finding is: Review of a facility policy and procedure titled Interdisciplinary Care Plan dated as effective on 1/10/11 revealed upon admission, the Charge Nurse/ Nurse Manager will document an interim care plan based on the information obtained from the transferring facility, the discharge summary, initial nursing assessment and physician orders [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Data Sheet dated 7/5/19 completed by a Registered Nurse (RN) documented the resident had bruising on BUE (bilateral upper extremities) and RLE. The resident was alert and oriented, able to make needs known and understands reason for admission. Review of a Progress Note written by an RN dated 7/6/19 at 1:01 AM revealed the resident required two-assist with a sit-to-stand lift for transfers and WBAT (weight bearing as tolerated). A nursing Progress Note dated 7/6/19 at 5:49 AM revealed laboratory (lab) results of a critical hemoglobin (Hgb-protein in red blood cells that carries oxygen) 6.5 (normal is 12-16). The NP (Nurse Practitioner) was called with orders to send to the Emergency Department (ED) for a blood transfusion. The resident was sent to the hospital and admitted on [DATE]. The hospital Discharge Summary dated 7/12/19 revealed a discharge [DIAGNOSES REDACTED]. The resident had been discharged for rehab (rehabilitation) on 7/5/19 but was sent back to the hospital the following day due to lab results for Hgb 6.5. In addition, the Patient Education/Follow Up titled [DIAGNOSES REDACTED], Adult discharge instructions to follow at home revealed, example, avoid any activities that your health care provider says is not safe; be careful not to cut yourself. There were no specific instructions in the Discharge Summary to the facility. The Admission Data Sheet dated 7/12/19 revealed the resident was admitted to the facility with bruising on her RLE, BUE and bilateral hands. The resident required a sit-to-stand lift with two-assist for transfers. The Interim Care Plan dated 7/12/19 documented the resident was at risk for bruising and bleeding. However, the Comprehensive Care Plan (CCP) dated 7/12/19 did not list the [DIAGNOSES REDACTED]. A nursing Progress Note dated 7/17/19 at 4:15 PM documented the resident was sent to the ED from a physician appointment due to concerns for possible LUE (left upper extremity) [MEDICAL CONDITION] (inflammation of tissue under the skin) and low Hgb that required blood [MEDICAL CONDITION]. The resident was admitted to the hospital with [REDACTED]. The hospital Discharge Summary dated 7/24/19 revealed the resident's [DIAGNOSES REDACTED]. Discharge Plan: discharge to the rehab facility with no restrictions in activity. An Addenda to the Discharge Summary documented the resident had [DIAGNOSES REDACTED] (redness) LUE extending from her wrist to above her left elbow and significant amount of ecchymosis (purplish patch caused by blood under the skin) in her BUE. She had a hematoma (collection of blood under skin) in her left bicep area. Assessment included to monitor closely for signs & symptoms of bleeding and hemodynamic instability (perfusion failure, represented by clinical features of circulatory shock and advanced heart failure). The Admission Data Sheet dated 7/24/19 documented the resident was admitted to the facility with [DIAGNOSES REDACTED] A and was noted to have extensive bruising to BUE, RLE, left side of torso (lateral aspect), right foot and right butt/ sacrum (area above the tail bone on right and left buttocks). The transfer status was documented as a one person assist stand-pivot with a gait belt and WBAT. The Interim Care Guide dated 7/24/19 documented the resident's skin was at risk for bleeding/bruising. However, the CCP dated 7/26/19 did not list the [DIAGNOSES REDACTED]. The Nurse Aide Kardex Report (used by Certified Nurse Aides (CNA) to provide care) dated 7/26/19 documented the resident's transfer status was extensive assist one-person with a gait belt and rolling walker. There was no documentation regarding the resident's [DIAGNOSES REDACTED]. Review of an Investigation Summary Form dated 7/27/19 documented that on 7/27/19 the resident and family reported to the supervisor that during the 10:00 PM - 6:00 AM shift the night before, staff used the sit-to-stand lift with the to toilet the resident because she was weak. The resident presented with bruising on the right and left side of her body and back area. The bruises measured 21 centimeters (cm) by 22 cm to the right lateral aspect of torso; two areas measured 22.5 cm by 8.5 cm and 20.5 cm by 7.8 cm to the left lateral side; and one area measured 34 cm by 36 cm on the back . A nursing Progress Note dated 7/28/19 at 10:43 AM documented the resident remained in bed and received medication for nausea. At 2:25 PM the resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The hospital History and Physical dated 7/28/19 documented in the ED the resident was found to be hypotensive; Hgb 5.7 and hematocrit (number of RBC to the total volume of blood) 19.2% (Hct-normal 37-47%). The resident had significant ecchymosis of the proximal BUE, significant ecchymosis covering the resident's back and flank areas wrapping around to her breasts laterally bilaterally. Upon return to rehab, the facility should be made aware that the resident is at significantly increased risk for bleeding and should be handled with extreme care with close monitoring for bleeding. During an interview on 8/2/19 at 9:57 AM, the Medical Director stated that the resident's [DIAGNOSES REDACTED]. The rehab unit was not the correct setting given her diagnosis. Her safety was the priority and she did not fall nor was she cut during her stay at the facility. He was aware of the new bruising leading to the resident's discharge and stated that her blood values had been monitored closely. During an interview on 8/2/19 at 12:29 PM, the Director of Nursing (DON) stated that the resident came in with extensive bruising and had been a sit-to-stand lift with previous admissions. The DON stated that there were no written protocols for [DIAGNOSES REDACTED], but the staff were well aware of how to handle residents at risk for bleeding and bruising. During an interview on 8/2/19 at 9:37 AM, the RN Unit Manager stated that the initial care plan development is based on medications coinciding with diagnoses. During a follow-up interview on 8/2/19 at 1:43 PM, the RN Unit Manager stated that the [DIAGNOSES REDACTED]. 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 3/27/19, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (Unit 2) of two resident units observed for medication storage. Specifically, resident medications were pre-poured, unlabeled and stored in the top drawer of a medication cart. This involved medications for Residents #41, 45, and 70. The finding is: 1. During an observation of the contents of the Unit 2, Team 2 medication cart with Registered Nurse (RN) #1 on 3/25/19 at 7:56 AM revealed there were two 4-ounce plastic cups, and one plastic medication cup containing unlabeled, pre-poured (prepared before the scheduled time of administration) pills located in a single top locked drawer of the medication cart. During an interview on 3/25/19 at 8:00 AM, RN #1 stated the medications were prepared for medication pass on her shift. RN #1 stated I have 20 people to give meds (medications) to. I usually do this when outside of the resident room. I guess I was trying to rush my med pass. RN #1 identified the contents of each cup and the name of the resident who was to receive the medication as follows: - Resident #41: One 4-ounce plastic cup containing one tablet each of [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]), aspirin, [MEDICATION NAME] (blood pressure medication), Senna (laxative), and a couple of other things I can't remember. The 4-ounce plastic cup contained nine tablets. - Resident #45: One 1-ounce plastic medication cup one tablet each of aspirin, [MEDICATION NAME], Senna-S (stimulant laxative), Vitamin B12, and two tablets of Tylenol ([MEDICATION NAME]). The 1-ounce plastic cup contained eight tablets. - Resident #70: One 4-ounce plastic medication cup containing one tablet each of [MEDICATION NAME] (antidepressant), and [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] reflux disease, GERD). In addition, there were crushed medications RN #1 identified as calcium and Vitamin C. The 4-ounce plastic cup contained seven whole tablets. During an interview on 3/25/18 at 8:11 AM, the Director of Nursing (DON) stated medications are not to be pre-poured nor stored pre-poured in the medication cart. Medications should be poured at the time of administration. During an interview on 3/27/19 at 12:47 PM, the Consultant Pharmacist stated the pre-pouring of medications was inappropriate when passing medications to residents. Medications should be poured immediately prior to administration to ensure the correct resident is receiving the correct medication. During an interview on 3/27/19 at 1:06 PM, a Pharmacist from the dispensing pharmacy stated medication packets should be opened at the time of administration. The Pharmacist would not recommend the pre-pouring of medications as the medications are being stored unlabeled with resident name, name of medication, and expiration date. 415.18(d)(e)

Based on observation, interview and record review conducted during the Standard survey completed on 12/4/17, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, one (Unit 2) of two resident units observed for blood glucose meter testing did not provide proper cleansing and disinfecting of shared glucose meters between resident use in accordance with the manufacture's guidelines. Residents #65 and 132 were involved. In addition, the facility's Legionella Management Program did not have a water management plan available for review. The findings are: 1. Review of the facility's current policy and procedure (P&P) entitled Infection Control dated 3/1/103 revealed that all equipment or instruments which are re-used, will be processed according to manufacturer's recommendation and in accordance with disinfection and sterilization policies and procedures. Observation on 12/1/17 at 11:49 AM revealed Registered Nurse (RN #6) used a Precision Xceed Pro glucose meter to obtain a blood glucose fingerstick (sample of blood obtained by pricking a finger, to determine glucose level) from Resident # 132. After obtaining the fingerstick, the RN left the resident's room and wiped the front and back of the glucose meter for 5 seconds with a Sani-Cloth germicidal disposable wipe and placed the glucose meter on the top of the medication cart. The surface of the glucose meter was observed to dry within 25 seconds. Continued observation on 12/1/17 at 12:14 PM revealed RN #6 obtained supplies and gathered the Precision Xceed Pro glucose meter to obtain a blood glucose fingerstick for Resident # 65. During an interview on 12/1/17 at 12:16 PM, RN #6 stated that when cleaning the glucose meter with the Sani-Cloth, the glucose meter requires 3 minutes dwell time, which means the machine should be dry in 3 minutes. The RN stated she did not know the glucose meter should be wet for 3 minutes for cleansing and disinfection. During an interview on 12/01/17 at 12:19 PM, the RN Infection Control Nurse stated that the glucose meter should remain wet (with the Sani-Cloth germicidal); however, she could not specify how long the glucose meter should remain wet for proper cleansing and disinfection. Review of the CDC (Center for Disease Control) Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings revealed Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be share, the device should be cleaned and disinfected after every use, per manufacturer's instruction, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Review of the manufacturer's instructions for cleaning the Precision Xceed Pro Monitor blood glucose meter, used to test blood glucose levels in the facility, revealed the Precision Xceed Pro Monitor should be cleaned after each patient for infection control; recommend solutions include the Sani-Cloth. Review of the Sani-cloth Plus Germicidal Disposable Cloth container revealed the cleaning procedure stated the following: - All blood and other body fluids must be thoroughly cleansed from surfaces and objects before disinfection by the germicidal wipe. - Open, unfold and use first germicidal wipe to remove heavy soil. - The instructions under Contact time stated Use second germicidal wipe to thoroughly wet surface. Allow to remain wet three (3) minutes, let air dry. Although efficacy at a 30 second contact time has been shown to be adequate against HIV-1, this time is not sufficient for the other organisms listed on this label. Therefore, a 3-minute wet contact time must be for all listed non-HIV organisms. Review of the website for Sani-Cloth Plus, the germicidal wipes have an overall contact time of three minutes. The website revealed that according to the Centers for Disease Control and Prevention Guidelines for Disinfection and Sterilization in Healthcare Settings, the overall contact time is the time it takes the product to disinfect all the microorganisms on the disinfectant's master label. 2. Review of the facility's Legionella Management documents revealed there was no water management plan for the potable water system. Review of the facility P&P entitled Legionella Prevention, Surveillance and Control issued 12/8/08 revealed the P&P contained corporate-wide information. Further review revealed the P&P did not provide site-specific details such as a description of the facility's potable water distribution system, site-specific water control measures, or site-specific procedures for responding to Legionella detection. Additional review revealed the P&P was most recently updated 9/12/16, greater than one year ago. Interview with the Facilities Manager on 12/4/17 at approximately 9:50 AM revealed a water management plan is currently under development and should be available on or about 12/14/17. 415.19(a)(1)(b)(2) 10 NYCRR Subpart 4-2.4

Based on interview and record review conducted during the Standard survey completed on 12/4/17, the facility did not ensure that residents are free from any significant medication errors. One (Resident #61) of thirteen residents reviewed for medications had issues involving the incorrect transcription of medication orders resulting in the omission of [MEDICATION NAME] (antidepressant medication). The finding is: 1. Resident #61 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/5/17 revealed the resident is severely cognitively impaired, rarely to never understands and is rarely to never understood. Review of a policy and procedure entitled LTC (Long Term Care) Medication Reconciliation dated 3/7/11 revealed the policy will delineate the process for obtaining and accurately documenting a complete list of a resident's current medications upon the resident's admission. Upon admission/ transfer to the LTC facility, Nursing/Physician shall compare the list of medications prescribed by the first level provider with the list of medications that will be given in the resident's current level to ensure accuracy. Discrepancies will be reviewed and documented with the Attending Physician. Review of the current Comprehensive Care Plan (CCP) dated 8/1/17 revealed the resident receives the antidepressant medication ([MEDICATION NAME]) related to depression. Planned interventions include administering antidepressant medications as ordered by the physician and monitoring/documenting side effects and effectiveness. Review of a Senior Living facility's discharge paper work dated 7/26/17 revealed a Medication Review Report included the following medications: [REDACTED] -[MEDICATION NAME] (Tylenol) 325 milligrams (mg), give 2 tablets every 6 hours for pain as needed -[MEDICATION NAME] (medication used to treat gout) 300 mg tablet, give one tablet daily by mouth for chronic gout -Aspirin 325 mg, give one tablet at bedtime related to essential hypertension (high blood pressure that does not have a known secondary cause) -[MEDICATION NAME] 40 mg (medication used to treat high blood pressure), give one tablet at bedtime related to essential hypertension -[MEDICATION NAME] (antipsychotic medication) tablet 0.25 mg, give one tablet by mouth twice a day for behaviors -Rosuvastatin Calcium ([MEDICATION NAME] - medication used to treat high cholesterol) 10 mg give one tablet by mouth at bedtime for [MEDICAL CONDITION] (elevated fat levels in the blood) -[MEDICATION NAME] HCL ([MEDICATION NAME] - antidepressant medication) 100 mg tablet give one tablet by mouth one time daily for major [MEDICAL CONDITION] Additional review of the Senior Living facility's paper work revealed there were handwritten check marks next to all the medications except [MEDICATION NAME]. Review of an interdisciplinary Progress Note dated 7/31/17 at 2:16 PM revealed the resident was admitted to the facility at 11:00 AM, the physician was notified of the admission and medications were reviewed. Review of a Health Status Note Progress Note dated 7/31/17 at 11:01 PM revealed all medications were clarified with the physician. New orders were as follows: discontinue all labs related to comfort approach; change Aspirin to 81 mg daily and [MEDICATION NAME] to 20 mg; and discontinue [MEDICATION NAME]. Review of the physician's History and Physical dated 7/31/17 revealed an assessment plan to continue current [MEDICATION NAME] for depression. Review of the Medication Review Report (admission orders [REDACTED]. A Psychosocial History, Assessment and Plan dated 7/31/17 and signed by the Social Worker (SW #1) documented that the resident is non-verbal and receives [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for behaviors. Review of the Medication Administration Record [REDACTED]. Review of Interdisciplinary Progress Notes dated 7/31/17 to 12/4/17 revealed there was no documentation regarding the discontinuation of the [MEDICATION NAME]. Review of Plan of Care Progress Notes, written by the Social Worker #1, dated 8/2017 to 11/9/17 revealed the following: -8/1/17 - Wife states resident has been in good spirits, she reports no mood issues and is aware of the resident being on [MEDICATION NAME] for depression. -8/17/17 - Resident's mood remains stable, he is on [MEDICATION NAME] for depression -11/9/17 - Resident is on [MEDICATION NAME] for depression Additional review of the Medication Review Reports (computerized physician orders) dated September 2017 through December 3, 2017 revealed there were no orders for [MEDICATION NAME]. Review of the MAR's dated 8/1/17 through 12/4/17 revealed there was no entry for [MEDICATION NAME] and no documented evidence that [MEDICATION NAME] was administered. During an interview 12/01/17 at 9:49 AM, Social Worker #1 stated that Resident #61 is on [MEDICATION NAME] for depression; he has been stable according to her notes; and the resident is care planned for the [MEDICATION NAME] use. During an interview on 12/1/17 at 10:06 AM, the Director of Nursing (DON) reviewed the resident's medical record. The DON stated that the admitting nurse reviews the paper work sent with the resident; checks off the medications; calls the physician to confirm the orders; and enters them into the computer. After reviewing the medical record, the DON stated the resident should have been on [MEDICATION NAME]. In addition, the DON stated that the night shift nurse checks the admission orders [REDACTED]. The Pharmacy Consultant should also be comparing the medications. During an interview on 12/1/17 at approximately 10:25 AM, the DON asked the Registered Nurse (RN #5) Charge Nurse #5 what would be used for the admission orders [REDACTED]. The RN Charge Nurse reviewed the paper work and stated that she was the nurse who checked off the medications on the Medication Review Report and put the orders in the computer. When asked if the resident should have been on the [MEDICATION NAME] that was listed on the Medication Review Report, the RN Charge Nurse reviewed the medical record again, and asked the DON if [MEDICATION NAME] HCL (and pointing in the medical record) is [MEDICATION NAME]. The DON stated yes. The RN Charge Nurse then stated I don't know and walked out of the DON's office. Review of an Admission Order Verification Audit revealed that on 7/31/17 the admission orders [REDACTED]. The form was signed by a night shift RN who completed the audit. During an interview on 12/1/17 at 10:43 AM, the RN (#3) Unit Manager stated that Social Work is responsible for the [MEDICAL CONDITION] medications and care planning for the use of them. The RN Unit Manager stated When we review the resident at the care plan meeting, everyone is responsible for their own sections. RN #3 also stated that she does not reconcile the discharge orders with the admitting orders because the night shift nurse checks them. RN #3 stated that she does not recall if the resident was on [MEDICATION NAME] or should have been on [MEDICATION NAME]. During a telephone interview on 12/1/17 at 11:22 AM, the Pharmacy Consultant stated that he reviews only the orders that are put into the computer by the nurses and he does not reconcile (medication orders) with the discharging facility's paper work. He relies on the nurses for putting the information into the computer system accurately. During an additional telephone interview on 12/1/17 at 2:49 PM, the Pharmacy Consultant stated [MEDICATION NAME] should not be stopped cold turkey, it is a medication that should be tapered, some residents can go through withdrawal. 415.12(m)(2)

Based on observation, interview, and record review conducted during the Standard survey completed 12/4/17, the facility did not ensure that staff treated each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life. One (Resident #31) of five residents observed for dignity during incontinence care was not offered or provided a bedpan to have a bowel movement, when needed. The finding is: 1. Resident #31 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/1/17 revealed the resident has severe memory impairment, usually understands and is understood. The MDS documented that the resident is incontinent of bowel and bladder and requires the extensive assistance of two staff members for bed mobility and toileting needs. Review of the Comprehensive Care Plan (CCP) dated 4/18/17 revealed the resident is incontinent of bowel and bladder related to [MEDICAL CONDITION] (enlargement of the prostate gland) with planned interventions to: administer medications per MD; provide incontinent care every 4 hours and as needed; and utilize the urinal at times, upon request, with staff assist. Review of the Kardex Report (Certified Nurse Aide (CNA) Care Guide) dated 10/6/17 revealed the resident requires total assist for incontinent care every 4 hours and as needed and utilizes the urinal at times, upon request, with staff assist. During an observation of morning care on 11/30/17 at 10:19 AM, the resident stated he had to urinate and move his bowels. CNA #1 continued to provide care and washed the resident's torso. At 10:22 AM, the resident stated That warm water is making me have to go and said he needed to urinate and move his bowels. CNA #1 provided the resident with the urinal. The resident stated he was moving his bowels in the bed. CNA #1 told the resident Do what you got to do. The CNA did not provide the bed pan and allowed the resident to move his bowels in the bed. During further observation on 11/30/17 at 10:28 AM, the resident was incontinent of a large amount of formed stool. While CNA #1 provided incontinence care, the resident's left buttocks was red and irritated and the resident stated his bottom was sore. During an interview on 11/30/17 at 11:01 AM, CNA #1 stated she normally offers the bedpan to the resident, but because he had to urinate and have a bowel movement at the same time she did not know what to and was nervous. The CNA stated she should have offered the bedpan, because it's undignified and stated I did not know what to do first. I would not want to go to the bathroom in bed either. During an interview on 11/30/17 at 11:05 AM, a Registered Nurse (RN #1) stated she would expect the CNA to provide the resident with the bedpan and urinal instead of just allowing him to move his bowels in bed and stated it's undignified. During an interview on 12/2/17 at 1:30 PM, the RN (#2) Unit Manager stated if a resident is aware they need to use the bathroom, she would expect staff to offer a bedpan. During an interview on 12/4/17 at 12:00 PM, the Director of Nurses (DON) stated the expectations are to toilet residents per their plan of care and offer the bed pan and urinal if they are incapable of going to the toilet. The DON stated It's undignified to let someone move their bowels in bed. Review of a document entitled Patients' Bill of Rights dated 8/10 revealed each resident is treated with consideration, respect and full recognition of his/her dignity and individuality, including care for personal needs in order to maintain their Quality of Life. 415.5(a)

Based on interview and record review conducted during the Standard survey completed on 12/4/17, the facility did not ensure the resident's right to refuse treatment. One (Resident # 61) of two residents reviewed for End of Life Care had laboratory (labs) work obtained which was not in accordance with the resident's MOLST (Medical Orders for Life -Sustaining Treatment). The finding is: 1. Resident #61 has was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/5/17 revealed the resident is severely cognitively impaired, rarely to never understands and is rarely to never understood. Review of a policy and procedure (P&P) entitled Advanced Directives - Health Care Proxy, Living Will, MOLST dated 4/15/13 revealed the MOLST is a recognized Physician order [REDACTED]. Review of a History and Physical, completed by the physician, dated 7/31/17 revealed the resident has a Health Care Proxy (HCP) in place and a MOLST form directing Do Not Resuscitate (DNR- to withhold emergency lifesaving measures in the event of the absence of a heartbeat and/or respiration)/ Do Not Intubate (DNI- to withhold the insertion of a breathing tube into the airway to artificially ventilate in the absence of respirations) and do not hospitalize/ complete comfort care (conservative, supportive measures to be provided at the end of life) status. Review of a Medication Review Report (admission orders [REDACTED]. Review of a Family Meeting Progress Note, written by the Social Worker, dated 8/31/17 revealed the resident's HCP is activated. The Social Worker documented MOLST already in place for comfort care, updated to include added limitations of no weights, labs, diagnostics and maximum pain relief. Review of the MOLST form dated 8/31/17, signed by the resident's Health Care Agent, Physician, Social Worker and the Registered Nurse (RN #3) Unit Manager revealed the following orders and instructions: DNR, DNI, Comfort Measures only, Do Not send to the hospital, No feeding tube, No IV (intravenous) fluids, Do Not use antibiotics, No weight, labs, diagnostics, and maximum pain relief. Review of a Consultant Pharmacist Medication Regime Review dated 11/8/17 revealed the resident was receiving ace inhibitor therapy - [MEDICATION NAME] (used to treat hypertension and heart failure). The Pharmacist recommended an electrolyte panel (basic chemistry studies of the blood) seven days after any change of dose/ therapy and at least every six months thereafter or document in the medical record why monitoring is not appropriate for this resident. The Physician signed the document that they were in agreement with the recommendation and to implement the recommendation. Review of physician progress notes [REDACTED]. There were no additional physician progress notes [REDACTED]. Review of the Medication Review Report (physician's orders [REDACTED]. Review of a Lab and Path Report dated 11/21/17 revealed the results of the BMP. Review of the computerized Progress Notes dated 7/31/17 to 12/4/17 revealed no documented evidence that the Health Care Agent was notified regarding the bloodwork order or gave permission to have the BMP drawn. During an interview in the presence of the Director of Nursing (DON) on 12/1/17 at 10:43 AM, the RN (#3) Unit Manager stated that she reviews the Pharmacy recommendations after the Physician signs them and puts any new orders into the computer. RN #3 stated that she did not refer to the resident's MOLST and she should have. RN #3 stated that the BMP should not have been drawn according to the MOLST orders. In addition, the RN stated that she did not call or get permission from the Health Care Agent to have the lab drawn. During an interview on 12/4/17 at approximately 9:07 AM, the Social Worker stated that she was not aware that the resident had blood work drawn despite the MOLST instructions. 415.3(e)(1)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed 12/4/17, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Four (Residents #28, 30, 31, 56) of six residents observed for personal care had issues involving toileting and/or incontinence care that was not provided as planned (#28, 56); barrier cream not applied (#31, 56); and transferring a resident without the use of a gait belt (#30). The findings include but are not limited to: Review of a policy and procedure entitled Incontinent Care, Long Term Care dated 1/11 revealed the Nurse Aides will be responsible for providing incontinent care and /or toileting their assigned resident every 2-4 hours and prn (as needed) or as specified per plan of care. 1. Resident #56 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/29/17 revealed the resident is severely cognitively impaired, is rarely to never understood and rarely to never understands. Further review of the MDS revealed the resident is always incontinent of bowel and bladder, is at risk for pressure ulcers, requires a mechanical lift for transfers and is non- ambulatory. Review of a policy and procedure entitled Incontinent Care, Long Term Care dated 1/11 revealed the Nurse Aides will be responsible for providing incontinent care and/or toileting their assigned resident every 2 to 4 hours and prn (as needed) or as specified per plan of care. Review of the current Comprehensive Care Plan (CCP) dated 7/26/17 revealed the resident is cognitively impaired, not able to make needs known, has limited physical mobility, is incontinent of bowel and bladder, and was identified at risk for pressure ulcers. Planned interventions included a toileting plan to toilet the resident every morning, after meals and at bedtime; checking for incontinence and providing care every two to three hours and as needed; and applying barrier cream after incontinence care. Review of the current Kardex Report (guide used by staff to provide care) dated 11/3/17 revealed instructions to toilet the resident every morning, after meals and at bedtime; check for incontinence and provide care every two to three hours and as needed; and apply barrier cream after incontinence care. Ongoing intermittent observations on 11/28/17 from approximately 8:40 AM to 1:15 PM revealed the resident was not toileted prior to lunch or checked by staff for incontinence. Ongoing intermittent observations on 11/29/17 from approximately 8:00 AM to 12:00 PM revealed the resident was not toileted prior to lunch or checked by staff for incontinence. Ongoing intermittent observation on 11/30/17 from approximately 7:35 AM to 1:00 PM revealed the resident was not toileted prior to lunch or checked for incontinence. Continued observation at 1:05 PM revealed the resident was mechanically lifted into bed with the assistance of two certified nurse aides (CNAs #3 and #4). The resident was observed to be incontinent of a moderate amount of urine and a scant amount of soft stool. CNA #3 provided incontinence care, dried the resident and applied a clean brief while being assisted by CNA #4. The CNAs did not check the Kardex prior to care and did not apply barrier cream as planned after providing incontinence care and before applying a clean brief. During an interview on 11/30/17 at approximately 1:20 PM, CNA #3 stated that she has been at the facility for a few weeks and received orientation. The CNA stated she was taught to read and follow the Kardex and that she has worked with the resident for the past several days. CNA #3 stated that she got the resident up around 7:00 AM and the resident's pattern is that he gets up for before breakfast and they put him back to bed after lunch to change him. The CNA further stated this how they taught me to take care of him. During an interview on 11/30/17 at 1:19 PM, RN #4 stated it is her responsibility to monitor the CNAs. The RN stated she was not aware that Resident #56 was not toileted and that the CNAs should be following the Kardex. RN #4 also stated that the resident has no scheduled treatments to his buttocks and the CNAs should be applying a barrier cream after providing incontinence care. During an interview on 11/30/17 at 1:29 PM, the Director of Nursing (DON) and the surveyor reviewed the resident's Kardex. The DON stated that Resident #56 is to be toileted every morning, after meals and at bedtime, checked for incontinence and provided with care every two to three hours and as needed, and to receive barrier cream after incontinence care. The DON stated that the CNA's should be following the Kardex (plan of care). 2. Resident #28 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairments, is usually understood and sometimes understands. Further review of the MDS revealed the resident is always incontinent of bowel and bladder. Review of the CCP dated 10/6/17 revealed resident has bowel and bladder incontinence related to dementia. Interventions included to provide incontinent care every four hours and as needed. Review of a Kardex Report dated 11/30/17 revealed instructions to provide incontinent care every four hours and as needed. Observation on 12/1/17 at 7:56 AM until 1:38 PM revealed the resident was not provided with incontinence every four hours. Observation at 1:38 PM revealed the resident's incontinence brief was heavily soiled as the resident had been incontinent of bowel and bladder. Interview on 12/1/17 at 2:09 PM CNA #1 revealed that incontinence care was not provided every four hours according to the plan of care. Interview on 12/1/17 at 3:15 PM with RN #2 Unit Manager revealed the Care Plan should be followed and incontinent care should have been provided every four hours. Interview on 12/4/17 at 10:10 AM with the Director of Nursing (DON) revealed the care plan should have been followed and incontinent care should have been provided every four hours. 3. Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairments, is usually understood and sometimes understands. The MDS also documented that the resident is transferred with the limited assistance of one staff member and requires extensive assistance of one staff member for toileting. Review of the resident's CCP dated 11/9/16 revealed the resident has limited physical mobility related to weakness. The CCP documented that the resident requires limited assistance of one staff person with a rolling walker and gait belt (a belt applied to the resident) for transfers. Review of the Kardex Report dated 10/30/17 revealed the resident requires the assistance of one person with a rolling walker and a gait belt (safety device) to transfer. Observations on 12/1/17 at 8:58 AM and 1:22 PM revealed Resident #30 was transferred from the wheel chair to the toilet (in the resident's bathroom) by CNA #4 without the use of a gait belt. Interview with CNA #4 on 12/1/17 at 1:24 PM revealed he should have applied the gait belt to the resident for the transfers. Interview with the RN (#2) Unit Manager on 12/1/17 at 3:15 PM revealed that the Care Plan should be followed and the gait belt should have been applied for the transfers. Interview with the Director of Nursing (DON) on 12/4/17 at 10:10 AM revealed a gait belt is used to guide the resident. The DON stated that the Care Plan should have been followed and a gait belt applied. Interview with a Physical Therapist on 12/4/17 at 10:18 AM revealed a gait belt is recommended for resident transfers for the safety of the resident and staff. The Physical Therapist stated that the Care Plan should be followed and the gait belt should be applied. 415.11(c)(3)(ii)