Every finding on record at Good Samaritan Nursing and Rehabilitation Care Ctr

Based on record review and interviews, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (1) (Resident #7) of one (1) resident reviewed for restraints. Specifically, the quarterly Minimum Data Set assessment dated [DATE] inaccurately indicated Resident #7 utilized a physical restraint in a chair or out of bed, when they did not.The findings include: The facility policy titled, MDS (Minimum Data Set) Completion dated 10/18/2024 documented the Interdisciplinary Team was responsible for completing the assigned sections in the Minimum Data Set. The policy did not document the information provided should also be accurate.Resident #7 has diagnoses that include frontotemporal dementia (an umbrella term for a group of brain diseases that mainly affect the frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior, and language) and depression. The quarterly Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set assessment documented the resident used physical restraints in a chair or out of bed. During an observation on 04/01/2026 at 10:20 AM, the resident was observed seated in a Geri chair (geriatric recliner) in the facility's main dining room with no physical restraint.A review of the resident's Physician Orders from January 2025 to March 2026 revealed no documented evidence that the resident used physical restraints. A review of Resident #7's entire Comprehensive Care Plan revealed no documented evidence that the resident used physical restraints.The annual Rehabilitation Screen dated 11/06/2025 documented the resident's type of wheelchair was a Geri chair. There was no documented evidence that the resident used physical restraints. During an interview on 04/02/2026 at 1:55 PM, Rehabilitation Coordinator #1 stated Resident #7 did not utilize any restraints. Rehabilitation Coordinator #1 stated the resident had poor trunk control and used a Geri chair for proper positioning, decreasing their fall risk, and maintaining their skin integrity. During an interview on 04/03/2026 at 9:55 AM, Registered Nurse Minimum Data Set Coordinator #1 stated the facility was restraint free. Registered Nurse Minimum Data Set Coordinator #1 stated they made a mistake on the quarterly Minimum Data Set assessment dated [DATE] by indicating Resident #7 had physical restraints in a chair or out of bed. Registered Nurse Minimum Data Set Coordinator #1 stated Resident #7 was totally dependent on staff for all Activities of Daily Living, had poor trunk control, could not sit upright, and could not move unless someone moved them, therefore use of the Geri chair was not considered a restraint. During an interview on 04/03/2026 at 12:15 PM, the Director of Nursing Services stated the documentation in the quarterly Minimum Data Set assessment dated [DATE] regarding the physical restraint was a mistake. Director of Nursing Services stated the information documented in a Minimum Data Ser assessment was expected to be accurate. During an interview on 04/03/2026 at 1:35 PM, the Administrator stated they would expect the information documented in a Minimum Data Set assessment to be accurate. 10 New York Code Rules and Regulations 415.11(b)

Based on observation, record review, and interviews, the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs. This was identified for one (Resident #7) of one resident reviewed for Restraints. Specifically, the Resident #7's out of bed status was not accurately reflected in the Comprehensive Care Plan The findings include:The facility policy titled, Comprehensive Person-Centered Care Planning dated 09/01/2025 documented the facility must develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet each individual resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.Resident #7 has diagnoses that include frontotemporal dementia (an umbrella term for a group of brain diseases that mainly affect the frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior, and language) and depression. The quarterly Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making. During an observation on 04/01/2026 at 10:20 AM, the resident was observed seated in a Geri chair (geriatric recliner) in the facility's main dining room with no physical restraint.The Certified Nursing Assistant Plan of Care, initiated on 01/03/2025 and last reviewed on 12/04/2025, documented no evidence of the resident being out of bed to a Geri chair.The Rehabilitation To Nursing Correspondence form dated 01/04/2025 documented the resident transferred dependently with a mechanical Hoyer lift with two people.On 04/02/2026 at 1:30 PM, the resident's current Physician Orders last renewed on 03/16/2026 were reviewed and there was no documented evidence of what the resident's out of bed status was.On 04/02/2026 at 1:35 PM, the resident's entire Comprehensive Care Plan was reviewed and there was no documented evidence of the resident being out of bed to a Geri chair. During an interview on 04/02/2026 1:55, Rehabilitation Coordinator #1 stated there was no documentation in the resident's Comprehensive Care Plan regarding the out of bed status to indicate use of a Geri chair and there should have been. Rehabilitation Coordinator #1 stated the resident was utilizing the Geri chair since admission and the Comprehensive Care Plan should have included the resident's out of bed status. During an interview on 04/03/2026 at 12:15 PM, the Director of Nursing Services stated the resident's Geri chair should have been documented on the resident's Activities of Daily Living Comprehensive Care Plan to show the resident transferred dependently to a reclining Geri chair so it would be also documented on the Certified Nursing Assistant Plan of Care. The Director of Nursing Services stated Rehabilitation Coordinator #1 was responsible for adding the Geri chair to the resident's Comprehensive Care Plan. 10 New York Code Rules and Regulations 415.11(c)(1)

Based on observation, interviews, and record review during survey, the facility failed to ensure each resident's environment remained free of accident hazards. This was identified for one (1) (Resident #6) of four (4) reviewed for Accidents. Specifically, on 04/01/2026, a bottle of Dicyclomine tablets and a bottle a Nitroglycerin sublingual tablets were observed on Resident #6's nightstand. Resident #6 had no physician's order to self-administer any medication or a physician's order for Nitroglycerin. Furthermore, the bottle of Dicyclomine documented instructions to discard the medication after 09/11/2025.The findings include:A facility policy titled Medication Storage Requirements dated 11/24/2025 documented medications are stored under proper conditions as defined by manufacturers to ensure medication stability. All medications will be stored in the medication refrigerators on the nursing unit or in a locked medication cart.Resident #6 was admitted with diagnoses including angina pectoris (chest pain or discomfort when blood flow to the heart is reduced), hypertension, and irritable bowel syndrome (a condition that causes recurrent attacks of abdominal discomfort in association with bowel habits). The five (5) day scheduled Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident's cognitive function was intact.A Comprehensive Care Plan titled Cardiovascular initiated 02/19/2025 documented interventions including administer medications as per the physician's orders and monitor for effectiveness and adverse effects; monitor for signs and symptoms of cardiovascular dysfunction; and monitor vital signs as per physician orders.A Comprehensive Care Plan titled Gastrointestinal initiated 02/19/2026 documented interventions including administer medications as per the physician's order and monitor for signs and symptoms such as abdominal pain, bleeding, nausea/vomiting, and tarry stools.A Comprehensive Care Plan titled Education and knowledge initiated 02/19/2026 documented the resident was unable to comprehend educational material related to forgetfulness. The interventions included to provide education at the appropriate educational level and to accommodate disabilities; provide education in the resident's primary language, using simple and direct wording.An admission Self Medication Assessment for Resident #6 dated 02/19/2026 documented Resident #6 was not a candidate to self-administer medications.A physician's order dated 03/14/2026 documented to administer Dicyclomine 20 milligrams tablet, one (1) tablet orally every eight (8) hours as needed for irritable bowel syndrome.A physician's order dated 03/14/2026 documented to administer Ranolazine 1,000 milligram tablet extended release, one tablet orally every 12 hours for angina pectoris.A review of the electronic medical record revealed there was no physician's order for Nitroglycerin or for the resident to self-administer any medications.During an observation and interview on 04/01/2026 at 10:00 AM, a bottle of Dicyclomine 20 milligram tablets and a bottle of Nitroglycerin 0.4 milligram sublingual tablets were observed on Resident #6's nightstand. The bottle of Dicyclomine documented instructions to discard the medication after 09/11/0225. Resident #6 stated they preferred to keep the medications on their nightstand for easy access even though the nightstand had a locked drawer. Resident #6 stated they were evaluated for self-administering medication at the facility and stated they had no issues self-administering these medications. Resident #6 stated they could not recall the last time they took either of the medications.During an interview on 04/01/2026 at 11:56 AM, Licensed Practical Nurse #3, the assigned medication nurse for Resident #6, stated they noticed the bottle of Dicyclomine and Nitroglycerin on Resident #6's nightstand when they entered the room at approximately 10:30 AM on 04/01/2026. Licensed Practical Nurse #3 stated Resident #6 could not self-administer their medications and the nurses were responsible for administering the medications to Resident #6. The resident's medications should be stored in the locked medication cart and there should not have been any medications, including expired medications on the resident's nightstand.During an interview on 04/01/2026 at 12:55 PM, Registered Nurse #1 stated Resident #6 could not safely self-administer their medication and the medications should not have been stored in the resident's room including any expired medication. Registered Nurse #1 stated the resident could inappropriately administer the medications or potentially take a duplicate dose as the resident can get confused or forgetful, or staff would not be monitoring for potential side effects or adverse reactions because they were not aware of the medication the resident kept at the bedside. Registered Nurse #1 stated there was potential for other residents to wander into Resident #6's room and potentially access the medication placed on the nightstand.During an interview on 04/03/2026 at 12:23 PM, the Director of Nursing Services stated the Resident #6 had an evaluation completed on admission that determined the resident was not able to self-administer medications. The Director of Nursing Services stated that no medications of any sort should have been stored in the resident's room, including any expired medications or medications that should be discarded.10 New York Code Rules and Regulations 415.18(e)(1-4)

Based on observation, record review, and interviews, the facility failed to ensure that it established and 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. This was identified for one (1) (Resident #65) of six (6) residents reviewed for the Infection Control task. Specifically, Resident #65 had a physician's order for Enhanced Barrier Precautions and Certified Nursing Assistant #3 was observed providing hands-on care without wearing a gown as required.The findings include:The facility policy titled Enhanced Barrier Precautions, last reviewed 04/07/2025, documented enhanced barrier precautions are an infection control intervention designed to reduce transmission of resistant organisms through employee transmission on hands and or on clothing. Gowns and gloves are required during high contact resident care activities. Residents who meet enhanced barrier precautions will have the enhanced barrier precautions sign above their bed to alert all staff. A physician's order for enhanced barrier precautions will be obtained and documented in the medical record. Gowns and gloves must be worn for high-contact resident care activities such as dressing, personal hygiene, changing of briefs or providing toileting assistance. All staff will be educated regarding enhanced barrier precautions upon initiation and annually thereafter.Resident #65 was admitted with diagnoses that included dementia (decline in mental ability), chronic respiratory failure (lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen), and anxiety (feelings of nervousness, or unease about imminent events or outcomes). The admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score was not completed indicating Resident #65 was rarely/never understood and had severely impaired cognition. The Minimum Data Set assessment documented Resident #65 was dependent upon staff for all activities of daily living, and was incontinent of bladder and bowel, and was admitted with one (1) stage 1 pressure ulcer and one (1) stage 3 pressure ulcer.A physician's order dated 03/03/2026, documented enhanced barrier precautions due to left breast and sacral wounds, personal protective equipment when performing high-contact care, resident is not restricted to their room.A care plan titled enhanced barrier precautions, for left breast and sacral wounds documented interventions that included proper personal protective equipment to be used during high contact resident care activities that included dressing, bathing, and changing briefs.The Certified Nursing Assistant instructions dated 03/03/2026, documented enhanced barrier precautions, use proper personal protective equipment during high contact resident care activities that included dressing, bathing, and changing briefs.During an observation on 04/01/2026 at 10:30 AM, Resident #65 was in bed sleeping, in a private room with an enhanced barrier sign observed over the bed. The enhanced barrier precaution signage documented staff must wear gowns and gloves for dressing, bathing, showering, transferring, changing linens, and providing hygiene care.During an observation on 04/02/2026 at 10:17 AM, Certified Nursing Assistant #3 was in Resident #65's room providing hands on care such as changing and checking the brief and dressing the resident and was not wearing a gown. The enhanced barrier precaution signage was observed posted above Resident #65's bed with guidance to wear gowns and gloves for dressing, bathing, showering, transferring, changing linens, and providing hygiene care. During an interview on 04/02/2026 at 10:18 AM, Registered Nurse Supervisor #2 stated Resident #65 was on enhanced barrier precaution because they had wounds. Certified Nursing Assistant #3 should have put on appropriate personal protective equipment to provide care to Resident #65. The enhanced barrier precautions are also documented on Resident #65's Certified Nursing Assistants instructions. Registered Nurse Supervisor #2 stated all staff must follow the instructions that are documented on the enhanced barrier precaution signs.During an interview on 04/02/2026 at 10:21 AM, Certified Nursing Assistant #3 stated they knew that the resident was on enhanced barrier precautions due to the wounds on the backside and on the breast; however, they forgot to put on a gown while providing care to Resident #65.[NAME] an interview on 04/03/2026 at 8:18 AM, the Director of Nursing Services stated to prevent the spread of infection, staff should be donning (put on) a gown and gloves when providing direct care to residents who are on enhanced barrier precautions.10 New York Code Rules and Regulations 415.19(a)(1-3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/16/2025 and completed on 3/19/2025, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident # 73) of two residents reviewed for Skin Conditions. Specifically, Resident #73 was observed with a dressing on the left forearm that had dried blood from an open purpura (Purpura happens when small blood vessels burst). There was no documented evidence that a skin assessment was completed, the Physician was not notified of the resident's skin tear, and a treatment order was not obtained before applying the dressing to the resident's left forearm. The finding is: The facility's policy titled Change in Skin Condition dated 3/1/2024 documented the facility will assess and accurately document any skin impairment that occurs and provide the necessary care and treatment indicated. In the event a staff member notices a change in skin integrity such as skin tear, laceration, abrasion, open area, pressure injury, or ecchymosis: immediately notify a registered nurse for an assessment. Notify the attending Physician /designee, notify the designated representative, provide treatment as ordered, and investigate the cause. If the cause cannot be identified, the Registered Nurse is to initiate an accident and incident report, [and obtain] witness statements. Assess skin impairment upon notification, order wound consult if warranted, and administer a review of all documentation to ensure completion, accuracy, and accountability. Resident #73 was admitted with diagnoses including Anxiety Disorder and Atherosclerotic Heart Disease. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of seven (7) which indicated the resident had severely impaired cognition. The Minimum Data Set documented the resident was at risk for developing skin pressure ulcers/injuries. The comprehensive care plan dated 10/25/2024 documented that Resident #73 had the potential for skin tears, open purpura, and abrasions related to Antiplatelet (medications that prevent blood clotting) medication use. The interventions included observing skin daily during care and reporting any concerns or changes. The physician's orders dated 3/3/2025 documented Aspirin tablet chewable 81 milligrams, 1 tablet once a day, and Plavix 75 milligrams, 1 tablet once a day for Atherosclerotic Heart Disease. During an observation on 3/16/2025 at 7:39 AM, Resident #73 was observed lying in bed with an undated gauze dressing to the left forearm. There was a moderate amount of dried blood on the dressing. The resident stated they are on blood thinners and often get skin tears. A review of Resident #73's medical record as of 3/16/2025 revealed no skin assessment that addressed the resident's open purpura to the left forearm; no treatment orders for the left forearm; and no documented evidence that the Physician was notified of the open purpura. During an interview on 3/17/2025 at 10:17 AM, Licensed Practical Nurse #3 stated Resident #73 was on Plavix and Aspirin (anticoagulant medications) which causes prolonged bleeding in the event of skin tear. Licensed Practical Nurse #3 stated on 3/15/2025, they were notified by a Certified Nursing Assistant (name not recalled) that Resident #73 had a skin tear on the left forearm. Licensed Practical Nurse #3 stated they applied gauze dressing to stop the bleeding. Licensed Practical Nurse #3 stated they forgot to notify the Registered Nurse Supervisor to assess the skin tear and the Physician about the resident's skin tear. Licensed Practical Nurse #3 stated they should have obtained a physician's order for the skin tear treatment. During a wound care observation with Licensed Practical Nurse #1 on 3/17/2025 at 2:01 PM, Resident #73's left forearm was noted with an open skin purpura that measured 3 centimeters in length by 0.3 centimeters wide with no drainage. During a re-interview on 3/18/2025 at 1:10 PM, Nurse Practitioner #1 stated Licensed Practical Nurse #3 was supposed to call them or the attending Physician to obtain a treatment order for Resident #73's left forearm skin tear on 3/15/2025. Nurse Practitioner #1 stated it was important to treat skin tears promptly to prevent infection or deterioration. Nurse Practitioner #1 further stated if the wrong treatment was applied to the skin tear, the injury may not properly heal. During an interview on 3/18/2025 at 1:21 PM, the Director of Nursing Services stated Licensed Practical Nurse #3 should have informed the Registered Nurse Supervisor to assess the skin tear and should have called the Physician to obtain a treatment order. 10 NYCRR 415.12

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 3/16/2025 and completed on 3/19/2025, the facility did not ensure all drugs and biologicals were stored in a locked compartment. This was identified for two (Resident #51 and Resident #7) of five residents reviewed for Accident Hazards. Specifically, 1) Resident #51 was observed with a bottle of Hydrocortisone lotion on their nightstand; the resident did not have a Physician's Order for the use of Hydrocortisone lotion. 2) Resident #7 was observed with a medication cup containing four tablets on their overbed table. There were nursing staff in the vicinity. The findings are: The facility's policy titled Medication Administration last revised on 10/2024 documented that only authorized licensed practitioners can administer medication. Nurses may not administer medications to residents during meals unless indicated by a Physician's Order. Nurses must observe the consumption of the medication before leaving the resident and document the administration/consumption of medications immediately. 1) Resident #51 was admitted with diagnoses including Cardiomegaly (enlarged heart), Congestive Heart Failure, and Candidiasis (fungal infection) of skin and nails. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated that Resident #51 had intact cognition. The Quarterly Minimum Data Set assessment documented Resident #51 did not have any wounds, ulcers, or skin problems. A Comprehensive Care Plan renewed on 12/10/2024 titled Skin: Potential for skin tears, open purpura and abrasions related to fragile skin documented interventions including keeping nails trimmed, checking and filing any rough edges, avoiding friction and sheer during care, repositioning and transfer; observe skin daily during care; and report any concerns or changes. During an observation on 3/16/2025 at 7:39 AM, Resident #51 was sitting in a wheelchair in their room. An unlabeled bottle of Hydrocortisone lotion 1% with an expiration date of 4/2025 was observed on top of the nightstand. Resident #51 stated they use the Hydrocortisone lotion when they have redness on their hands and cheeks. Resident #51 stated they could not recall where the medication bottle came from. A review of Resident #51's electronic medical record revealed there was no Physician's Order for Hydrocortisone lotion 1% as of 3/16/2025. During an interview on 3/16/2025 at 7:57 AM, Licensed Practical Nurse #1 stated Resident #51 did not have a Physician's order for Hydrocortisone use and they had never seen the bottle of Hydrocortisone lotion with Resident #51. Licensed Practical Nurse #1 stated if they had seen the Hydrocortisone lotion, they would have taken the bottle of Hydrocortisone lotion and made the Charge Nurse aware. During an interview on 3/17/2025 at 1:15 PM, Licensed Practical Nurse #2 stated they had never seen Resident #51 use the Hydrocortisone lotion. Licensed Practical Nurse #2 stated if they had seen the lotion, they would have taken it and given the lotion to the supervisor. During an interview on 3/17/2025 at 1:54 PM, Certified Nursing Assistant #1 stated they took care of Resident #51 during the 7:00 AM to 3:00 PM shift. Certified Nursing Assistant #1 stated they had never seen the Hydrocortisone lotion on Resident #51's nightstand. Certified Nursing Assistant #1 stated they would have reported to the Nurse if they had seen the Hydrocortisone lotion in Resident #51's room. During an interview on 3/18/2025 at 8:06 AM, Registered Nurse #1, the Unit Supervisor, stated that residents should not have medications stored in their rooms. Registered Nurse #1 stated they did not know Resident #51 had a bottle of Hydrocortisone lotion. Registered Nurse #1 stated they would have assessed the resident and notified the Physician. During an interview on 3/18/2025 at 11:29 AM, the Director of Nursing Services stated nursing staff should be aware of the environment when taking care of residents. The Director of Nursing Services stated Resident #51 should not have any medications stored in their room. All medications should be locked and stored in the medication carts and only the Nurses can administer medications. 2) Resident #7 was admitted with diagnoses including Malnutrition, Hypertension, and Bradycardia (slow heart rate). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #7 had intact cognition. An Admission Self-Medication assessment dated [DATE] revealed that Resident #7 did not want to self-medicate. The current Physician's Order documented Multivitamin one tablet orally once a day for Nutritional Deficiency; Preservision AREDS-2 (Vitamin C, E-Zinc-Copper-Lutein-Zeaxan) capsule; 250-90-40-1 milligrams one capsule orally twice a day for Vitamin Deficiency; Loratadine 10 milligrams one tablet orally once a day for Allergic Rhinitis (allergic response causing itchy, watery eyes and sneezing); Calcium 500 milligrams plus D (calcium carbonate-vitamin d3) tablet; 500 milligrams-5 micrograms (200 units) one tablet orally once a day for Nutritional Deficiency; and Sotalol 80 milligrams give 40 milligrams orally once a day. Hold for systolic blood pressure of less than 90 and/or Heart rate of less than 55 for Hypertension. A Comprehensive Care Plan dated 11/7/2022 last revised on 1/24/2025 titled PolyPharmacy documented interventions including administering medications as per Physician's Order; monitoring for side effects of medications, being alert for drug-to-drug interactions; and notifying the Physician for any untoward effects of medications observed. During an observation on 3/16/2025 at 7:57 AM, Resident #7 was sitting in a wheelchair in front of their overbed table. The resident stated they finished their breakfast meal a few minutes ago. A cup of medications containing four tablets (Calcium, Loratadine, Preservision AREDs, and Multivitamins) was observed on the overbed table next to the completed breakfast meal tray. There was no Nurse in the vicinity. Resident #7 stated they requested for the Nurse to leave the medications in their room at 7:35 AM and told the Nurse that they would take the medications after breakfast. During an interview on 3/16/2025 at 8:00 AM, Licensed Practical Nurse #1 stated Resident #7 requested to leave the cup of their medications on their overbed table because Resident #7 was still eating their breakfast. Licensed Practical Nurse #1 stated Resident #7 was alert and oriented and knew their medications. Licensed Practical Nurse #1 stated they went to another resident's room to finish their medication administration after leaving Resident #7's room at 7:35 AM. Licensed Practical Nurse #1 stated they should have waited for Resident #7 to finish breakfast before giving the medications. Licensed Practical Nurse #1 stated they should have never left the medications with Resident #7 unattended. During an interview on 3/17/2025 at 1:40 PM, Resident #7 stated they did not want to be responsible for self-administration of their medications while living at the facility. During an interview on 3/18/2025 at 8:06 AM, Registered Nurse #1, the Unit Supervisor, stated Licensed Practical Nurse #1 should not have left the medications in the resident's room unattended. Registered Nurse #1 stated Nurses should not give medications during mealtimes or when residents are eating. Registered Nurse #1 stated Resident #7 was alert and oriented but did not have an order to self-medicate. Registered Nurse #1 stated the Nurses are still responsible for administering medications to the resident. During an interview on 3/18/2025 at 11:41 AM, the Director of Nursing Services stated that all residents are screened for medication self-administration during admission. The Director of Nursing Services stated Resident #7 was capable but did not want to be responsible for their medications while in the facility. The Director of Nursing Services stated that residents should not have any medications stored in their rooms without the supervision of a licensed nurse. 10NYCRR 415.18(e)(1-4)

Based on interviews and record review during an abbreviated survey (Complaint Number: NY00344815), the facility did not ensure resident rights to be free from neglect. Specifically, one (Resident #1) of three residents reviewed for neglect. After the resident fell to the floor, the Licensed Practical Nurse #2 picked Resident #1 up off the floor and sat the Resident#1 back into the wheelchair and did not call for a Registered Nurse. This negligence resulted in Resident #1 not being assessed by the Registered Nurse to assess for injury and need for immediate intervention. The Findings are: The review of the facility policy dated 6/2019 titled accident/incident reports for the resident, documented any accident/incident must be reported by the staff member to the Registered Nurse. The Nursing Supervisor/Registered Nurse must be notified immediately. The Nursing Supervisor/Registered Nurse will assess for injury and need for immediate intervention. Resident#1, admitted to the facility on [DATE] with diagnoses that included anxiety disorder, macular degeneration, unsteadiness on feet stroke, arthritis, and depression. The review of the 14 day, Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 13 indicating intact cognition skills for decision making, behaviors-none, sit to stand -substantial/maximal assist, for Resident#1. The Fall Risk assessment dated [DATE] documented Resident #1 at risk for falls. The review of the Comprehensive Care Plan (CCP) documented dated 3/30/2024 at risk for falls the interventions documented, remains on 30-minute safety checks. The review of the Comprehensive Care Plan (CCP) documented dated 6/8/2024 skin, resident has a skin tear the interventions updated 6/12/2024 documented, 2 cm by 1 cm skin tear to right side of forehead, 3 cm by 2 cm red purple eccymotic area to right cheek, orders for normal saline cleanse bowed by bacitracin, open to air twice a day for 7 days; The review of the Resident Profile dated 3/30/2024 documented wheelchair mobility-one person assists, high fall risk alerts, updated 5/23/2024 30-minute checks, keep in supervised areas when out of bed. The review of the Resident Progress Notes dated 6/7/2024 at 3:13PM documented continues 30-minute checks; no behavior issues, half hour safety check in progress; 6/8/2024 at 3:31PM self-wheeling within unit, yelling and screaming, able to redirect, currently in recreational activities. The review of the Resident Progress Notes dated 6/8/2024 at 10:03PM documented resident in main dining room, irate and yelling when a 2 cm laceration to forehead was noticed, cleansed with normal saline, bacitracin, Next of Kin aware. The resident was brought to the Registered Nurse Supervisor in wheelchair with a 2 cm by 2 cm skin tear to right side of forehead and a 3 cm by 2 cm red purple eccymotic area to right cheek. Resident screaming and kicking, wants to go to hospital, the Nurse Practitioner made aware, order for normal saline cleanse, neuro checks for 24 hours placed on 1:1 supervision. The review of the Nursing Home Investigative Report documented Resident#1 was interviewed by Assistant Director of Nursing and, the Administrator regarding Accident & Incident. Resident#1 stated, one person came, kept pushing me, kicked the chair and dropped me on the floor and took me off the floor. Licensed Practical Nurse#1 assigned to work on the Unit on 6/8/2024, stated, on the date of 6/8/24, they were walking down the hallway on the Unit heading towards the dining room when a resident was waving for attention in the main dining room. At this time the Licensed Practical Nurse#2 was in the hallway standing at medication cart facing the wall. When Licensed Practical Nurse#1 went into the dining room saw the resident on the floor laying on right side trying to get up. Licensed Practical Nurse#2 ran in the dining room and picked the resident up off the floor and put them in the chair. Witness interviews summarize that Resident #1 was seen on the floor on 6/8/2024, when Licensed Practical Nurse#2 ran into the Main Dining Room to assist the resident back into the wheelchair. The review of the Accident/Incident Report dated 6/8/2024 at 9:45PM the resident#1 brought to the Registered Nurse with a 2 cm skin tear to right side of forehead, bruise noted to right cheek, neurological checks, remined 1:1 until back to bed. Unwitnessed fall in the dining room, the staff was interviewed, and the Resident was assessed, The review of the Department Orientation Checklist dated 8/25/14 documented the Licensed Practical Nurse #2 signed as trained in review of the policy and procedure for reporting incident/injuries. During the telephone interview dated 6/27/2024 at 12:34PM, with the 3:00 PM -11:00 PM shift Licensed Practical Nurse (LPN) #1 who was on duty on 6/8/2024 and the Licensed Practical Nurse stated was on duty 6/8/2024 and recalls an incident with Resident#1 who self-propels wheelchair throughout the facility and is always watched for falls. The Nurse stated at a time not recalled walking in the hallway and Resident#2 was waving at the nurse, but then the Resident #2 was pointing at the floor and the Licensed Practical Nurse#1 ran into main dining room and observed resident lying on left side on the floor, bump on left forehead, left cheek and left shin and saw a little blood ,suddenly Licensed Practical Nurse#2 ran into main dining room and picked the Resident#1 up off floor and placed Resident #1 back into wheelchair. The Licensed Practical Nurse stated did not have time to say to Licensed Practical Nurse #2 we have to get the Registered Nurse Supervisor before the resident is picked up off the floor. Licensed Practical Nurse #2 was just too quick. Licensed Practical Nurse#1 wheeled the resident to the Registered Nurse Supervisor and reported the incident to the Registered Nurse. The interview dated 6/27/2024 at 3:30PM with the Assistant Director of Nursing, and they stated, the Licensed Practical Nurse #2 should not have placed the Resident back into the wheelchair from the floor and should have called for the Registered Nurse before moving the Resident. During the telephone interview dated 12/30/2024 at 10:55PM, with the unit 7:00 AM -3:00 PM Registered Nurse Supervisor # 5 and the Registered Nurse stated if any resident has a fall or other type of incident, the Registered Nurse must be called to assess the resident prior to picking a resident up from the floor. The Registered Nurse Supervisor #5 stated they were on duty dated 6/8/2024 and assessed the resident, who had a small laceration to right forehead and right check, ecchymosis to right knee, resident denied pain. Resident speaking incoherently, resident stated fell , hit head, and put back in the chair, not agitated or in distress. During the telephone interview with Licensed Practical Nurse#2 on duty dated 6/8/2024, 3:00PM-11:00PM and they stated was passing medications in the hall and would stand in the doorway to watch the residents in the main dining room, they stated staff is supposed to watch residents in dayroom. They stated saw Licensed Practical Nurse#1 walking into the dayroom and stated Resident #1 is on the floor and Licensed Practical Nurse#2 stopped passing medications and went to the dayroom. They stated did a bad thing and they helped resident #1 back into wheelchair but should have called the Registered Nurse to check the resident but did not do that. They stated should have left the resident on the ground until they were assessed by a Registered Nurse. 415.4 (b)

Based on record review and interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/4/2023, the facility did not ensure that the resident's Primary Care Physician (PCP) comprehensively reviewed the resident's total program of care including medications and treatments and a decision about the continued appropriateness of the resident's current medical regimen. This was identified for one (Resident #54) of two residents reviewed for Antibiotics. Specifically, Resident #54 had a physician's order to administer Xifaxan (an antibiotic that fights bacterial infection only in the intestines) for a prolonged period from 6/26/2023 until 5/30/2024. The physician's progress notes lacked documentation related to the prolonged use of and reason for the antibiotic. The finding is: The policy and Procedure for Antibiotic Stewardship dated February 2022 documented harm from antibiotic overuse is significant for the frail and elderly, including but not limited to risk of serious events and drug interactions, colonization, diarrhea, infection, Clostridium Difficile, and increased adverse and/or infection with antibiotic-resistant organism. Resident # 54 was admitted with diagnoses that included Unspecified Dementia, mild, with mood disturbance, Irritable Bowel Syndrome without diarrhea, and Dysphagia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) was not conducted due to severe cognitive impairment. The resident had a gastric tube and was receiving tube feeding formula. The Physician orders dated 6/26/2023 - 12/1/2023 documented to administer Xifaxan (Rifaximin) tablet; 550 milligrams (mg); 1.5 tabs twice a day via gastric tube. The resident was hospitalized from 7-2-2023 to 7-5-2023. A hospital Infectious Disease Consultant report dated 7-4-2023 recommended to administer Rifaximin with a stop date of 5/30/2024. The reason for the use of Rifaximin was documented as Irritable Bowel Syndrome. A review of Physician progress notes from June 26, 2023, to December 1, 2023 revealed no documentation related to the prolonged use and the indication for the use of Xifaxan antibiotic. The Medical Director, who is the Primary Care Physician for Resident #54, was interviewed on 12/04/2023 at 12:08 PM and stated the resident is on the antibiotics due to an Infection Disease Consult that was completed in the hospital. The Infectious Disease Consultant recommended the medication to be used until May of 2024. The Medical Director stated there should have been documentation for the long-term use of the antibiotic. The infectious Disease Registered Nurse # 2 was interviewed on 12/01/2023 at 2:08 PM and stated the resident is on the antibiotics and as per the antibiotic stewardship program there should have been an evaluation and documentation by the resident's physician for the long term use of the antibiotic. 10 NYCRR 415.15(b)(2)-(iii)

Based on observation, record review and staff interviews during the Recertification Survey completed on 12/7/2019, the facility did not ensure that each resident is treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for 2 (Resident #72 and Resident #56) of 2 residents reviewed for Dignity. Specifically, during a lunch meal observation on 11/30/2021 at 12:40 PM and on 12/3/2021 at 12:24 PM the Licensed Practical Nurse (LPN) # 1 was observed standing over the resident while feeding the residents. The findings are: The facility undated policy and procedure titled Dining Experience documented staff must sit when feeding a resident (be at eye level) and cannot stand over the resident. 1) Resident #72 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long-term memory problems. The resident required extensive assistance of one staff member for eating. The Resident Care Profile, direction provided to the Certified Nursing Assistants (CNA) for resident care, dated 1/21/2021 documented the resident required tray set up with extensive assist hand feeding of all food and liquids and to maintain aspiration precaution. During a lunch meal observation conducted on 11/30/2021 at 12:40 PM in the South Bay Dining room, LPN #1 was observed standing over Resident #72 while feeding the resident. LPN #1 was interviewed on 12/3/21 at 12:48 regarding resident #72. The LPN stated that she was so accustomed to standing for all their task that they forgot to sit and feed the resident. LPN #1 also stated that the resident required extensive of one staff for eating to complete meals and that she should have being siting while feeding the resident. 2) Resident #56 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented short- and long-term memory problems and required extensive assistance of one staff member for eating. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident is to be fed only by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). The diet order included a regular diet, pureed consistency and honey thickened liquids due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Care Profile, direction provided to the Certified Nursing Assistants (CNA) for resident care, dated 11/21/2021 documented the resident was to be fed only by an RN or an LPN due to Aspiration Precautions. On 12/3/2021 at 12:24 PM LPN #1 was observed standing while feeding Resident #56. After the observation was made by the surveyor LPN #1 sat down in a chair to continue feeding Resident #56. LPN #1 was interviewed 12/3/21 at 12:48 PM regarding Resident #56 and stated at times Resident #56 will attempt to feed self, however, due to spillage the resident requires assistance. LPN #1 stated that when feeding the resident staff should be seated and that they (LPN #1) should have been seated while feeding the resident. The Director of Nursing Services (DNS) was interviewed on 12/7/2021 at 5:42 PM and stated that when feeding a resident, the staff should be at eye level with the resident which requires the staff member to sit and feed the resident. LPN #1 should have been sitting while feeding the residents. 415.3(c)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey and an Abbreviated Survey (Complaint number NY 227), completed on 12/7/2021, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse, neglect, exploitation, or mistreatment for two (Resident #70 and Resident #14) of two residents reviewed for Accidents. Specifically, Resident #70 and Resident #14 were found on the floor. The Accidents/Incidents (AI) were not thoroughly investigated by the facility. Additionally, an alleged physical abuse allegation against a facility staff member, regarding bruising to both upper extremities for Resident #70, were not investigated. The findings are: The facility's Policy and Procedure (P/P) dated October 2021 titled Abuse Prohibition documented that all accident reports will be screened/investigated for evidence of failure to follow the care plan, delay in assessment/treatment, and injuries of unknown origin. The P/P also documented that all allegations of abuse will be investigated, and monitoring, education, and interventions will be implemented to prevent abuse/neglect. 1) Resident #70 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident exhibited no behaviors and required extensive assistance of one person for transfers, walking in the room, and toileting. The resident was frequently incontinent of bowel and bladder. The MDS also documented that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The Comprehensive Care Plan (CCP) for Falls dated 6/4/2021 documented the Resident was at risk for falls with injury secondary to impaired cognition, impaired balance, medications, need for assistance with toileting, incontinence, and history of falls with [CONDITION(S)] prior to admission. The interventions included to apply an Anti-rollback device to the wheelchair, assist with personal care and Activities of Daily Living (ADLs), and to apply Dycem (anti-slip material) to the wheelchair. The Accident/Incident report dated 4/4/2021 at 7:15 AM documented that the resident was observed falling forward from the wheelchair hitting their forehead on the floor. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The forehead was observed with bleeding and a raised hematoma. There were no other injuries documented on the Accident and Incident report. The Accident and Incident report did not include an investigation to determine if the Dycem pad on the wheelchair was in place at the time of the fall. The nursing progress notes dated 4/04/2021 at 8:19 AM documented that the resident fell from the wheelchair hitting their forehead. Resident #70 sustained a hematoma (bruise) and a laceration. The Physician was notified and ordered to transfer Resident #70 to the hospital for evaluation. The Social Worker (SW) progress note dated 4/05/2021 at 3:48 PM documented a meeting held with the Director of Nursing Services (DNS), the SW, and the resident's family member. The resident's fall and recent increased agitation and disorientation were discussed. A Family member was interviewed on 12/6/2021 at 3:30 PM and stated that the resident was found with bruises to bilateral arms when the resident was brought to the hospital. The bruises were to both arms and the family was not made aware of these bruises by the facility. The family member stated they (family member) called the facility to investigate the bruises on the resident's arm. The family member was told by the facility that the bruises were related to the fall and the resident's agitation causing the resident to hit their arms against the side rails. The family member stated that prior to the fall the resident told the family member that the staff were grabbing the resident by the arms and hurting the resident. The Family member also stated there was an evening shift male Licensed Practical Nurse (LPN) that was often quite violent with residents that did not cooperate with the LPN. The family member requested a meeting with the facility and discussed their concerns. The Accident/Incident report dated 4/4/2021 at 7:15 AM did not include bruises to the resident's bilateral arms and there was no investigation initiated by the facility regarding the alleged physical abuse that was reported by a family member including the bruises to bilateral arms. The Registered Nurse (RN) Manager #1 was interviewed on 12/07/2021 at 11:08 AM and stated they (RN #1) could not recall if the resident was observed with bruises to the resident's arms at the time of the incident. RN #1 stated that the resident's family had not reported any bruises to the resident's arms nor did the family ever report a concern about staff members. RN #1 stated they (RN #1) could not recall what devices were in place at the time of the fall. RN #1 further stated the investigation should have included a review of the devices, such as a Dycem pad, to rule out neglect. LPN #1 was interviewed on 12/07/2021 at 12:36 PM and stated they (LPN #1) witnessed the fall out of the wheelchair but could not recall what devices were in place at the time of the fall. LPN #1 could not recall if they (LPN #1) were asked during the investigation whether the Dycem pad was in place at the time of the fall. LPN #1 further stated they (LPN #1) could not recall if the resident had bruises on their arms. The SW was interviewed on 12/07/2021 at 3:15 PM and stated that the resident's family member notified the SW of the resident's arm bruises, and this was brought to the attention of the former DNS. The SW stated the former DNS should have started an investigation to determine if abuse or neglect occurred. The former Director of Nursing Services (DNS) was interviewed on 12/07/2021 at 4:40 PM and stated the resident had very bad behaviors around the time the resident fell in April 2021. The resident was so agitated, that the bruises the family member brought to the former DNS's attention were due to the resident's behaviors. The former DNS further stated that the resident was hitting their arms against the wheelchair which caused the bruising. The bruising was not due to staff abuse and an investigation into the bruising was not initiated. The current Director of Nursing Services (DNS) was interviewed on 12/07/2021 at 4:50 PM and stated any allegations of abuse by a family member should have been thoroughly investigated. The current DNS further stated the investigation should have included reviewing all interventions in the resident's fall CCP to rule out neglect. 2) Resident #14 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The resident required extensive assistance of two persons for bed mobility, and toilet use; was totally dependent on staff for transfers and was non-ambulatory. The MDS documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The Comprehensive Care Plan (CCP) dated 8/5/2021 for at risk for falls secondary to medications, bilateral [CONDITION(S)] status, impaired balance, [CONDITION(S)], and seizures documented interventions that included use of a Dycem pad on the wheelchair, maintain call bell, and frequently used objects within reach, provide adequate lighting and instruct/reinforce safety measures such as locking the wheelchair, proper transfer techniques and encourage use of a Reacher. The Accident/Incident (A/I) report dated 11/16/2021 documented the resident was found on the floor in their room in the prone (face down) position in front of the wheelchair. The investigation concluded there was no probable evidence of abuse/neglect or mistreatment. The Accident and Incident report did not include an investigation to determine if the Dycem pad on the wheelchair was in place, if the wheelchair was in a locked position, or if the call bell and the resident's Reacher were within reach at the time of the fall. A Nursing Progress Note, written by Registered Nurse (RN) #4, dated 11/17/2021 at 1:19 PM documented Resident #14 was found on the floor in their room on 11/16/2021. The resident was noted with blood on their face, an abrasion, and a hematoma above the right eye. The resident was transferred to the hospital for evaluation. RN #4 was interviewed on 12/03/2021 at 12:44 PM and stated the resident was able to self-propel the wheelchair and was able to unlatch the wheelchair lock. RN #4 stated they (RN#4) responded to the resident's fall on 11/16/2021 and saw the resident on the floor. RN #4 could not recall if the resident's wheelchair had the Dycem pad in place or if the Reacher and the call bell were within the resident's reach. RN #4 stated that the interventions to prevent falls, such as Dycem, Reacher, or the call bell, were not included in the investigation. RN #4 further stated that these interventions should have been documented in the investigation. The Licensed Practical Nurse (LPN) # 3 was interviewed on 12/03/2021 at 12:46 PM and stated they (LPN #3) recalled observing the resident on the floor at the time of the incident. The resident fell face down from the wheelchair. LPN #3 stated they (LPN #3) recalled that the resident's call bell was not activated. LPN #3 could not remember if the call bell or the Reacher were within the resident's reach. LPN #3 stated that they (LPN #3) were not asked what devices were in place at the time of the resident's fall during the resident's fall investigation. Certified Nursing Assistant (CNA) #4 was interviewed on 12/06/2021 at 3:25 PM and stated they called the supervisor when the resident was found on the floor on 11/16/2021. The call bell was within the resident's reach. CNA #4 could not remember if the Reacher was in place. 415.4 (b)(3)

Based on observation, record review, and interviews during the Recertification Survey completed on 12/7/2021 the facility did not ensure that care was implemented in accordance with each resident's Comprehensive Care Plan (CCP). This was identified for one (Resident #49 ) of one resident reviewed for [CONDITION(S)]. Specifically, Resident #49 was observed on two separate occasions not wearing the Physician-ordered surgical compression stockings ([CONDITION(S)]-[CONDITION(S)] Deterrent -TED stockings). The finding is: The facility policy and procedure for Application of Thromboembolitic (TED) Hose dated December 4th, 2020 documented application of TED stocking(s) will be applied by the Registered Nurse (RN), Rehabilitation staff, Licensed Practical Nurse (LPN), or the Certified Nursing Assistants (CNA). The purpose is to reduce [CONDITION(S)] and swelling of the extremities to promote venous return and prevent Thrombophlebitis ([CONDITION(S)] process that causes a blood clot to form and block one or more veins) and Pulmonary Embolism (A condition in which one or more arteries in the lungs become blocked by a blood clot). Resident # 49 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for the Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS documented the resident did not exhibit the behavior of rejection of care and required extensive assistance of one staff member for dressing and personal hygiene. The Vascular Consult dated 7/21/2021 recommended Bilateral Lower Extremities (BLE) elevation, BLE Knee-high 10-20 millimeters of mercury (mmHg) compression stocking during the daytime due to BLE swelling related to Congestive Heart Failure (CHF) and immobility. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) for Cardiovascular dysfunction related to Congestive Heart Failure (CHF), Hypertension ([CONDITION(S)]), and [CONDITION(S)] dated 6/2/2021 and updated on 7/27/2021 documented interventions including to apply surgical stockings to BLE; apply in morning (AM) and remove at bedtime. The current Certified Nursing Assistant Resident Care Profile, under the Activities of Daily Living (ADL) section, included instructions to apply the surgical stockings to BLE in the morning and remove the surgical stockings at bedtime. Resident #49 was observed in the wheelchair in their room on 11/30/2021 at 11:00 AM and 2 PM without wearing the TED stockings. Resident #49 was interviewed on 11/30/2021 at 11 AM and stated the staff are supposed to put the TED stockings on when Resident #49 is taken out of bed but the staff forgot to put the TED stocking on today. CNA #3 was interviewed on 12/06/2021 at 3:52 PM and stated they (CNA #3) took care of Resident #49 on 11/30/2021. CNA# 3 stated that it was their (CNA #3's) responsibility to put the TED stockings on the resident's BLE. CNA #3 further stated they (CNA #3) forgot to put the TED stockings on because they (CNA #3) were busy and thought that the nurse had placed the stockings on the resident. RN #5 was interviewed on 12/07/2021 at 3:20 PM and stated that CNA #3 should have applied the TED stockings to Resident #49's BLE. The Director of Nursing Services (DNS) was interviewed on 12/07/2021 at 10:39 AM and stated that the nurses or the CNAs can apply the TED stockings for the residents. The CNA should have read the Resident Care Profile and should have followed the directions to apply the TED stockings. 415.11(c)(1)

Based on observations, interviews and record review during the Recertification Survey completed on 12/7/2021, the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #21) of one resident reviewed for positioning. Specifically, Resident #21 with a history of poor postural control, was observed leaning in the Geri recliner. The resident did not have proper positioning devices to address the poor posture and maintain proper body alignment. The finding is: Resident #21 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two persons for transfers, bed mobility, and toilet use and was non-ambulatory. The MDS documented the resident had no functional limitations in Range of Motion to both upper and lower extremities. Resident #21 was observed sitting in a Geri recliner on 11/30/2021 at 12 PM, the resident was leaning to the right in the Geri recliner in the main dining room with the pillow observed on the floor. The Geri recliner leg rest was in the downward position. During an observation on 12/3/2021 at 9:50 AM Resident #21 was observed sitting in a Geri recliner in the hallway. The resident was awake and was leaning to the right. During a subsequent observation on 12/3/2021 between 11:53 AM-12:28 PM Resident #21 was observed sitting in a Geri recliner in the main dining room. The resident was awake and was leaning to the right side of Geri recliner. The Geri recliner leg rest were in the downward position. The Certified Nurse Accountability Care Plan dated 4/6/2021 documented the resident required one person assistance for wheelchair mobility. The resident prefers to sit in a Geri recliner at times for positioning and comfort. The Comprehensive Care Plan (CCP) for impairment in Activity of Daily Living (ADLs) secondary to impaired cognition, impaired balance, impulse disorder, Dementia, [CONDITION(S)] dated 10/4/2021 documented interventions including to observe and report changes in the resident's ability to move or perform self-care. A Physical Therapy (PT) evaluation dated 7/12/2021 documented the resident had difficulty transferring with one person and at times required two people for safe transfers. The PT evaluation documented the resident had weakness in both lower extremities and their trunk with postural and balance deficits identified. Resident #21 required increased assistance from caregivers related to decreased strength, balance, and endurance. The resident would benefit from Restorative PT services. The Director of PT services was interviewed on 12/3/2021 at 4:45 PM and stated Resident #21 had utilized a wheelchair in the past when out of bed. The resident was noted by nursing staff to be leaning and the PT department recommended a high back wheelchair. The nurses took the high back wheelchair away and gave the resident a Geri recliner for comfort. Although the PT department was made aware of the change to a Geri recliner, the PT department was not made aware that Resident #21 was leaning. The Director of PT services stated that the PT department should have been made aware of the resident's leaning in the Geri recliner. The Director of PT services further stated that lateral supports in a Geri recliner would help the resident from leaning. Registered Nurse (RN) #1 was interviewed on 12/07/2021 at 11:27 AM and stated that they (RN #1) were aware the resident was leaning and did not notify the PT department for further evaluation. The Certified Nurse Assistant (CNA) #1 was interviewed on 12/07/2021 at 12:30 PM and stated they (CNA #1) have been caring for the resident and reported to RN #1 that the resident leans in the Geri recliner. CNA #1 stated RN #1 told CNA #1 to place a pillow to position the resident and to prevent leaning. 415.12

Based on observation, record review, and interviews during the Recertification Survey completed on 12/7/2021, the facility did not ensure that each resident who needs respiratory care is provided such care consistent in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #6) of one resident reviewed for Respiratory care. Specifically, 1a) Resident #6, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was observed with an empty oxygen tank and complained of feeling short of breath. Additionally, 1b) Resident #6 complained that the oxygen concentrator utilized by Resident #6 on 11/30/2021 was not functioning. Upon observation on 12/1/2021, the oxygen concentrator was found with a yellow warning light with no oxygen output from the concentrator. The findings are: Resident # 6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS documented the resident required extensive assistance of one person with dressing and personal hygiene. The MDS documented the resident did not have a behavior of rejection of care and utilized oxygen therapy. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) for [CONDITION(S)] dated 1/6/2021 documented interventions including but not limited to administering oxygen at 2 liters per minute. 1a) Resident #6 was observed on 11/30/2021 at 12:35 PM sitting in the resident dining room in a wheelchair with an oxygen tank mounted behind the wheelchair. Resident #6 attempted to adjust the nasal cannula and the oxygen tubing multiple times and then verbalized they (Resident #6) were short of breath and needed oxygen. Resident #6's lips were observed to be purple. The oxygen tank gauge needle was observed below the red indicator, revealing the oxygen tank was empty. Resident #6 was interviewed on 11/30/2021 at 12:35 PM and stated that the Certified Nursing Assistant (CNA#2) applied the oxygen to the resident's wheelchair when the resident was transferred from the bed to the wheelchair in the morning. Resident #6 stated that they were short of breath and needed oxygen. Resident #6 further stated they need supplemental oxygen at all times. Registered Nurse (RN) #3, who was in the resident's dining room at the time of the observation, was notified immediately that the resident was having difficulty breathing. RN #3 confirmed that Resident #6's oxygen tank gauge needle was below the red indicator which specified the oxygen tank was empty. RN #3 immediately changed Resident #6's oxygen tank. RN #4 was interviewed on 11/30/2021 at 2:28 PM and stated all Certified Nursing Assistants (CNA) and nurses are responsible to make sure the residents' oxygen tanks have enough oxygen supply at all times. CNA #2 was interviewed on 11/30/2021 at 3:16 PM and stated they (CNA #2) transferred Resident #6 out of bed to the wheelchair in the morning and applied the nasal cannula tubing to Resident #6. CNA #2 further stated they (CNA #2) checked the oxygen tank to make sure the oxygen tank supply was adequate. 1b) Resident #6 was observed on 12/01/2021 at 10:03 AM sitting in a wheelchair in their room receiving oxygen from the oxygen tank that was mounted on the wheelchair. An oxygen concentrator with a humidification chamber was observed in the resident's room. Resident #6 stated that the oxygen concentrator was used by Resident #6 at night on 11/30/2021. Resident #6 stated that the concentrator with the humidification chamber was not working last night. Resident # 6 further stated they reported the oxygen concentrator's malfunctioning to the nursing staff, however, this issue was never addressed. The Oxygen concentrator was observed with a yellow warning light and no air was noted coming out of the oxygen tubing. The humidification chamber was observed without indication of any airflow. RN #1 was immediately made aware by the surveyor and stated they (RN #1) were not aware that Resident #6's oxygen concentrator was not functioning. The Maintenance Supervisor was interviewed on 12/07/2021 at 2:04 PM and stated they (Maintenance Supervisor) were notified of Resident #6's concentrator malfunction on 12/1/2021. The Maintenance Supervisor stated the concentrator was not functioning properly and was replaced on 12/1/2021. The Maintenance Supervisor stated the yellow light on the concentrator indicates that the concentrator is not functioning. The Maintenance Supervisor further stated nurses should notify the Maintenance Department when an oxygen concentrator is not functioning properly. The Director of Nursing Services (DNS) was interviewed on 12/7/2021 at 3 PM and stated nurses are responsible to ensure the portable oxygen tank and oxygen concentrators used by the residents are functioning at all times. If an oxygen tank or an oxygen concentrator is not functioning nurses have to replace them with the new oxygen concentrator or oxygen tanks immediately. The DNS further stated that only nurses are responsible for handling oxygen, not the CNAs. 415.12(k)(6)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner that promotes enhancement of his or her quality of life. This was identified for 4 (Residents #1, #57, #6, and #28) of 4 residents reviewed for dignity. Specifically, the Night 11:00 PM-7:00 AM shift Certified Nursing Assistant (CNA) and the Registered Nurse (RN) Night Supervisor entered the room where Residents #1 and #57 and the room where Residents #28 and #6 resided, and did not knock on the doors prior to entering the room. The finding is: The facility's policy and procedure dated 12/2015 titled Dignity documented . Respecting resident's private space and property .knocking on doors and requesting permission to enter . Resident #1 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8 indicating the resident was moderately impaired in cognition. Resident #57 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's BIMS score was 5 indicating the resident was severely impaired in cognition. Residents #1 and #57 shared the same room. Resident #6 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's BIMS score was 6 indicating the resident was severely impaired in cognition. Resident #28 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident had severely impaired cognition. Residents #6 and #28 shared the same room. On 8/22/19 at 6:50 AM, it was observed that the assigned Night 11:00 PM-7:00 AM shift CNA did not knock the on doors prior to entering the room of Residents #1 and #57 and on 8/22/19 at 6:51 AM the room of Residents #6 and #28. On 8/22/19 at 7:00 AM, it was observed that the Night RN Supervisor did not knock on the doors prior to entering the room of Residents #1 and #57 and on 8/22/19 at 7:01 AM the room of Residents #6 and #28. An interview with the assigned 11:00 PM- 7:00 AM shift CNA was conducted on 8/22/19 at 6:55 AM. The CNA stated that he should have knocked on the residents' room door before entering. An interview with the RN Night Supervisor was conducted on 8/22/19 at 7:05 AM. The RN Supervisor stated that she should have knocked on the residents' room door before entering. 415.3(c)(1)(i)

Based on observation, record review and interviews during the recertification survey the facility did not ensure that each resident had a call bell within the resident's reach to provide necessary assistance. This was identified for one resident (Resident # 1) residing on one of two nursing units. Specifically, the call bell for Resident #1 was observed on the floor, out of the resident's reach. The finding is: The facility's policy and procedure dated 5/2013 titled Call [NAME]s documented . 2) Call bells are to be kept within the reach of each resident while the resident is in the room. 3) The call bells are to be clipped to the top sheet to permit easy accessibility to the call bell . Resident #1 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8 indicating the resident was moderately impaired in cognition. The MDS documented the resident was able to understand others and made self understood. The MDS further documented the resident had limitation of functional range of motion of both upper and lower extremities. The Comprehensive Care Plan (CCP) developed for at risk for falls with injury secondary to history of [MEDICAL CONDITION], history of falls, Dementia, impaired balance and incontinence dated 8/12/19 documented to maintain the call bell within reach of the resident. On 8/22/19 at 6:35 AM and at 6:50 AM, the resident was observed sleeping in bed with the call bell on the floor. An interview with the assigned 11:00 PM- 7:00 AM shift Certified Nursing Assistant (CNA) was conducted on 8/22/19 at 7:00 AM. The CNA stated that the resident's call bell should be clipped at his bedside. An interview with Resident #1 was conducted on 8/22/19 at 7:01 AM. The resident stated that he can can use the call bell for his needs or assistance. An interview with the Registered Nurse (RN) Night Supervisor was conducted on 8/22/19 at 7:05 AM. The RN Supervisor stated the resident is able to use his call bell. The RN stated that the call bell should be clipped to the resident's bed. An interview with the assigned 7:00 AM- 3:00 PM shift CNA was conducted on 8/23/19 at 10:20 AM. The CNA stated that Resident #1 is able to use his call bell for assistance. An interview with the 7:00 AM - 3 PM RN Supervisor was conducted on 8/23/19 at 10:22 AM. The RN stated that the resident is able to use his call bell. 415.5(e)(1)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not implement the comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs. This was evident for 1 (Resident #55) of 3 residents reviewed for limited range of motion (ROM) and 1 (Resident #55) of 2 residents reviewed for positioning. Specifically, 1) Resident #55 had a physician's orders [REDACTED]. The resident was observed with a loosely fitted compression left hand glove. 2) Resident #55 had a physician's orders [REDACTED]. The resident was observed either with no pillow applied to float the heels while in bed or the heels were directly touching the bed. The findings are: The facility's policy and procedure dated 2/2016 titled Adaptive Devices/Splints/Braces documented ( . Upon receipt of the equipment, Rehabilitation will ensure the equipment fits properly and will be effective for the issue identified . All devices will be reviewed by Rehabilitation for continued need and effectiveness. 1) Resident #55 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 9 indicating the resident was moderately impaired in cognition. The MDS documented the resident was not receiving Occupational Therapy/Physical Therapy (OT/PT) and not on a Restorative Nursing Program. The OT Discharge Summary dated 7/9/18 documented a Discharge Plan and Instruction for the resident to continue to wear a compression glove daily, with skin checks and hygiene to be provided daily to maintain skin integrity. The current physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) developed for ADL Functional/Rehabilitation Potential dated 7/2/19 documented the resident was to wear a compression glove on the left hand during the day while up in a gerichair in order to reduce [MEDICAL CONDITION] and to check the resident's skin every shift. The resident was observed on 8/21/19 at 9:55 AM in a recliner chair in the recreation/day room with an OT Staff member present. The resident had a very loose fitting left hand compression glove in place. The OT Staff member stated that she would replace the glove with a glove that would snuggly fit the resident's left hand. An interview with the OT Staff member was conducted on 8/21/19 at 10:00 AM. The OT staff member stated the resident sustained [REDACTED]. The OT staff member stated that resident was sent to OT for positioning and contracture prevention in (YEAR). The OT Staff member stated that she expected the nursing staff to report to the Rehabilitation Department if the compression glove was not effective anymore since the certified Nursing Assistants (CNAs) were responsible to apply them. An interview with the assigned 7:00 AM-3:00 PM shift Certified Nursing Assistant (CNA) was conducted on 8/21/19 at 1:00 PM. The CNA stated that she was not aware the compression glove was loose. The CNA stated that she was instructed on how to apply the glove and did not know when the glove became loose. An interview with the 7:00 AM -3 PM RN Supervisor was conducted on 8/21/19 at 1:10 PM. The RN stated that she could not recall if the CNA had notified her that the resident's compression glove was loosely fitting. 2) The current physician's orders [REDACTED]. The Resident's Profile Care Plan Approaches on ADLs Functional Rehabilitation Potential dated 7/2/19 documented under the skin care section to float the resident's heels off the bed with a pillow. The CNA's Point of Care (P[NAME]) for skin care dated 7/2/19 documented to float the heels off the bed with pillows. On 8/20/19 at 7:10 AM and on 8/21/19 at 7:15 AM, the resident was observed in bed without the heels floated while in bed. The heels were in direct contact with the bed. An interview with the assigned 7:00 AM-3:00 PM shift Certified Nursing Assistant (CNA) was conducted on 8/21/19 at 7:15 AM. The CNA stated that she was just about to clean the resident. The CNA stated that she would use a folded blanket to float the heels when the resident is in bed. An interview with the assigned 11:00 PM-7:00 AM shift CNA, who worked on 8/20/19, was conducted on 8/21/19 at 8:11 AM. The CNA stated that the evening shift CNAs put the resident back to bed. The CNA stated that her work would only be to straighten out the bed and comforter and that she did not look at the resident's heels when the resident was in bed. The CNA also stated that a folded blanket would be placed underneath her feet to float the heels. The CNA stated that she does not use a pillow since this would elevate the resident's feet higher. An interview with the Registered Nurse (RN) Day Supervisor was conducted on 8/21/19 at 7:16 AM. The RN stated that the resident's heels should be floated off the bed using a pillow as ordered and planned. The RN stated that it was the night shift CNA who did not apply the pillow to float the heels while in bed. 415.11(c)(1)

Based on observation, record review and interview during the recertification survey, the facility did not ensure that each resident was provided appropriate treatment and services to maintain the ability to carry out activities of daily living, including ambulation. This was identified for 1 of 2 sampled residents (Resident #63) reviewed for Rehabilitation and Restorative services. Specifically, the facility did not carry out the physician's orders [REDACTED].#63 with Extensive Assistance of 1 person for ambulation to the bathroom with a Rolling Walker. From 7/18/19 to 8/5/19 during the day shift (7 AM-3 PM), there was no documented evidence the Certified Nursing Assistants (CNA) provided extensive assistance of 1 person for walking in the room. Additionally, there was no documented evidence from 7/18/19 to 8/22/19 that the evening shift (3 PM-11 PM) CNAs provided extensive assistance of 1 person for walking in the room. The finding is: Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #63 had a Brief Interview for Mental Status (BIMS) Score of 8 indicating moderately impaired cognition. The MDS documented Resident #63 required extensive assist of one person for transfer and ambulation did not occur in our out of the resident's room. The MDS also documented Resident #63 had unsteady balance and could only stabilize with staff assistance when walking. The MDS indicated that Resident #63's mobility devices included a walker and a wheelchair and that Resident #63 was actively receiving 214 minutes of individual Physical Therapy which started 7/5/2019. The physician's orders [REDACTED].#63 was able to ambulate to the bathroom with rolling walker and extensive assistance of 1 person. The Physical Therapy (PT) discharge summary dated 7/18/19 documented Resident #63 met the goal to safely ambulate on level surfaces 50 feet using a rolling walker with contact guarding (physical contact). The discharge summary further documented that Resident #63 and nursing staff were educated on the patient's functional abilities and has optimized her ability to ambulate with a rolling walker in room. The discharge recommendations documented assistive device for safe functional mobility. The Rehabilitation to Nursing Correspondence form dated 7/18/19 documented ambulation directives to the north nursing unit. The directives documented Resident #63 was able to ambulate to the bathroom with a Rolling Walker and extensive assistance of 1 person. The correspondence documented the signatures of the day shift RN Supervisor and the Director of Rehabilitation. The nurse's progress note, completed by the day shift RN Supervisor, dated 7/18/19 at 1:06 PM was reviewed. The progress note documented that Resident #63 was able to ambulate to the bathroom in her room with a rolling walker and extensive assistance of one person as per PT and the Physician. The 24-hour Nursing Service report dated 7/18/19 documented Resident #63 was able to ambulate to the bathroom in the resident's room with a rolling walker and extensive assistance of 1. The Comprehensive Care Plan (CCP) for ADL Functional/Rehabilitation Potential was dated 7/18/19. The CCP documented Resident #63 was able to ambulate to the bathroom in her room with a rolling walker and extensive assistance of one person. The Comprehensive Care Plan (CCP) for the CNA Plan of Care dated 7/18/19 documented Ambulation: Resident is able to ambulate to bathroom in room with rolling walker and extensive assistance of one. The resident was interviewed on 8/19/19 at 9:27 AM. Resident #63 was seated in her bed connected to an oxygen concentrator. Resident #63 stated that she cannot walk but would like to regain her ability to walk. The resident stated that she used to walk when she was admitted to the facility and had a rolling walker in the past. She stated that she does not currently receive physical therapy and is not on an ambulation program. She stated that she was injured some time ago, recovered and received therapy but she did not know why she was not assisted with walking again. She stated that she does not currently have a rolling walker, but her roommate has one. A rolling walker was observed on her roommate's side which is labeled with the roommate's name. She stated that her aides have her stand to sit in the wheelchair and wheel her to the bathroom and on the unit. The CNA Accountability Record from 7/18/19 to 8/22/19 was reviewed. From 7/18/19-8/5/19 the assigned CNAs on the 7 AM-3 PM shift documented that Walking in the Room did not occur. From 7/18/19 to 8/22/19 the evening shift (3 PM-11 PM) CNAs documented Walking in the Room did not occur. The regularly assigned day shift (7 AM-3 PM) Certified Nursing Assistant (CNA #1) was interviewed on 8/22/19 at 1:00 PM. CNA #1 stated that Resident #63 began to request to walk in her room about a month ago and she assists her with walking from her bed to the bathroom. She stated that she could not recall an exact date and did not have the ability to see the history in the care accountability system. She stated that Resident #63 used to have her own rolling walker when she was first admitted but it was taken away last (MONTH) after she sustained a [MEDICAL CONDITION]. CNA #1 stated she was not sure why it was taken away. CNA #1 further stated that she has been using the roommate's walker and wipes it down prior to using it with Resident #63. The Director of Rehabilitation was interviewed on 8/22/19 at 1:39 PM. The Director of Rehabilitation stated Resident #63 was in physical therapy upon admission and reached her to maximum potential and was able to ambulate with assist of one. She had a fall, broke her hip in (MONTH) (YEAR), and she was subsequently fearful of walking and did not want to walk in the room. In the beginning of (MONTH) 2019, she expressed wishes to walk again and the resident was placed back on a Physical Therapy program from 7/5/19 to 7/18/19. She was subsequently placed on an ambulation program to walk in the room up to 50 feet. The Rehabilitation Director stated this information was conveyed to the dayshift nursing supervisor and the physician on 7/18/19. The order was put in the medical record and the plan of care was updated on 7/18/19. He stated that Resident #63 used to have her own rolling walker upon admission, but the nursing staff probably removed it after she sustained a [MEDICAL CONDITION]. He stated that he was not aware of any reason why it was taken away. A daytime CNA (CNA #2) that provided coverage for CNA #1 who cared for Resident #63 on 8/20/19 was interviewed on 8/22/19 at 2:15 PM. CNA#2 stated that she documented Resident #63 did not walk in her room because she does not walk and that she broke her hip months ago. She stated that Resident #63 is not on an ambulation program and does not walk from her bed to bathroom. She stated that when she provides coverage, she has Resident #63 stand to sit onto the wheelchair, wheels the resident across the room and transfers Resident #63 onto the toilet. CNA #2 stated that Resident #63 does not have a rolling walker to use. The regular evening shift (3 PM-11 PM) CNA (CNA #3) was interviewed on 8/22/19 at 3:25 PM. CNA #3 stated that he has regularly provided care for Resident #63 for the past 6 months. He stated that Resident #63 cannot walk because she sustained a fracture in (MONTH) (YEAR). He stated that he helps her to stand and sit into the wheelchair and wheels her to the bathroom. He stated that he was not updated on an ambulation program for the resident. The evening shift RN Supervisor was interviewed on 8/22/19 at 3:45 PM. He stated that Resident #63 had a decline in physical condition after she had a [MEDICAL CONDITION] in (MONTH) (YEAR). He stated that Resident #63 cannot walk at this time and that he was not made aware of any change of status with ambulation. The RN Supervisor further stated that he does not know if Resident #63 can walk from her bed to the bathroom. The day shift RN supervisor (7 AM-3 PM) was interviewed on 8/23/19 at 11:53 AM. She stated that she received education from the Rehabilitation Director regarding Resident #63's change in ambulation status on 7/18/19. She stated that she cannot recall if she verbally updated the evening supervisor, but it would be documented in the 24 hour report. The Director of Nursing Services (DNS) was interviewed on 8/23/19 at 12:28 PM. She stated that Resident #63 sustained a [MEDICAL CONDITION] in (MONTH) (YEAR) and was put on a Physical Therapy program to regain walking. She stated that she will have the Rehabilitation staff re-evaluate the resident regarding her ambulatory status. 415.12(a)(2)

Based on record review and interviews during the Recertification Survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices for 1 (Resident #31) of 9 residents reviewed for Unnecessary Medications, 1 (Resident #43) of 1 resident reviewed for limited range of motion, and 1 (Resident #37) of 2 residents reviewed for Adaptive Devices. Specifically, 1) Resident #31 was prescribed the medication [MEDICATION NAME] (a medication for [MEDICAL CONDITION], low blood pressure); however, the blood pressure parameter to hold the medication was entered into the order incorrectly and the resident received the medication unnecessarily on one occasion. 2) Resident #43 was discharged from Physical Therapy (PT) with instructions including educating the family to perform Passive Range of Motion (PROM) to bilateral lower extremities (BLE). The family member was not educated and did not perform PROM to BLE. 3) Resident #37 had a physician's orders [REDACTED]. The Treatment Administration Record (TAR) contained signatures from the night shift nurse documenting that the devices were applied during the night shift. The findings are: 1) Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/21/19 Significant Change Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. A physician's orders [REDACTED]. The blood pressure parameter entered was to hold for systolic blood pressure (SBP) less than 120. The parameter was entered as follows: Hold for SBP < 120 (with the < symbol). The category entered in the order was Antihypertensive and the [DIAGNOSES REDACTED]. A Comprehensive Care Plan (CCP), effective 6/21/19, titled Cardiovascular, had an intervention to monitor for signs and symptoms of cardiovascular dysfunction such as shortness of breath, chest pain, [MEDICAL CONDITION], mental status changes, weakness, [MEDICAL CONDITIONS], hypertension, and palpitations. The Director of Nursing (DNS) and Registered Nurse (RN) unit supervisor were interviewed concurrently on 8/21/19 at 9:02 AM. They stated that the order was wrong and that it should say hold for SBP greater than 120 because the medication raises blood pressure. Review of the Medication Administration Record [REDACTED]. The 3 PM-11 PM Licensed Practical Nurse (LPN) who administered the medication on 8/15/19 at 4:30 PM was interviewed on 8/21/19 at 2:24 PM. He stated that he was aware the medication treats low blood pressure and that the medication should have been held for the SBP above 120. He stated that he should have been more diligent. The 7 AM-3 PM LPN who had also administered [MEDICATION NAME] was interviewed on 8/22/19 at 8:20 AM. She stated that she just saw the 120 in the order. She stated that she did not notice that the symbol was wrong that said to hold for less than 120. She stated that she knew the medication is to treat low blood pressure and you would want to hold the medication for a SBP greater than 120. The LPN who entered the hold parameter for the [MEDICATION NAME] was interviewed on 8/22/19 at 10:54 AM. She stated that she received direction from the Nurse Practitioner (NP) to hold the medication for greater than SBP of 120. She stated it was an entry error to hold for less than 120. The NP was interviewed on 8/23/19 at 11:14 AM. She stated she directed the LPN to add a parameter to hold the medication for SBP of greater than 120 and that the medication is used to treat [MEDICAL CONDITION]. The DNS was re-interviewed on 8/23/19 at 11:28 AM. She stated all staff will receive in-service education to not use symbols when entering orders. She also stated that the [DIAGNOSES REDACTED]. 2) The facility's policy and procedure dated 3/31/19 titled Range Of Motion Exercises documented ROM exercises will be provided to preserve Range of Motion in the joints and prevent deformities caused by inactivity of a body part . The Rehabilitation Department provides an evaluation of the resident/patient's joint status through goniometry readings . The Passive PROM exercise is done by nursing staff without any assistance from the resident/patient. Each joint is moved through ROM exercise 3-5 repetitions whether by staff or resident/patient. The CNA will perform ROM as indicated on the CNA Plan of Care and will sign the attestation to confirm ROM completion . Resident #43 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and the resident was severely impaired for daily decision making. The MDS documented the resident required extensive assistance of two persons for bed mobility and had impairment of functional range of motion of both upper extremities. The MDS did not document the resident was on restorative nursing program. The Physical Therapy (PT) Discharge Summary dated 9/12/16 documented the family was educated regarding Passive ROM on bilateral lower extremities (BLE) and Home Exercise Program (HEP) to promote patient's participation during transfer. The resident's Patient's Profile Care Plan for ADL Functional/Rehabilitation Potential dated 2/12/19 documented to provide the resident gentle passive ROM to all extremities with care to minimize risk of further joint stiffness, and further decline in extension/flexion. An interview with PT Director was conducted on 8/22/19 at 12:00 PM. The Director stated that the PT educated and in-serviced the family member, who visits the resident daily in the facility, to do the resident's PROM. The PT Director stated that he does not have signed documentation from the family member that the family member was in-serviced for PROM. An interview with the resident's family member was conducted on 8/22/19 at 2:25 PM. The family member stated that he visits the resident daily and stays at her bedside. The family member stated he does not do PROM on the resident. The family member stated that he was not provided with an in-service on PROM by the PT Department. The family member stated that he wished he was in-serviced on PROM so he could do it. 3) Resident #37 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident had a short term memory problem and was moderately impaired in cognition. The Treatment Administration Record (TAR) dated 5/7/19 documented right hand compression glove during the day in order to reduce [MEDICAL CONDITION] every shift. The TAR dated 4/22/19 documented to place a pillow under the Right Upper Extremity (RUE) in the highback reclining wheelchair (w/c) whenever the resident is in the w/c for proper RUE positioning. The TAR dated 6/21/19 documented to a apply right resting hand splint when the resident is out of bed (OOB) for proper hand positioning, prevention of hand/finger contracture every shift. An interview with the Night shift Licensed Practical nurse (LPN), who signed the TAR on the night shifts, was conducted on 8/23/19 at 6:47 AM. The LPN stated that she signed the TAR on the night shifts only as an acknowledgment that she was aware of the presence of the adaptive/assistive device. The LPN stated that she should not have signed for use of adaptive/assistive devices if they were not applicable on the night shift. An interview with the Registered Nurse (RN) Night Supervisor was conducted on 8/23/19 at 7:20 AM. The RN stated that the night nurses should not be signing for adaptive/assistive device on the TAR when the device was not in place during the night shift. An interview with the Director of Nursing Services (DNS) was conducted on 8/23/19 at 7:25 AM. The DNS stated that she will have to change the frequency as documented in the order for Adaptive/assistive device to reflect the shifts that the devices were in use. 415.22(a)(1-4)

Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents reviewed for Pressure Ulcers. Specifically, Resident #27 had a Deep Tissue Injury (DTI) to the right heel that developed in the facility; however, multiple observations were made of the heel not being offloaded (to prevent contact with any surface) per physician's orders [REDACTED]. The finding is: The facility's policy and procedure titled Wound Care-Pressure Ulcer Prevention dated (MONTH) 26, 2010 documented for a resident with a score of 13-14 on the Braden Scale (a tool for predicting pressure sore risk) to use heel-lift suspension boots or pillows to off-load the heels and to prevent contact with any surface if appropriate. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/10/2017 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the cognition interview. The MDS documented the resident required extensive assist of two persons for bed mobility, the resident was at risk for pressure ulcers, but did not currently have a pressure ulcer. A Braden assessment dated [DATE] documented a score of 14, which indicated the resident was at moderate risk for pressure ulcer development. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) titled Resident at risk for Pressure Ulcers dated 6/30/2017, and last updated 12/12/2017, had an intervention to float the heels with pillows while in bed to relieve pressure. A CCP titled Activities of Daily Living (ADL) Functional/Rehabilitation Potential due [MEDICAL CONDITION] Right [MEDICAL CONDITION] dated 6/30/2017, and last updated 12/12/2017, had an intervention for protective and preventive foot care daily. A nursing progress note dated 2/21/2018 documented the resident was noted to have a dried-up blister to the right heel. The area was 2.5 centimeters (cm) x 4.4 cm with a purple center and no drainage present. The primary physician was notified and an order was received to apply a clean dry dressing daily and treat as it evolves. The wound physician consult dated 2/21/2018 documented the area to the right heel as a DTI, apply dry padding, and treat as it evolves. A CCP was created on 2/21/2018 for the right heel DTI. There was an intervention for heel booties to relieve pressure. The CCP was not specific as to when the heel booties should be used or if they were for both feet. In addition, this care plan did not include an intervention to float the heels in bed. The Certified Nursing Assistant (CNA) Accountability Record (CNAAR) dated 1/19/2018 documented interventions to float the heels off the pillow while in bed. However, the CNAAR was not updated with an intervention to apply heel booties or heel pads. On 2/26/2018 at 10:45 AM Resident #27 was observed in her wheelchair in her room. The resident had a sock on her right foot that was pulled up mid-foot, exposing the dry dressing on the right heel. Her right foot was resting on the wheelchair foot plate with no padding. There were no heel booties in place. There was a sneaker on her left foot. On 2/27/2018 at 11:41 AM Resident #27 was observed in her wheelchair being wheeled to the day room for lunch by a CNA. The resident had sneakers on both feet. On 2/28/2018 at 8:04 AM Resident #27 was observed in bed. The observation was made with the Licensed Practical Nurse (LPN) medication/treatment nurse. The LPN said the wound physician had just seen the resident. The dressing on the right foot was open and there were no heel booties on and the heels were not floated on a pillow. Both heels were resting on the mattress. The LPN said the booties may have been taken off by the doctor. The Wound Physician consult note, dated 2/28/2018, documented that a dry clean dressing and offloading were the only treatments at present. On 2/28/2018 at 9:47 AM Resident #27 was observed in bed. The observation was made with the LPN medication/treatment nurse. There were no booties on the heels and the heels were not floated on a pillow. The heels were resting on the mattress. The LPN said the heels should be floated. She stated she was preparing to do the wound care per the wound physician's consult instructions as of 2/28/2018, which added an intervention to cleanse the heel with normal saline and then apply the dry dressing. On 2/28/2018 at 9:57 AM the wound care treatment was observed. The treatment was done by the LPN. The right heel DTI was approximately 3 cm x 3 cm with no drainage, circular, and reddish/purple in color. On 2/28/2018 at 11:37 AM the resident was observed in her wheelchair in the lobby. She had a heel bootie on her right foot and a sneaker on the left foot. The resident's CNA was interviewed on 2/28/2018 at 12:12 PM and stated she was just assigned to the resident today, but she knew the resident. She stated that the resident required total care because her right side is a problem due to a stroke, the resident is unable to turn and position herself in bed, and that the staff has to turn and position the resident every two hours. She stated that this morning she did not want to put a shoe on the resident's right foot because the shoe was tight because of a dressing, so she put a heel bootie on. She stated the heel booties were not in the CNAAR. On 2/28/2018 at 12:30 PM the resident's room was observed with the Registered Nurse (RN) unit manager. There was one heel bootie in the room. The RN said both heel booties should be worn when in bed in addition to the heels being floated, and when out of bed just the right heel bootie should be worn. She stated that the CNAAR and the pressure ulcer care plan need to be updated because they do not reflect these interventions. She said that the care plan has general interventions for pressure ulcers but needs to be personalized. The CNA who was assigned to the resident on 2/27/2018 on the 7 AM-3 PM shift was interviewed on 3/1/2018 at 08:13 AM. She stated she does not know the resident well, so she had to refer to the CNAAR for directions. The CNA stated the CNAAR did not have specific instructions for the resident's feet when she was dressed and out of bed, so she put sneakers on both feet. The Director of Nursing Services (DNS) was interviewed on 3/1/2018 at 10:27 AM. She stated she did not know why the heel bootie was just for the right foot when the resident was out of bed. The DNS stated that the care should have been better coordinated and clear and the care plan should have been updated with specific interventions. 415.12(c)(1)

Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 3 residents reviewed under the General Investigative Care Area. Specifically, Resident #62 was observed on multiple occasions with blood on his pillow that came from the upper edge of his left ear (the pinna). The Certified Nursing Assistants (CNA) were aware of this change in condition but did not report the blood observed on the resident's pillow to the nurses. The finding is: Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/31/2018 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. There were no pressure ulcers documented in the MDS. The Resident's Interdisciplinary Admission and Intake assessment dated [DATE] did not identify any skin concerns with the resident's ears. On 2/26/2018 at 8:12 AM Resident #62 was observed in his room in bed. Blood was on his pillow near his left ear. He said the bleeding has been occurring for about a week-and-a-half and only when he sleeps. The resident stated that he has a history of [MEDICAL CONDITION] and the bleeding could be from the pillow because he sleeps with his head tilted to the left, causing the pillow to come in contact with the ear. There was no dressing observed on the resident's ear. He stated that the staff knew about the ear condition but could not recall the names of the staff members. Review of the medical record on 2/26/2018 revealed that there was no documentation, care plans, or treatment orders in place for this ear condition. On 2/27/2018 at 7:55 AM Resident #62 was observed in his room in bed. There was blood on his pillow near his left ear. The resident stated that yesterday a Certified Nursing Assistant (CNA) had changed the pillow case. Resident #62's regular 7 AM-3 PM CNA was interviewed on 2/27/18 at 8:34 AM. She stated she worked with the resident on 2/26/2018. The CNA stated she changes the resident's pillow case on a regular basis because his left ear bleeds and that the resident told her that he was going to see a doctor and the nursing staff was aware. She stated she did not report the bleeding to the nurse. Resident #62's Licensed Practical Nurse (LPN) medication nurse was interviewed on 2/27/2018 at 8:49 AM and stated she had not seen the resident today and stated she did not recall seeing any blood on the resident's pillow in the past. The Registered Nurse (RN) unit supervisor was interviewed on 2/27/2018 at 11:28 AM and stated she went in and observed the blood on the resident's pillow this morning after it was brought to her attention. She stated she was not aware of any problems with resident's ear and that if the aides notice blood they should tell the nurse. The RN further stated that she was not aware of the resident having [MEDICAL CONDITION] and there was no documentation of [MEDICAL CONDITION] in the medical record. A nursing note was entered on 2/27/2018 at 10 AM documenting that the resident had a small abrasion to the top of the left ear. A telephone order from the physician was received to cleanse with normal saline and to apply [MEDICATION NAME], in addition to an order for [REDACTED].>On 2/28/2018 at 8:15 AM Resident #62 was observed in his room in bed. There was blood observed on his pillow near his left ear. An abrasion was observed near the edge of his left outer ear and the area was bloody. There was no dressing in place. The resident stated that various aides have seen the blood and changed his pillow case. On 2/28/2018 at 10:30 AM a 11 PM - 7 AM CNA was interviewed who was assigned to the resident the weekend prior to 2/26/2018. The CNA stated she did see blood on his pillow. She stated she asked the resident about it and he said his ear always bleeds because of the pillow. The CNA further stated she did not tell the nurse because the resident said he told the nurse. The RN Inservice Coordinator was interviewed on 3/1/2018 at 9:51 AM. The RN stated that the CNAs are supposed to report anything that is not normal and any change in a resident's condition and that this training is part of the abuse, neglect, and mistreatment inservice the CNAs have received. She further stated she would have expected the CNAs to check with the nurse to make sure the condition was being taken care of. The Director of Nursing Services (DNS) was interviewed on 3/1/2018 at 10:25 AM and stated the CNAs should have reported the blood on the resident's pillow. 415.26(c)(1)(iv)