Every finding on record at Haym Solomon Home for the Aged

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00323375 & NY00316928), the facility failed to ensure that a resident received adequate supervision to prevent accidents. This was evident for two (2) out of two (2) residents (Resident #1 & Resident #2). Specifically, On [DATE] at 5:30 AM, Certified Nurse Assistant #1 transferred Resident #1 from their bed to the wheelchair and Resident #1 fell . Resident #1 required two-person assist with mechanical lift. Resident #1 was assessed by Nursing Supervisor #1 and was observed with an opened purpura (purple-colored spots and patches on the skin) on their left lower extremity. A nursing note dated [DATE] documented Resident #1 was transferred to the emergency room at 8:38 AM on [DATE] after being observed with decreased oxygenation and breathing with their abdominal muscles. Emergency Department Provider's note, by a Doctor of Osteopathic Medicine, dated [DATE] at 9:27 AM, documented the following: fractured right proximal tibia and fibula, fractured left proximal tibia, fractured left Distal Tibia/Fibula (two long bones in the lower left that connect the knee and ankle), and bimalleolar fracture (involved both inner and outer ankle bone) to the left ankle. Resident #1 was pronounced deceased in the hospital on [DATE] at 12:25 AM. On [DATE] at 9:00 AM, Certified Nurse Assistant #3 left Resident #2 unattended on the toilet and Resident #2 fell in the bathroom. A nursing note dated [DATE] at 10:51 AM, by Licensed Practical Nurse #2, documented Resident #2 was observed lying on their right side on the bathroom floor with a lump on the right side of their head with some blood. Tylenol 650 milligrams administered for pain. Resident #2 was transferred to the hospital for a Computed Tomography scan (a medical imaging test) of the head. A hospital After Visit Summary dated [DATE] - [DATE] documented bruising on Right forehead. This resulted in actual harm to Resident #1 and Resident #2 that was not Immediate Jeopardy. The findings include: The Policy and Procedure titled Accident/Incident Reporting dated ,d+[DATE], was revised on ,d+[DATE]. The policy documented it is the policy of the facility to promote resident/patient safety through staff education and provide a safe environment by identifying and eliminating risk without compromising independence. The facility shall ensure that the facility's environment remains free of accident hazards as possible, and that each resident receives adequate supervision and assistive devices to prevent occurrences. Resident #1 was admitted to the facility with diagnoses that include Cerebrovascular Accident with Hemiplegia, Displaced Spiral Fracture Shaft of Right Femur, and Alzheimer's Disease. The Minimum Data Set (a resident assessment tool) dated [DATE], documented Resident had impaired cognition. A Briggs Fall Risk Evaluation dated [DATE] documented Resident #1 was assessed for fall and scored a total of 20 points indicating High Risk. A Fall Care Plan created on ,d+[DATE] documented interventions to maintain plain pathway free of obstacles, keep personal items (eyeglasses and television remote control) within reach, and to keep bed/wheelchair in locked position. Resident Nursing Instructions dated [DATE] to [DATE] documented Resident #1 as totally dependent and required two-persons for physical assist with mechanical lift. A Nursing Progress Note dated [DATE] at 5:30 AM, written by Nursing Supervisor #1, documented at around 5:30 AM, Resident #1 was observed on the floor (in their room) with an opened purpura to their left lower extremity. There were no changes in range of motion. Xeroform (mesh dressing infused with petrolatum) treatment was applied. Resident #1's vital signs were taken; a head-to-toe assessment was done, and Resident #1 was transferred back to bed. The Medical Doctor was notified and ordered an X-ray of bilateral knee and pelvis. The facility's Incident Investigation Report dated [DATE] documented at 5:30 AM, Certified Nursing Assistant #1 assisted Resident #1 out of bed and Resident #1 went down on the floor mat on both knees. Resident #1 was assessed with visible injuries and no complaints of pain or discomfort. Certified Nursing Assistant #1 was removed from the unit and the Director of Nursing was immediately notified. The investigation concluded that Certified Nursing Assistant #1 took the wrong resident out of bed and violated the plan of care. The facility Incident Investigation also documented that on [DATE] at around 7:15 AM, Resident #1 was found lying in bed by Licensed Practical Nurse #2. Resident #1 was unresponsive, breathing with their abdominal muscles, and their face was pale. The Medical Doctor was on the unit and was called to assessed Resident #1. The Medical Doctor ordered for Resident #1 to be transferred to the hospital for further evaluation. The investigation also concluded there was reasonable cause to suspect resident abuse, neglect, or mistreatment had occurred. A nursing note, by Licensed Practical #2, dated [DATE] at 10:54 AM documented Resident #1 left for the hospital at 8:38 AM. There was no disposition note in the medical record. Licensed Practical Nurse #1 provided the facility with a written statement dated [DATE]. The statement documented Licensed Practical Nurse #1 was the charge nurse on the 11:00 PM to 7:00 AM shift on [DATE]. Licensed Practical Nurse #1 gave Certified Nurse Assistant #1 a printed assignment with residents who were to be taken out of bed. Licensed Practical Nurse #1 documented at around 5:30 AM (on [DATE]), while they were giving medications, they saw Certified Nurse Assistant #1 walking towards a room, and they followed Certified Nurse Assistant #1 into Resident #1's room. Licensed Practical Nurse #1 saw Resident #1 kneeling on the floor mat next to their bed holding onto their wheelchair. Licensed Practical Nurse #1 immediately called Nursing Supervisor #1, who assisted Resident #1 back to their bed via mechanical lift. Resident #1 had an abrasion to their left leg. An order was given to clean the area with normal saline, apply Xeroform, and wrap with Kling. Resident #1 was stable after the incident. A Hospital Emergency Department Provider's Note, by the Doctor of Osteopathic Medicine, dated [DATE] at 9:27 AM to [DATE], documented Resident #1 is being treated for sepsis (related to urinary tract infection) as well as orthopedic fractures from a fall at the nursing facility. Resident #1 had sustained a trauma by being dropped in nursing home with bilateral lower extremity fractures, these fractures are considered non-operative per the orthopedic surgery team. A Computer Tomography scan was documented and showed Resident #1 sustained tibia/fibula fracture right proximal tibia and fibula, fracture left proximal tibia, left distal tibia/fibula fracture, and bimalleolar fracture left ankle. Mild swelling about both knees and painful response with palpation about the leg just below the joint lines on the right was also noted. Resident #1 was pronounced deceased at 12:25 AM on [DATE]. Reported to the New York City Medical Examiner office on 12:31 AM. Resident #1's adult child declined an Autopsy. During a telephone interview on [DATE] at 12:50 PM, Certified Nurse Assistant #1 stated they worked on [DATE] on the 11:00 PM to 7:00 AM shift with Licensed Practical Nurse #1 and another Certified Nursing Assistant. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 gave them their assignment on a piece of paper. Certified Nurse Assistant #1 stated they lost the piece of paper with their assignment. Certified Nurse Assistant #1 stated Licensed Practical Nurse #1 did not explain to them that when there are only two Certified Nurse Assistants on the unit, they do not take the residents out of bed. Certified Nursing Assistant #1 stated Resident #1 was not on their assignment and that they took the wrong resident out of bed. Certified Nurse Assistant #1 stated they should have taken the resident from the A-Bed instead of the B-Bed (Resident #1). Certified Nurse Assistant #1 stated while they were taking Resident #1 out of their bed, they were also positioning the wheelchair under the resident. Certified Nursing Assistant #1 stated the wheelchair moved, and Resident #1 fell on the floor. Certified Nursing Assistant #1 stated Resident #1 had a cut and some bleeding on their leg and got Licensed Practical Nurse #1. Certified Nurse Assistant #1 stated they worked for an agency, and they were not trained by the facility to use the Kiosk (a piece of electronic equipment where Certified Nursing Assistants review their assignment before caring for a resident). Certified Nursing Assistant #1 stated they did not ask anyone for assistance. Certified Nurse Assistant #1 stated they were not aware Resident #1 was a two-person transfer with the mechanical lift and that Licensed Practical Nurse #1 did not give them report. Certified Nurse Assistant #1 stated they became aware of Resident #1's plan of care when Licensed Practical Nurse #1 came into Resident #1's room and assisted with transferring Resident #1 back into the bed. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 cleaned Resident #1's cut. Certified Nurse Assistant #1 stated they did not receive any training on the facility's policy and procedures, no training on abuse, no training on how to use the Kiosk to access their assignment. During a telephone interview on [DATE] at 03:37 PM, Licensed Practical Nurse # 1, stated that they do not recall the alleged incident and it was a long time ago and ended the interview. During a telephone interview on [DATE] at 01:43 PM, Nursing Supervisor #1 stated on [DATE] on the 11:00PM to 7:00 AM shift, they were called to assess Resident #1 who had fallen. Nursing Supervisor #1 stated when they arrived at Resident #1's room, they observed Resident #1 lying on their back on the floor mat next to their bed. Nursing Supervisor #1 stated Resident #1 was assessed to be alert, confused, not in any distress, but was unable to give an account of the incident. Nursing Supervisor #1 stated Resident #1 had no complaints of pain, had a skin tear to the left lower extremity with no deformities observed. Nursing Supervisor #1 stated they assisted Resident #1 back to the bed with the mechanical lift and the physician was notified. Nursing Supervisor stated wound care was done and a report was given to the incoming shift. Nursing Supervisor #1 stated they left Resident #1 in no acute distress. During an interview on [DATE] at 01:45 PM, Licensed Practical Nurse #2 stated during the 7:00 AM rounds, at around 07:15 AM (on [DATE]), they observed Resident #1 lying in bed, unresponsive, breathing with their abdominal muscles and face pale. Licensed Practical Nurse #2 stated the physician was on the floor and was called to assess Resident #1 who was placed on a non-rebreather oxygen mask and vital signs taken. Licensed Practical Nurse #2 stated Resident #1 was assessed to have had a dressing on their left lower leg due to a previous skin tear. Licensed Practical Nurse #2 stated a nursing supervisor was called (do not recall name), and an Intravenous fluid drip was started. Licensed Practical Nurse #2 stated the physician ordered Resident #1 to be transferred to the hospital via 911. Licensed Practical Nurse #2 stated Resident #1 was bedbound and required two-person assist with mechanical lift transfer. During a telephone interview on [DATE] at 2:36 PM, the Director of Nursing stated Resident #1 was found on their knees at the bedside after Certified Nurse Assistant #1 attempted to transfer Resident #1 out of bed. The Director of Nursing stated Certified Nursing Assistant #1 was not given any instructions to take Resident #1 out of bed. The Director of Nursing stated they learned through a third party that Resident #1's adult child reported Resident #1 expired in the hospital from broken bones. The Director of Nursing stated Resident #1 was not assessed to have any broken bones, prior to going to the hospital. During a telephone interview on [DATE] at 12:13 PM, the Medical Doctor stated they did not recall the actual accident. Resident #2 was admitted to the facility with diagnoses that included Dementia and Diabetes. The Minimum Data Set assessment dated [DATE] documented Resident #2 had severe cognitive impairment. A Briggs Fall Risk Evaluation created on [DATE] showed documentation that Resident #2 was assessed for fall and scored 9. The form did not indicate level of fall risk. A Fall Risk Care Plan dated [DATE] documented interventions to follow toileting plan as appropriate, keep bed/wheelchair in locked position, and bed in lowest position when in bed. The Care Plan was updated [DATE] post incident. An Activity of Daily Living Care Plan dated from ,d+[DATE] revealed Resident #2 required extensive assist of one-person. There was no documented evidence on the Fall Risk Care Plan and the Activity of Daily Living Care Plan indicating Resident #1 should not be left alone in the bathroom prior to the accident. The instructions were entered after the accident on [DATE]. The Resident Certified Nursing Assistant Documentation History Detail from [DATE] through [DATE] documented Resident #2 required extensive assist of one-person for toilet use and transfers. There were no documented instructions for staff to not leave Resident #2 in the bathroom unattended. by themself on the toilet or in the bathroom. A Progress Note (nursing) dated [DATE] at 9:46 AM, by Nursing Supervisor #2, documented they observed Resident #2 lying on their right side in the bathroom. Resident #2 had a hematoma (collection of blood outside of blood vessels that forms due to injury or trauma) on the right side of their forehead with a small amount of sanguinous (fluid contains both blood and liquid) drainage. Resident #2 was transferred to the hospital. The facility Accident/Incident Report dated [DATE] at 9:00AM, documented according to Certified Nursing Assistant #3 they had Resident #2 on the toilet and left to put an empty denture cup on the nightstand in the resident's room. Certified Nursing Assistant #3 stated Resident #2 was screaming and demanding they put the cup back on the nightstand. Certified Nursing Assistant #3 heard a sound and when they entered the bathroom, Resident #2 was lying on their right side on bathroom floor. Assessment revealed Resident #2's head was touching the floor and Resident #2 had a hematoma on the right side of their forehead. Resident #2 was confused and was unable to explain what had occurred. Ice pack and dressing applied, and neuro check initiated. On [DATE], Resident #2 was transferred to the emergency room for Computed Tomography scan of the head and bilateral hip and pelvis x-rays. The investigation concluded Certified Nursing Assistant #3's actions were not intentional; however, Certified Nursing Assistant #3 violated the facility policy by leaving Resident #2 unattended in the bathroom. There was no reasonable cause to suspect any Resident Abuse, Neglect, or Mistreatment. The investigation also revealed Resident #2 had a Computed Tomography scan of the head that revealed subdural hematoma (bleeding near the brain). There was no documented evidence in facility policy for staff not to leave residents in the bathroom or on the toilet by themselves prior to the accident on [DATE]. There was a lesson plan dated [DATE] with CNA signature on in-service sheet stating not to leave resident alone in bathroom. A Hospital emergency room Visit document dated [DATE], documented Resident #2 was transferred back to the facility with primary diagnosis status post fall. Skin observation documented bruising on the right forehead. A Nursing Progress Note dated [DATE] at 8:35 PM, documented Resident #2 was readmitted from the hospital with primary diagnosis status post fall and head injury. Assessment revealed ecchymosis on right knee, ecchymosis on upper right hand, and ecchymosis (a medical term for a bruise, which is a discoloration of the skin caused by leakage of blood from damaged blood vessels into surrounding tissues) and swelling over the right eyebrow with dried blood. During an interview on [DATE] at 2:10 PM, Certified Nurse Assistant #3 stated they put Resident #2 on the toilet and put the denture cup on the bathroom sink and Resident #2 began yelling demanding Certified Nursing Assistant #3 put the denture cup on their bedside table. Certified Nurse Assistant #3 stated they explained to Resident #2 that they could not leave them on the toilet and Resident #2 kept yelling for Certified Nursing Assistant #3 to put the denture cup on the bedside table. Certified Nursing Assistant #3 stated they did what Resident #2 asked and then they heard a fall like noise and found Resident #2 on the bathroom floor. Certified Nursing Assistant #3 stated they called for Licensed Practical Nurse #3 to check Resident #2. Certified Nursing Assistant #3 stated Resident #2 had a bump and bleeding on their head. During an interview on [DATE] at 11:00 AM, Licensed Practical Nurse #3 stated Certified Nurse Assistant #3 called them to Resident #2's bathroom and they observed Resident #2 lying next to the toilet with a hematoma to the right side of their face. Licensed Practical Nurse #3 stated Resident #2 was assisted off the floor. The doctor was notified and ordered for Resident #2 to be transferred to the emergency room for evaluation. Licensed Practical Nurse #3 stated Certified Nurse Assistant #3 left Resident #2 on the toilet to do something else. During an interview on [DATE] at 2:30 PM, Nursing Supervisor #2 stated they observed Resident #2 lying on the bathroom floor on their right side. Nursing Supervisor #2 stated they assessed Resident #2, who had a hematoma on the right side of the forehead with bleeding. Nursing Supervisor #2 stated Resident #2 was assessed to be alert with some confusion. Neuro check was at their baseline and Resident #2 had no complaints of pain or discomfort. Registered Nurse Supervisor #2 also stated the Medical Doctor was notified and ordered Resident #2 to be transferred to the hospital for a head Computed Tomography scan, bilateral hip, and pelvis x-ray. As per the Registered Nurse Supervisor #2, the fall was not witnessed, and it was uncertain as to why Certified Nurse Assistant #3 left Resident #2 alone on the toilet. During a telephone interview with the Director of Nursing on [DATE] at 1:50 PM, the Director of Nursing stated the Fall Risk Lesson Plan Policy dated ,d+[DATE] was developed by them after Resident #2's fall. The Director of Nursing stated staff were told not to leave residents at risk for fall in the bathroom by themselves. The Director of Nursing also stated the instruction (not to leave resident in the bathroom by themself) would be on the electronic kiosk and a green star (at risk for fall) would also be at the resident's name. The Director of Nursing further stated after Certified Nursing Assistants receive their resident assignment, they must check the kiosk for resident level of care before caring for the resident. The Director of Nursing stated after the charge nurse gives report, they also tell the Certified Nursing Assistants to check the kiosk. The Director of Nursing stated Certified Nursing Assistant #2 is from an agency and had been assigned to Resident #2's unit. The Director of Nursing stated they didn't know why Resident #2's latest [NAME] assessment dated [DATE] identified Resident #2 not at High Risk for fall. The Director of Nursing stated Resident #2 sustained a hematoma to the head. 10 NYCRR 415.4(b)(1)(i)

Based on record review and staff interviews conducted during the Recertification survey from 10/31/2024 and 11/07/2024, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. This was evident for 2 (Residents #60 and #174) of 2 residents reviewed for Personal Funds out of a total sample of 38 residents. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. The findings are: The facility policy and procedure titled Resident's Personal Funds Account dated 05/2018, last revised 05/2024 documented that the resident and/or Designated Representative will receive an account statement on a quarterly basis, and all inquiries will be addressed in a timely fashion. The Residents Fund Listing printed 11/05/2024 documented that Residents #60 and #174 had active accounts and funds with the facility. 1. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #60 had intact cognition and participated in their assessment and goal setting. On 10/31/24 at 11:09 AM, Resident #60 was interviewed and stated that they have an account with the facility, but they have never received any statement from the facility. There was no documented evidence provided that Resident #60 or their representative had been provided with copies of their quarterly statements. 2. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #174 had intact cognition and participated in their assessment and goal setting. On 10/31/24 at 11:25 AM, Resident #174 was interviewed and stated that they have an account but cannot recollect when last their statement was given. There was no documented evidence provided that Resident #174 or their representative had been provided with copies of their quarterly statements. On 11/04/24 at 01:24 PM, an interview was conducted with Social Worker #1 who stated that resident's fund and their statements are handled by the business office. Social Worker #1 also stated that they intervene if residents complain of not getting their funds, but residents have not been reporting that they are having problem getting their money, and they are not aware that the statements are not being given to the residents. On 11/04/24 at 02:38 PM an interview was conducted with the Director of Finance who stated that residents' statements are mailed to the resident's family and also mailed to the alert residents in the facility every quarter, the recreation staff delivers the statements to the residents in the facility when they are delivering their mails, and if any resident requests for the copy of the statement, it is given to them at any time. The Director of Finance further stated that there is no way the facility can confirm if the statements are received or not, because they use the regular mails to send to the family and the alert residents in the facility receive the statement with their other regular mails which they don't sign for. The Director of Finance stated that they follow the procedure of mailing the statements out, and they do not document it in the residents' chart but only save the copy of the statement mailed out in the logbook. On 11/05/24 at 09:55 AM, the Director of Recreation was interviewed and stated that mails are delivered to the residents every morning which include their financial statements. The Director of Recreation also stated that they are notified by the Finance department whenever residents' statements are generated, and they are physically hand delivered to the residents. The Director of Recreation further stated that the statements are usually delivered to the residents with their other regular mails, but the residents are not made to sign for the statements, and they are not documenting the delivery of the statement in the residents' charts. On 11/05/24 at 11:54 AM, the Administrator was interviewed and stated that they believe the business office keep the log of the statements mailed out to the residents and the residents' family members. The Administrator could not explain why there was no documentation in the residents' charts when the statements are mailed out to the residents. 10 NYCRR 415.26(h)(5)(i)

Based on record review and staff interviews conducted during the Recertification survey between 10/31/24 and 11/07/24, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds was obtained to assure the security of all personal funds of residents deposited with the facility. This was evident for 81 residents who maintained personal funds accounts with the facility. Specifically, the surety bond obtained by the facility was not sufficient to cover the total held in all resident's accounts. The findings are: The facility policy and procedure titled Resident's Personal Funds Account dated 05/2018, revised 05/2024 documented that the facility purchases a surety bond to assure the security of all funds which residents have deposited with the facility. The Residents Fund Listing printed documented resident's funds which totaled $191,407.87, The bond #10BSBEX0694 created October 4, 2023, to cover the period January 2024 to December 2024 was in the amount of $175,000 and was insufficient to cover the total balance of all resident's accounts. On 11/04/2024 at 02:38 PM, an interview was conducted with the Director of Finance who stated that they have a current bond which covers the funds up to January 1, 2025. The Director of Finance also stated that they received notice of the cancellation of the bond which will be effective as of 01/01/2025, and they are already shopping for another insurance company through their insurance [NAME] to get another bond before the current bond expires. The Director of Finance further stated that when preparing the 3rd Quarter resident funds statements in October they realized that the surety bond amount was not enough to cover the residents' total fund and they are already making arrangement to increase the amount of the bond. On 11/05/2024 at 11:54 AM, the Administrator was interviewed and stated that they were just informed by the Director of Finance that the surety bond value is not enough to cover the current residents' fund, and they are already making efforts to adjust the bond accordingly. 10 NYCRR 415.26(h)(5)(v)

Based on observations, record reviews and interviews during the Recertification and Abbreviated Survey (NY00341031, NY00353026) conducted from 10/31/2024 to 11/07/2024 the facility did not ensure that injuries of unknown origin were reported immediately but not later than 2 hours after the allegation was made, if the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the New York Department of Health. This was evident for 2 (Resident #144 and #130) of 2 residents reviewed for Abuse out of 38 total sampled residents. Specifically, 1). on 04/29/2024 at 10:00 AM Resident #144 observed with large bluish/purple discoloration to the left breast and yellowish fading discoloration to the chest area that were not reported to the New York State Department of Health in a timely manner, and 2). on 10/23/2023 at 10:00 AM, Resident #130 was observed with a hematoma on left lower leg of unknown origin and the facility failed to report to the State Survey Agency within 2 hours of becoming aware of the injury. The findings are: The facility's policy titled Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Resident Property - Investigation and Reporting last revised 09/2024 documented that if the Administrator, Director of Nursing, or Grievance Officer has reasonable cause to believe that abuse, neglect, or misappropriation of resident property took place, they will report to the New York State Department of Health and take all necessary corrective action depending on the results of the investigation. The policy did not outline any timeframes for reporting incidents to the Department of Health 1. Resident #144 (NY00341031) was admitted with diagnoses including Non-Alzheimer's Dementia, Old Rib Fractures, and Muscle Wasting. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #144 as severely cognitively impaired with no physical or verbal behavioral symptoms directed toward others. The Quarterly Minimum Data Set Assessment also documented that Resident #144 required dependent assistance with personal hygiene and toileting hygiene, substantial/maximal assistance with sit to stand, chair/bed-to-chair transfer and toilet transfer with Activities of Daily Living. A Nursing note dated 04/29/2024 at 12:49 PM documented Resident #144 was observed with large bruising involving the left breast. The note also documented that Resident #144 was on Eliquis 2.5 milligram which put Resident #144 at risk for bruise formation. The Full Quality Assurance Report dated 04/29/2024 at 10:00 AM documented that Resident #144 was observed with large bruising involving left breast and bruise on sternum yellowish fading discolorations. The Medical Doctor, Director of Nursing and family were notified. The Registered Nurse Supervisor #1 and Director of Nursing reassessed Resident #144 and observed with a large area of purplish discoloration extended from areola to the lateral side of the left breast, however in the evening, the discoloration had spread to the right breast and right axillary swelling noted. Resident #144 observed with behavior of repetitive uncontrolled movements, moving back and forth, rubbing, and stroking the table with their hands while leaning forward to the table. Resident #144 was on long term Eliquis therapy. The Medical Doctor examined Resident #144 and noted with chest hematoma, upper area of chest with yellow-greenish discoloration, both breasts with dark blue, non-tender and right axillary area with cystic lesion. On 04/30/2024 approximately 7:15 AM, Resident #144 observed with extensive ecchymosis to both breast and sternal area with multiple diffused ecchymosis to upper chest wall. A nursing note titled Resident Transfer Summary dated 04/30/2024 documented Resident #144 was transferred to hospital on 04/30/20204 and left unit at 6:30 PM due to bilateral breast hematoma. The Webform Submission from Nursing Home Facility Incident Report emailed to Director of Nursing documented the incident was submitted to the New York State Department of Health on 05/02/2024 at 13:43. On 11/05/2024 at 11:57 AM, Registered Nurse Supervisor #1 was interviewed and stated they were called on 04/29/2024 at 10:00 AM to Resident #144's room and observed Resident #144 with yellowish-greenish discoloration on chest area and large bruising, purplish discoloration on the left breast. Registered Nurse Supervisor #1 called Certified Nursing Assistant #7 who worked on 04/28/2024 on the 11PM-7AM shift who stated they did not observe any skin discoloration on Resident #144. Registered Nurse Supervisor #1 also stated they did not observe signs of pain, and nobody knew how Resident #144 sustain the discoloration. Registered Nurse Supervisor #1 further stated that by the morning of 04/30/2024 the discoloration had spread to Resident #144's right breast and right arm, so they initiated the report, and the Director of Nursing followed it up and reported to the Department of Health. On 11/05/2024 at 4:19 PM, the Director of Nursing was interviewed and stated they started their investigation on 04/29/2024, and they gathered statements and interviewed staff who had direct contact from 04/27/2024 and 04/28/2024 and documented they did not observe discoloration on Resident #144's skin. The Director of Nursing stated they did not report to the Department of Health because they thought Resident #144 was having blood dyscrasia (a disease or disorder of the blood, bone marrow or lymph nodes) and because Resident #144 was on long term use of Eliquis with a behavior of leaning towards the table. The Director of Nursing stated as the day progressed the discoloration became more pronounced, and Resident #144 was transferred to the hospital on 04/30/2024 at 6:30 PM. On 05/02/2024 at approximately 10:30 AM, the hospital Case Worker called them and reported Resident #144 had right chest wall hematoma which appeared to be trauma and a left acute pelvic fracture. The Director of Nursing stated they reported to Department of Health on 05/02/2024 at 1:43 PM. The Director of Nursing stated there was no witness to how Resident #144 sustained the injury, no report of fall, and they had no evidence to conclude the investigation and that is why they then reported to the Department of Health. On 11/06/2024 at 2:39 PM, the Administrator was interviewed and stated they were notified of the incident when discoloration and hematoma on the chest wall was discovered. The Administrator also stated it was not reported to Department of Health because they did not know the cause. The Administrator further stated it started as slight discoloration on the chest wall and when they noticed it was spreading further, Resident #144 was sent to the hospital. The Administrator stated since it was a slight discoloration, the facility would do investigation and if they determined that there was an abuse, it must be reported to the Department of Health within two hours. 50894 2. Resident #130 (NY00353026) had diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Muscle Weakness. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #130 had moderate cognitive impairment and was assessed to require dependent two-person assistance for transfers. The Physician's Order dated 10/20/2023 documented that Resident #130 required two-person dependent assistance using a Hoyer lift for transfers. An Accident/Incident Report dated 10/23/2023, which included Date/Time of Incident as 10/23/2023 at 10:00 AM, documented that Resident #130 was observed with a hematoma and ecchymosis to the outer side of the left lower extremity below the knee. Resident #130 denied falling and stated that it may have happened during a transfer with the Chinese guy but could not describe the allegation more specifically. The Investigation Summary also documented that the facility concluded that there was reasonable cause to believe that the injury occurred on 10/22/2023 at 04:00 PM during a Hoyer lift transfer completed by Certified Nursing Assistant #3 and Certified Nursing Assistant #2, when the resident's left leg encountered a surface during the transfer. The Nursing Home Facility Incident Report Submission documented that the Director of Nursing submitted a report to the New York State Department of Health on 10/25/2023 at 15:55 PM related to Resident #130's hematoma of unknown origin. The Incident Report documented that the Director of Nursing became aware of Resident #130's injury on 10/23/2023 at 10:00 AM. On 11/05/2024 at 04:25 PM, Certified Nursing Assistant #3 was interviewed and stated that they assisted Certified Nursing Assistant #2 with a Hoyer lift transfer for Resident #130 on 10/22/2023. Resident #130 was assigned to Certified Nursing Assistant #2 on this shift but because Resident #130 requires a two person assist for Hoyer lift transfers, Certified Nursing Assistant #3 was assisting as the second person in the transfer. Certified Nursing Assistant #3 also stated that they transferred Resident #130 without issue or concern and that they did not recall Resident #130's leg encountering a surface during the transfer. On 11/05/2024 at 04:33 PM, Certified Nursing Assistant #2 was interviewed and stated that on 10/22/2023, they transferred Resident #130 from their wheelchair to their bed with the assistance of Certified Nursing Assistant #3. Certified Nursing Assistant #2 also stated that they held the resident's legs while Certified Nursing Assistant #3 operated the Hoyer lift. Certified Nursing Assistant #2 further stated that Resident #130's leg did not encounter any surfaces during the transfer. Certified Nursing Assistant #2 stated that they worked with Resident #130 for approximately three hours after the transfer and Resident #130 did not complain to them about leg pain. On 11/06/2024 at 09:46 AM, Licensed Practical Nurse #5 was interviewed and stated that on 10/23/2023 at 02:00 AM, they were providing incontinence care to Resident #130 with Certified Nursing Assistant #5 and observed a hematoma on the resident's left leg. Licensed Practical Nurse #5 also stated that they notified their supervisor of this finding but was unable to recall which supervisor they notified. Licensed Practical Nurse #5 further stated that they were unable to recall if they documented the finding in Resident #130's electronic medical record. An Accident/Incident Report Employee Statement completed by Certified Nursing Assistant #4 on 10/23/2023 documented that Certified Nursing Assistant #4 was providing personal hygiene care to Resident #130 at around 08:30 AM on 10/23/2023 when they observed the hematoma on Resident #130's leg. The statement documented that Certified Nursing Assistant #4 had provided care to Resident #130 on 10/22/2023 and had not observed the hematoma during that shift. On 11/06/2024 at 10:14 AM, the Director of Nursing was interviewed and stated that they became aware of the hematoma on 10/23/2023 at around 10:00 AM and reported it to the New York State Department of Health on 10/25/2023 at 03:55 PM. Certified Nursing Assistant #4 observed the hematoma and notified Registered Nurse Supervisor #2, who immediately notified Medical Doctor #2. Resident #130 was seen by Medical Doctor #2 who ordered an X-ray and CT scan. The X-ray was completed on 10/23/2023 and revealed no fractures. The CT scan was completed on 10/26/2023 and revealed that the injury was a superficial hematoma. The Director of Nursing also stated that when they first became aware of the hematoma, it was an injury of unknown origin. The Director of Nursing further stated that they did not report this to the Department of Health within two hours because they did not know how Resident #130 had developed the injury. The Director of Nursing stated that the facility's typical procedure is to wait until after they receive the results of the X-ray and understand the severity of the injury before they report it, unless the resident verbalizes that someone harmed them. The Director of Nursing also stated that abuse could not be ruled out until the investigation was completed but that at the time of the incident, Resident #130 was not reporting that they had been abused. On 11/07/2024 at 11:18 AM, the Administrator was interviewed and stated that they are not involved in making reports to the Department of Health. The Administrator also stated that the Director of Nursing will make them aware of concerns within the facility, but the responsibility of reporting in a timely manner falls on the Director of Nursing. 10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during the Recertification and Abbreviated (NY00330333) survey from 10/31/2024 to 11/07/2024, the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident for 1 (Resident #3) of 6 residents reviewed for Pain out of 38 sampled residents. Specifically, Resident #3 had a Morphine pump installed in 7/2020, and there was no documented evidence that the cartridge of the pump was changed and or refilled as required every 6 months, or that Resident #3 had been referred to pain management in over 12 months. In addition, there was no documented evidence that Resident #3's had an active order for the morphine pump or as needed pain medication as documented monthly by the physician. The findings are: The facility policy titled Pain Assessment and Management revised 5/2024 stated that residents who experience pain will have a comprehensive assessment of pain and a treatment plan established for his/her pain. The policy also stated ongoing assessment shall be done to evaluate the changing nature of pain as well as the effectiveness of the treatment of the pain. The facility policy titled Infusion Therapy Continuous Ambulatory Delivery Device Patient Controlled Infusion Pump effective 9/22/2023 documented the resident should be under the care of a Licensed physician familiar with intrathecal therapy including indications, contraindications, administration, monitoring, and potential adverse reactions. The policy also documented prescription guidelines should include medication, length and frequency of therapy and parameters for notifying the physicians, order for Narcan, lab work and order for antiemetic as needed. Resident #3 was admitted to facility with diagnosis including Low Back Pain, Rheumatoid Lung Disease, and Benign Prostatic Hyperplasia. The Minimum Data Set assessment dated [DATE] documented Resident #3 was cognitively intact, received a pain medication regime, was not offered pain medication as needed, did not receive nonpharmacological interventions for pain, and experienced moderate pain frequently. The Complaint Intake Form dated 12/21/2023 documented that Resident #3 complained of being in pain due to back surgery, and the facility had not offered them anything other than Tylenol for pain and seemed unconcerned with their pain. On 11/05/2024 at 09:07 AM, Resident #3 was observed lying in bed awake and stated they are reading prayers. Resident #3 also stated they are always in pain but is not sharp pain, because the pump takes care of the sharp pain. Resident #3 pointed to a pump placed in their left lower abdomen, and stated the pump is for lifelong use to help control pain. On 11/05/2024 at 11:40 AM, Resident #3 was interviewed and stated they have a morphine pump in their left lower abdomen which was placed by their private doctor who had cared for them for many years. Resident #3 also stated had they had multiple back surgeries, and the morphine pump takes away most of the pain, but not all the pain and they may have called the Department Of Health on one of those days when they had shooting pain. Resident #3 further stated that every 6 months their doctor comes to the facility to replace the cartridge and they were not sure what dosage of medication they were receiving. Resident #3 stated the pump itself needs to be replaced every 5 or 6 years and they were not sure when it was last replaced. Resident #3 was unable to recall the last time the pump was changed and showed the State Surveyor a card which stated the pump was last refilled in May 2023. Resident #3 stated that their pain today is 6/10 and they are resting in bed as this is what relieves most of their pain now. The Comprehensive Care Plan titled Pain Management Advance Disease process Low Back Pain status post L4 laminectomy and T4-T5 fusion. Resident is on a morphine Pump dated effective 09/25/2016 and last evaluation dated 09/4/2024 with interventions including Morphine pump is pre-set up for automatically delivered morphine, as prescribed, via pump and adjust medications and non-medication interventions. Non-pharmacological interventions to address pain were not documented. The Physician Orders last reviewed 10/16/2024 contained no current orders for a Morphine pump. The Physician orders 6/8/2021 and last reviewed on 10/16/2024 documented Lyrica 50 mg capsule give 1 capsule (50 mg) by oral route once daily at bedtime for low back pain. The Physician Monthly notes dated 10/27/2024, 09/21/2024, 08/17/2024, 08/17/2024, 06/25/2024, 07/23/2024, 06/25/2024 and 05/21/2024 under the section title Active Diagnosis and Plan of Care documented continue with Lyrica, Tylenol as needed, status post intrathecal Morphine pain pump implant replacement, pain management follow up. Review of the medical record revealed no orders for Tylenol as needed or for monitoring of pain. The Nursing progress note dated 5/23/2023 documented as per resident private doctor came today and refilled resident's medication pump. There was no documented evidence that Resident #3's morphine pump was refilled after 05/23/2023. The Pain Management consult dated 10/6/2022 documented pain management follow up. Pain control stable, no changes to pump regimen. Pump refill without complications. Hydromorphone 1.0mg/1ml. Current setting reservoir: 20.0 ml. Duration: 12:00 AM -12:00am 24 hours. 0.2002 mg (0.0083 mg/hour. 24-hour dose: 0.2002 mg/day. Estimated replacement 2029. There was no documented evidence that Resident #3 had been evaluated by pain management since 10/06/2022. Pain monitoring entered on the Medication Administration Record rating of 2/10 for Lyrica to high of 6/10. On 11/05/2024 at 09:19 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #3 is alert, able to speak all needs, but needs assistance with Activities of Daily Living and they must do everything for them because they have difficulty moving. Certified Nursing Assistant #1 also stated Resident #3 requests a bed bath every morning after which they get dressed for the day. Certified Nursing Assistant #1 further stated that Resident #3 used to go to religious services every day at 8:00 am but now gets ready and sits in the room on the bed and does prayers there. Certified Nursing Assistant #1 stated that Resident #3 does not like to sit in the chair for long periods and will always request to go back to bed, as they prefer to sit on their bed or lie in bed throughout the day, their back hurts if they sit in the chair for too long. Certified Nursing Assistant #1 also stated Resident #3 does not complain of pain during care. Certified Nursing Assistant #1 further stated that Resident #3 has a machine on the left side of their abdomen that beeps at times, and they are not sure what it is. Certified Nursing Assistant #1 further stated they did not ask the nurse about the machine and was not told about it. On 11/05/2024 at 10:19 AM, Licensed Practical Nurse #1 was interviewed and stated Resident #3 is alert and oriented, able to make needs known, and has pain in their back. Licensed Practical Nurse #1 also stated that Resident #3 does not receive pain medication on the day shift and Resident #3 stated when they feel pain, they take a walk on the unit and then lie down. Licensed Practical Nurse #1 further stated that they believe Resident #3 has a morphine pump in their back. Licensed Practical Nurse #1 stated they have nothing to do with the pump, never saw the pump, did not ask Resident #3 about the pump, are not sure how to monitor the pump and was not inserviced about it. Licensed Practical Nurse #1 stated that they ask Resident #3 every day about pain and Resident #3 stated that when they walk, they feel better. On 11/05/2024 at 10:45 AM, Registered Nurse Supervisor #1 was interviewed and stated Resident #3 is alert and oriented, is on Lyrica at bedtime for pain, and takes the pain medication as ordered. Registered Nurse Supervisor #1 also stated that Resident #3 displayed no non-verbal signs of pain and the morphine pump in place relieves the pain. Registered Nurse Supervisor #1 further stated that Resident #3 was seen by psychiatry and is receiving medication based on complaints of pain secondary to spine operation which they had prior to coming to the facility. The Attending Physician manages the Resident #3's pain and Resident #3 refused Tylenol and has been receiving Lyrica since June 2021. Registered Nurse Supervisor #1 stated Resident #3 participates in regular activities and is very vocal about their needs. Registered Nurse Supervisor #1 also stated that Resident #3 has a morphine pump on the right side of their stomach which is replaced every 5 years, and the cartridges are replaced every 6 months by Resident #3's pain management doctor. Registered Nurse Supervisor #1 further stated they were not sure when the cartridge was last replaced. Registered Nurse Supervisor #1 stated that the pump is automatic and is set up to deliver the medications, and there is no monitoring being done for the pump and they are not sure what needs to be done with it. Registered Nurse Supervisor #1 also stated that they have been in the role as supervisor since April 2024, and was aware that the morphine pump was in place. On 11/05/2024 at 12:47 PM, the Attending Physician for Resident #3 was interviewed via telephone and stated that Resident #3 has a history of refusing care such as lab work and was non-compliant with medical care on occasion such as refusing x-rays after multiple falls. The Attending Physician also stated that they examined Resident #3 recently for complaint of insomnia on 10/24/2024, and Resident #3 was stable and not in pain. The Attending Physician further stated that Resident #3s' morphine pump was placed in 2022 because Resident #3 had a lot of pain due to back surgery, and Resident #3's pain is controlled with Lyrica and Resident #3 does not currently complain about pain. The Attending Physician stated Resident #3 morphine cartridge needs to be replaced every 6 months and they last spoke to Resident #3's private doctor in May 2023 when the pump was last changed, and that physician has since moved to New Jersey and no longer takes Resident #3's insurance. The Attending Physician also stated that they are not sure who the pain management specialist is that will replace the pump. The Attending Physician stated that the facility has monitored Resident #3's pain by checking labs, and through vital signs which have been stable and Resident #3 attends recreational activities and does not stay in their room all the time, so they believe that Resident #3 is not in any pain. The Attending Physician further stated that Resident #3 will be referred to pain management. On 11/05/2024 at 03:35 PM, Licensed Practical Nurse #2 was interviewed and stated they have worked as a float nurse and has administered medications to Resident #3 on multiple occasions. Licensed Practical Nurse #2 also stated that Resident #3 is alert and oriented and able to verbalize all needs. Licensed Practical Nurse #2 further stated that Resident #3 will complain about pain and was prescribed pain and at one point Resident #3 was refusing the patches, and medication was changed to Lyrica at bedtime. Licensed Practical Nurse #2 also stated Resident #3 takes their medication and does not complain of pain. Licensed Practical Nurse #2 further stated that they were not aware that Resident #3 had a morphine pump until today, as this was reported to them by the outgoing day shift nurse. Licensed Practical Nurse #2 stated they never saw the pump, and was not provided in-service on the pump, or on how to monitor a resident on a morphine pump. On 11/05/2024 at 03:38 PM, Licensed Practical Nurse #3 for the evening shift was interviewed and stated they have worked on the unit as a float nurse on multiple occasions in the past but was not aware until today that Resident #3 had a morphine pump in place. Licensed Practical Nurse #3 also stated that Resident #3 is alert and able to make all needs known, is prescribed Lyrica for pain and has voiced no complaint of pain to Licensed Practical Nurse #3. Licensed Practical Nurse #3 further stated they did not receive in-service on the morphine pump or how to monitor a resident on a morphine pump. On 11/06/2024 at 11:24 AM, the Director of Nursing was interviewed and stated they were not aware that Resident #3 had a morphine pump in place and were informed of this by staff on 11/05/2024. The Director of Nursing also stated that they have worked at the facility since January 2023, and they never heard of any complaints about pain for Resident #3 or staff reporting that Resident #3 was in uncontrolled pain in morning report. Care of any resident in pain is discussed in the morning meeting and the resident is referred to pain management for follow up. The Director of Nursing further stated that a resident with a morphine pump should have been discussed in morning report, to ensure they are followed by pain management, and staff is inserviced on the pump. The Director of Nursing stated that after becoming aware of the morphine pump, they realized that Resident #3 had no orders in place for the morphine, or orders in place to monitor the resident. The Director of Nursing also stated they also learned that morphine pump was last refilled in May 2023, and no follow up has been done after that date, and Resident #3 is only receiving Lyrica for pain control at present. The Director of Nursing further stated that if a resident was admitted on a morphine pump, the Director of Nursing would be made aware before the resident is admitted to the facility, would in-service the staff, and ensure that pain management is in place to follow up, as well as physician orders to monitor resident. The Director of Nursing also stated that they had not been informed by the two prior Directors of Nursing that there was a resident with a morphine pump in the facility. 10 NYCRR 415.12

Based on observations, record reviews, and staff interviews conducted during the recertification survey, the facility did not ensure that residents observed using bed side rails were appropriately assessed for risk of entrapment or that the risks and benefits of side rail use was explained to the resident and/or representative. This was evident for 4 of 7 residents reviewed for accidents out of a sample of 40 residents (residents #184, #218, #519, #522) The findings include but are not limited to: The facility's Policy and Procedure for side rail usage, last reviewed 3/1/22, documented that it is the policy of the facility to ensure residents attain and maintain their highest practicable level of well-being and be free of restraints. Each resident will be assessed for functional status on admission, readmission and quarterly, for any significant change as needed. A resident will only use partial side rails to assist with his or her bed mobility in accordance with individual facility IDT team assessment. Partial side rails will not interfere with the resident's ability to egress from the bed surface. Partial siderails will be analyzed for safety and prevention of entrapment utilizing the guidelines of the USFDA. 1) Resident #522 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had severely impaired cognition. No behaviors, rejection of care or wandering were documented. Resident required extensive assistance and 2-person assist with bed mobility, transfer, and toilet use, and extensive assistance and 1-person assist with dressing and personal hygiene. Resident was always incontinent for urine and bowels. No restraints or alarms were used. On 09/19/22 at 11:17 AM and 03:18 PM, 09/20/22 at 11:25 AM, and 09/21/22 at 11:19 AM and 04:04 PM, resident #522 was observed in bed with bilateral half side rails up. 09/22/22 at 10:04 AM, an interview was conducted with Resident #522's family member, who stated the side rails have been up all the time. He/she also stated that facility staff explained how to use the side rails properly to the family, but nobody explained the risks of having them there. He/she stated, [Resident #522] has a little dementia but can understand when things are explained, maybe they explained it to them. Resident #522 fell at home, fractured their hip and had surgery before coming here. The Comprehensive Care Plan (CCP) dated 9/1/22 identified the resident at risk for falls. The CCP did not document or instruct that side rails should be used as an intervention for falls for the resident. Further review of the CCP did not provide documented evidence that side rails were to be used as an intervention for any other identified concern, including during Activities of Daily Living (ADL) care or assistance in positioning the resident. There was no documented evidence in the medical record that the resident was assessed for risk of entrapment from bed rails prior to installation or use. There was also no documented evidence that facility staff reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation or use. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for side rails. There were no accident reports for resident #522 since admission. On 09/22/22 at 10:17 AM, an interview was conducted with CNA #3 who stated resident #522 uses siderails to go back to bed and has remote control for siderails. CNA #3 stated that siderails are used to prevent falls and that they received in service on use of siderails, but they don't remember when. 2) Resident #519 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had severely impaired cognition. No behaviors, rejection of care or wandering were documented. Resident required total dependence and 2-person assist with transfer, extensive assistance and 2-person assist with toilet use and bed mobility. Resident was always incontinent for bowels and had indwelling urinary catheter. The MDS documented that there were no restraints or alarms used. On 09/21/22 at 04:02 PM, Resident #519 was observed in bed, with bilateral half side rails up. On several other observations between 9/20/22 and 9/23/22, the resident's bed was observed with bilateral half side rails up while resident #519 was sitting in a wheelchair next to the bed. The Comprehensive Care Plan (CCP) dated 8/26/22 identified the resident at risk for falls. The CCP did not document or instruct that side rails should be used as an intervention for falls for the resident. Further review of the CCP did not provide documented evidence that side rails were to be used as an intervention for any other identified concern, including during Activities of Daily Living (ADL) care or assistance in positioning the resident. There was no documented evidence in the medical record that the resident was assessed for risk of entrapment from bed rails prior to installation or use. There was also no documented evidence that facility staff reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation or use. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for side rails. There were no accident reports for resident #519 since admission. 3.) Resident # 218 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15. The MDS further documented the resident had no behaviors, rejection of care or symptoms of [CONDITION(S)]. The MDS documented the resident required extensive assistance and 1-person assist with bed mobility, transfer, dressing, personal hygiene, and toilet use. Resident was always continent for urine and bowels. The MDS documented that there were no restraints or alarms used. On 09/19/22 at 03:16 PM and 09/20/22 at 11:34 AM, Resident #218 was observed in bed with bilateral half siderails up. Resident stated siderails stay up all the time and help them move in bed. The Comprehensive Care Plan (CCP) dated 8/22/22 identified the resident at risk for falls. The CCP did not document or instruct that side rails should be used as an intervention for falls for the resident. Further review of the CCP did not provide documented evidence that side rails were to be used as an intervention for any other identified concern, including during Activities of Daily Living (ADL) care or assistance in positioning the resident. There was no documented evidence in the medical record that the resident was assessed for risk of entrapment from bed rails prior to installation or use. There was also no documented evidence that facility staff reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation or use. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for side rails. There were no accident reports for Resident #218 since admission. On 09/22/22 at 10:51 AM, an interview was conducted with LPN #3 who stated: They took out some of the siderails 3-4 months ago. They left some up because residents are very alert, and families request them. They are a kind of restraint. When CNAs are doing ADL care, the residents can use them to hold on to. The ones that are left is because they were requested. Every resident who requests siderails gets them. The social worker talks to residents to make sure they are aware they are on. The residents need to be very alert in order to use them. They are a restraint, and we don't want the residents to get hurt. Maintenance installs the siderails and takes them out. They need to have orders and care plans. On 09/22/22 at 11:01 AM, an interview was conducted with RN #5, who stated It was recently brought to our attention that siderails can be harmful for residents, so we had to take them out. It is frustrating with some residents because they can use them during care, and it helps them. Now siderails are only for very alert and oriented residents who request them. The families sign a consent that they agree and request to install the siderails. In my practice nobody was injured by siderails. For a siderail to be present on a bed, they would have an order, resident would have to verbalize that they want them. We speak to social work, RN supervisor, and we make a decision to put the order in. Then we put the order. I know which resident can use them. Final decision is made by director and supervisor. Care plan should be there as well. We have several people in the team: Nurse, supervisor, DNS. IT director monitors orders and gives us input. If we have orders, we have care plans. Maintenance department checks siderails if they don't work properly. Also install and uninstall. Every person who has siderails now should have order and care plan. Assessment is usually done by nurse. PT might recommend, but they don't usually assess. Nurse agreed that residents 522, 184, 218, 519 and 87 should have orders and care plans and could not answer why they didn't. On 09/21/22 at 03:25 PM, the Information Technology (IT) Nurse was interviewed and stated he/she creates care plans in the electronic record. The IT Nurse stated the facility does not use siderails for restraints, only for bed mobility and repositioning. The facility utilizes assessments, care plans, and orders for siderails, but first the residents get evaluated by rehab for ability to turn and positioning using the siderails. Those residents who don't use siderails, don't have siderails on the bed at all because they are removed from the bed. Residents should not be confused in order to use the siderails. On a second interview on 09/22/22 at 12:25 PM, IT/nursing person stated Some of our beds are special hospital beds, for which we cannot remove the siderails. They come attached to the bed and cannot be removed. They are not like regular beds. We only have those beds on this floor, which is the rehab floor. Resident #184 has a regular bed with siderails. I don't see orders or care plans, but they should be there. On 09/23/22 at 02:54 PM, the DNS was interviewed and stated siderails are not used as restraints. They are used for bed mobility. The residents have to be able to use them, demonstrate they can use them for mobility. Rehab does assessment, then we get consent from resident and order from doctor, and we develop a care plan. We don't use them as restraints. We are working on the residents who didn't have orders. Sometimes they move the beds. When the residents move to another room sometimes the bed stays in the room. It's an ongoing process. On 09/26/22 at 10:24 AM, the Director of Maintenance was interviewed and stated that Physical Therapy decides if the bedrails need to be installed. For new residents, the default is that there are no siderails. If we get an order, we have to install them. We test the siderails on the bed when the resident is not on the bed. I make sure there is no entrapment risk. I measure that there are no more than 4 inches between head of bed and start of rail. The holes in the rails should be smaller than 4 inches, so that resident's head can't get trapped in there. Every month I check beds for safety: electrical, no loose parts, bed is secure.

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 5 of 5 residents reviewed for Accidents out of a sample of 40 residents (Resident #s 156, 184, 218, 519, 522). Specifically, no CCP was developed and implemented for residents' use of side rails. The findings include but are not limited to: The facility Policy on Comprehensive Care Plan (CCP), last reviewed on 01/22 documented: Each resident shall have a Comprehensive care Plan that includes the strengths and weakness measurable objectives, and timetables to meet medical, nursing, and psychological needs that are identified in the MDS assessment and review of the triggered RAPS. 1) Resident #156 was admitted to the facility 08/10/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented that the resident had Intact cognitive status and required the Extensive Assistance of staff for most Activities of daily Living. On 09/19/22 at 12:21 PM, Resident #156 was observed in bed with 2 upper half side rails up. Resident #156 stated they use the side rails to pull up and reposition themselfes in bed, and they have been using the [NAME] rails since admission. On 09/20/22 at 12:13 PM, and 09/21/22 08:10 AM, the Resident was also observed in bed, with the 2 upper side rails up. The Side Rail Assessment Form dated 8/10/2022 documented Resident #156 verbalized a need for a side rail as an enabler. A Resident Bed Rail Consent Form dated 8/11/2022 was signed by Resident #156. The Comprehensive Care Plan (CCP) for Accident dated 8/10/22 documented that Resident is at risk for accident/falls/injury. Goals included: Resident will be free of falls through the next review date Interventions included: - Complete Fall Risk Assessment and review quarterly as necessary; Maintain a clear pathway, free of obstacles; Keep personal items - eyeglasses, TV remote control, within reach; Keep bed/ wheelchair in locked position; Avoid repositioning furniture; Keep call bell within reach. There was no documented evidence a Comprehensive Care Plan was developed to include the use of side rails as an enabler. On 09/22/22 at 11:27 AM, an interview was conducted with the Certified Nursing Assistant CNA #1. CNA #1 stated that he/she has been giving care to the resident since the resident was transferred to the unit. CNA also stated that resident uses the side rails to turn and reposition in bed and can hold on to the side rail when changing the resident in bed. CNA further stated that resident has been using the side rails since resident was admitted . On 09/23/22 at 10:20 AM, an interview was conducted with the Licensed Practical Nurse, LPN #1. The LPN stated that resident can wheel self on the unit, is transferred from bed to chair with 1 staff assist, able to turn with minimum assistance in bed with the use of the upper side rails as enablers. LPN #1 further stated that they are not allowed to touch the Resident's Care plan, LPN stated that the care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/23/22 at 10:52 AM, an interview was conducted with the Registered Nurse in charge, RN #2. RN #2 stated that Resident was recently admitted on [DATE], has been attending therapy daily with a lot of improvement, now able to turn and reposition self in bed. RN stated that resident was admitted to the 3rd floor and did not realize that resident is using the side rail. RN stated that most of the time the Supervisor is responsible for checking the resident care plan for update and to get doctor's order if needed as most of the time the charge nurse is busy passing the medication or doing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/23/22 at 11:25 AM, an interview was conducted with the Director of Rehab (DOR), stated that resident was assessed by Rehab staff for safe use of both upper side rails and was given consent to sign. DOR stated that the staff should have gotten the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DOR further stated that the nursing is expected to update the care plan with the side rail after the assessment and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/23/22 at 11:39 AM, an interview was conducted with the RN Nursing Supervisor, RN #1. RN #1 stated that any RN in the building can initiate and update the care plan for the residents, and any licensed nurse can get a telephone order from the physician. RN #1 further stated that when information is received from rehab by nursing, the RN is supposed to initiate the CCP and get the order for the resident's side rail. RN #1 also stated that the nurse is supposed to make rounds to see if the resident has a side rail, place the order, and initiate the CCP accordingly. RN #1 stated they usually make rounds on the units, but RN #1 did not realize that the resident has a side rail, and they were not aware that there was no CCP and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] O 09/23/22 at 11:52 AM, an interview was conducted with the Director of Nursing, DNS. The DNS stated that when the Rehab staff evaluates and assesses the resident to be fit for, and in need of the side rail, the consent is received from the resident, Rehab should contact the nursing to get the order from the doctor, and the nursing should initiate the care plan for the resident's side rail. The DNS stated that there has been ongoing evaluation to assess what is missing, and needed to be done, and the facility has not been able to get to that to see the missing order and the missing CCP for the side rail. The DNS stated that the team supposed to have been going round to discover the missing items. 2) Resident #522 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had severely impaired cognition. No behaviors, rejection of care or wandering were documented. Resident required extensive assistance and 2-person assist with bed mobility, transfer, and toilet use, and extensive assistance and 1-person assist with dressing and personal hygiene. Resident was always incontinent for urine and bowels. No restraints or alarms were used. On 09/19/22 at 11:17 AM and 03:18 PM, 09/20/22 at 11:25 AM, and 09/21/22 at 11:19 AM and 04:04 PM, resident #522 was observed in bed with bilateral half side rails up. 09/22/22 at 10:04 AM, an interview was conducted with Resident #522's family member, who stated the side rails have been up all the time. He/she also stated that facility staff explained how to use the side rails properly to the family, but nobody explained the risks of having them there. He/she stated, [Resident #522] has a little dementia but can understand when things are explained, maybe they explained it to them. Resident #522 fell at home, fractured their hip and had surgery before coming here. The Comprehensive Care Plan (CCP) dated 9/1/22 identified the resident at risk for falls. The CCP did not document or instruct that side rails should be used as an intervention for falls for the resident. Further review of the CCP did not provide documented evidence that side rails were to be used as an intervention for any other identified concern, including during Activities of Daily Living (ADL) care or assistance in positioning the resident. There was no documented evidence in the medical record that the resident was assessed for risk of entrapment from bed rails prior to installation or use. There was also no documented evidence that facility staff reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation or use. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for side rails. There were no accident reports for resident #522 since admission. On 09/22/22 at 10:17 AM, an interview was conducted with CNA #3 who stated resident #522 uses siderails to go back to bed and has remote control for siderails. CNA #3 stated that siderails are used to prevent falls and that they received in service on use of siderails, but they don't remember when. 3) Resident #519 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had severely impaired cognition. No behaviors, rejection of care or wandering were documented. Resident required total dependence and 2-person assist with transfer, extensive assistance and 2-person assist with toilet use and bed mobility. Resident was always incontinent for bowels and had indwelling urinary catheter. The MDS documented that there were no restraints or alarms used. On 09/21/22 at 04:02 PM, Resident #519 was observed in bed, with bilateral half side rails up. On several other observations between 9/20/22 and 9/23/22, the resident's bed was observed with bilateral half side rails up while resident #519 was sitting in a wheelchair next to the bed. The Comprehensive Care Plan (CCP) dated 8/26/22 identified the resident at risk for falls. The CCP did not document or instruct that side rails should be used as an intervention for falls for the resident. Further review of the CCP did not provide documented evidence that side rails were to be used as an intervention for any other identified concern, including during Activities of Daily Living (ADL) care or assistance in positioning the resident. There was no documented evidence in the medical record that the resident was assessed for risk of entrapment from bed rails prior to installation or use. There was also no documented evidence that facility staff reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation or use. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for side rails. There were no accident reports for resident #519 since admission. On 09/22/22 at 10:39 AM, an interview was conducted with CNA #2, who stated resident #519 can hold on to the siderails while being turned in bed. CNA further stated siderails are used when resident needs help to hold on to get up. On 09/22/22 at 10:51 AM, an interview was conducted with LPN #3 who stated: They took out some of the siderails 3-4 months ago. They left some up because residents are very alert, and families request them. They are a kind of restraint. When CNAs are doing ADL care, the residents can use them to hold on to. The ones that are left is because they were requested. Every resident who requests siderails gets them. The social worker talks to residents to make sure they are aware they are on. The residents need to be very alert in order to use them. They are a restraint, and we don't want the residents to get hurt. Maintenance installs the siderails and takes them out. They need to have orders and care plans. On 09/22/22 at 11:01 AM, an interview was conducted with RN #5, who stated, It was recently brought to our attention that siderails can be harmful for residents, so we had to take them out. It is frustrating with some residents because they can use them during care, and it helps them. Now siderails are only for very alert and oriented residents who request them. The families sign a consent that they agree and request to install the siderails. In my practice nobody was injured by siderails. For a siderail to be present on a bed, they would have an order, resident would have to verbalize that they want them. We speak to social work, RN supervisor, and we make a decision to put the order in. Then we put the order. I know which resident can use them. Final decision is made by director and supervisor. Care plan should be there as well. We have several people in the team: Nurse, supervisor, DNS. IT director monitors orders and gives us input. If we have orders, we have care plans. Maintenance department checks siderails if they don't work properly. Also install and uninstall. Every person who has siderails now should have order and care plan. Assessment is usually done by nurse. PT might recommend, but they don't usually assess. RN #5 agreed that residents 522, 184, 218, 519 and 87 should have orders and care plans and could not answer why they didn't. On 09/21/22 at 03:25 PM, the Information Technology (IT) Nurse was interviewed and stated he/she creates care plans in the electronic record. The IT Nurse stated the facility does not use siderails for restraints, only for bed mobility and repositioning. The facility utilizes assessments, care plans, and orders for siderails, but first the residents get evaluated by rehab for ability to turn and positioning using the siderails. Those residents who don't use siderails, don't have siderails on the bed at all because they are removed from the bed. Residents should not be confused in order to use the siderails. On a second interview on 09/22/22 at 12:25 PM, IT/nursing person stated Some of our beds are special hospital beds, for which we cannot remove the siderails. They come attached to the bed and cannot be removed. They are not like regular beds. We only have those beds on this floor, which is the rehab floor. Resident #184 has a regular bed with siderails. I don't see orders or care plans, but they should be there. On 09/23/22 at 02:54 PM, the DNS was interviewed and stated siderails are not used as restraints. They are used for bed mobility. The residents have to be able to use them, demonstrate they can use them for mobility. Rehab does assessment, then we get consent from resident and order from doctor, and we develop a care plan. We don't use them as restraints. We are working on the residents who didn't have orders. Sometimes they move the beds. When the residents move to another room sometimes the bed stays in the room. It's an ongoing process. 415.11(c)(1)

Based on record review and staff interviews conducted during a Recertification/Complaint Survey from 9/19/2022 to 9/26/2022, the facility did not ensure that a resident's designated representative was provided with a written summary of the baseline care plan. This was evident for 1 of 2 residents reviewed for Care Plan out of 40 sampled residents. (Residents # 431). The findings are: The facility policy titled Baseline Care Plan (BCP) created 10/7/2017 and updated September 1, 2022 documented that the completed BCP will be provided to the resident and/or designated representative within 5-7 days. It also documented that Evidence of completion of the baseline care plan with notification to resident/des.rep of BCP will be in the assessment section of the EMR and in the Social Service section of the hard copy chart. Resident # 431 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented Resident # 431 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, indicating Resident #431 had severely impaired cognition. The MDS also documented Resident # 431 and family or significant other participated in the assessment. On 09/19/22 at 11:03 AM, the designated representative was interviewed and stated Resident # 431 was admitted to the facility on [DATE]. The representative stated they made decisions for Resident # 431 and did not recall receiving a written summary of the initial care plan since Resident # 341 was admitted to the facility. The Baseline Care Plan (BCP) was dated as created on 9/9/2022 and completed on 9/18/2022. The acknowledgement of receipt section of the BCP had a Social Worker signature on 9/13/2022. There was no resident or representative signature on it. The progress notes from 9/9/2022 to 9/23/2022 in the Electronic Medical Record (EMR) and Social Service section of the hard copy chart contained no documented evidence the designated representative was provided with a copy of or signed the baseline care plan. On 09/21/22 at 09:52 AM, Registered Nurse (RN) # 3 was interviewed and stated that the Baseline Care Plans (BCP) are provided to the resident and/or designated representative by the Social Work Department after completion. RN # 3 also stated they did not know when the Social Worker gave the BCP to the resident and/or representative or where this would be documented in the medical record. On 09/21/22 at 10:06 AM, Assistant Director of Social Work (ADSW) was interviewed and stated they had 2 days to complete the BCP and then gave a copy of BCP to residents. The ADSW also stated the residents had to sign it and then a copy was filed to the medical chart and another copy was given to resident. The ADSW stated Resident # 431 was cognitively unable to sign the BCP and they called the representative and left a copy of BCP in Resident # 431's room for pick-up. The ADSW also stated they did not follow up with representative to see if they received the copy or not. The ADSW further stated that there was no documentation in their notes regarding the BCP, when they left the copy of BCP in Resident # 431's room, or if the representative actually picked up the copy or not. On 09/21/22 at 10:36 AM, Social Work Director (SWD) was interviewed and stated they completed the BCP and gave a copy of it to residents and/or representatives within 48 hours. The SWD also stated the residents/representative have to sign the BCP, then the BCP is filed in the medical record and a copy is given to the resident. The SWD further stated the Social Workers (SW) call the representative to ask if they prefer a copy of the BCP is left in the resident's room or mailed to them if the resident is confused. The SWD stated the SW should document the communication with the representative in the medical record regarding the BCP. The SWD also stated that there was no documentation in Resident # 431's medical chart regarding the BCP, SW not being able to give the BCP copy to representatives, when SW left the BCP copy in Resident # 431's room, or if the representative was provided copies of the BCP. 415.11 (c)

Based on observations, record reviews and interviews during the recertification survey the facility failed to ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. Specifically, the physician did not review the Rehab assessment and place order for the resident's use of bed side rails. This was evident for 1 of 5 residents reviewed for Accidents out of a sample of 40 residents. (Resident #156). The findings are: The facility Policy on Physicians/Rehab Recommendation Orders, dated 11/2020, last reviewed on 06/22 documented: Recommendation for rehabilitative services (including Nursing Rehabilitation) will be reviewed and included in the medical record as signed orders or telephone orders within 24 hours after being recommended by the rehab therapist. Resident #156 was admitted to the facility 08/10/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition and required extensive assistance from staff for most Activities of daily Living. On 09/19/22 at 12:21 PM, Resident #156 was observed in bed with 2 upper side rails up. Resident stated that the side rails are used to pull up and reposition self while in bed and has been using the side rails since admission. On 09/20/22 at 12:13 PM, and 09/21/22 08:10 AM, the Resident was also observed in bed, with the 2 upper side rails up. The Rehab Side Rail Assessment Form dated 8/10/2022 documented Resident #156 verbalized a need for a side rail as an enabler, resident was assessed, and 2 upper side rails were recommended by the Rehab as enablers in bed mobility rolling or positioning. The Resident Bed Rail Consent Form dated 8/11/2022 documented that Resident #156 had the cognitive capacity to utilize side rails and signed the consent. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/22/22 at 11:27 AM, an interview was conducted with the Certified Nursing Assistant CNA #1. CNA #1 stated that he/she has been giving care to the resident since the resident was transferred to the unit. CNA also stated that resident uses the side rails to turn and reposition in bed and can hold on to the side rail when changing the resident in bed. CNA further stated that resident has been using the side rails since resident was admitted . On 09/23/22 at 10:20 AM, an interview was conducted with the Licensed Practical Nurse, LPN #1. The LPN stated that resident can wheel self on the unit, is transferred from bed to chair with 1 staff assist, able to turn with minimum assistance in bed with the use of the upper side rails as enablers. LPN #1 further stated that they are not allowed to touch the Resident's Care plan, LPN stated that the care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/23/22 at 10:52 AM, an interview was conducted with the Registered Nurse in charge, RN #2. RN #2 stated that Resident was recently admitted on [DATE], has been attending therapy daily with a lot of improvement, now able to turn and reposition self in bed. RN stated that resident was admitted to the 3rd floor and did not realize that resident is using the side rail. RN stated that most of the time the Supervisor is responsible for checking the resident care plan for update and to get doctor's order if needed as most of the time the charge nurse is busy passing the medication or doing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/23/22 at 11:25 AM, an interview was conducted with the Director of Rehab (DOR), stated that resident was assessed by Rehab staff for safe use of both upper side rails and was given consent to sign. DOR stated that the staff should have gotten the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DOR further stated that the nursing is expected to put in the care plan for the side rail after the assessment and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/23/22 at 11:39 AM, an interview was conducted with the RN Nursing Supervisor, RN #1. RN #1 stated that any RN in the building can initiate and update the care plan for the residents, and any licensed nurse can get telephone order from the physician if the physician is not present in the facility at the time the order is needed. RN #1 further stated that when information is received from the rehab by the nursing, the RN is supposed to initiate the CCP and get the order for the resident's side rail. RN #1 also stated that the nurse supposed to make rounds to see if the resident is having side rail and place the order and initiate the CCP accordingly. RN #1 stated that as a supervisor, they usually make rounds on the units but did not realize that resident is having the side rail on, and they are not aware that there was no CCP and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . O 09/23/22 at 11:52 AM, an interview was conducted with the Director of Nursing, DNS. The DNS stated that when the Rehab staff evaluates and assesses the resident to be fit for, and in need of the side rail, the consent is received from the resident, Rehab should contact the nursing to get the order from the doctor, and the nursing should initiate the care plan for the resident's side rail. The DNS stated that there has been ongoing evaluation to assess what is missing, and needed to be done, and the facility has not been able to get to that to see the missing order and the missing CCP for the side rail. The DNS stated that the team supposed to have been going round to discover the missing items. On 09/23/22 at 12:28 PM, an interview was conducted with the Medical Director. The MD stated that they come to the facility every day in the evening to examine the residents, review the orders and sign off the orders that are pending. MD stated that the facility has protocol for ordering the lab works and Rehab evaluations needed. MD further stated that Rehab comes in to evaluate the resident to ensure that the resident is alert enough to use the side rails safely, gets resident's consent and communicates with Nursing to place the order to be signed by the physician. MD stated that the missing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.15(b)(2)(iii)

Based on observations, record review, and interviews conducted during the Recertification and Complaint survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, two expired boxes of enteral feeding was found in the central supply storage room on the 2nd floor in the enteral feeding and liquid nutritional supplement storage area on the main floor of the facility. This was evident during the Kitchen Observation task. The findings are: The Facility Policy and Procedure titled Securing and Storage of Tube Feeding reviewed ,d+[DATE] documented when residents are discharged unused feeding will be returned to storage area, The Facility Policy and Procedure titled Storage and Distribution Enteral Feeding Products reviewed [DATE] documented Nursing will pick up the enteral feeds from the second floor as needed and check the date to ensure formula has not expired. Any expired enteral feed will be discarded, purchasing will check the storage area every two weeks to ensure all products are up to date. Nursing staff will check the expiration date of all enteral feedings before removing them from storage. On [DATE] at 09:36AM an initial tour of the kitchen was done. At 10:18AM the enteral storage area and 2 expired boxes of enteral feeding were observed. One box of Peptide Sole Source Nutrition Formula with a best by date of [DATE] and one box of Peptide Sole Source Nutrition Formula with a best by date of [DATE] were noted in the storage room. Each box contained 12 cartons of 11-ounce enteral feeding formula per box . On [DATE] at 10:21AM, an interview was conducted with Central Supply Person who stated they have to throw it away as it's expired. On [DATE] at 10:22AM, an interview was conducted with the Director of Food Service (DFS) who stated the resident who used the tube feeding formula is no longer in the facility, and he/she was not sure when they left. On [DATE] at 3:37PM, an additional interview was conducted with the Central Supply Person who stated their supervisor orders the enteral feeding and nursing distributes the enteral feeding. When the enteral feeding arrives, they put it on the shelf and organize it. They check the dates all the time and this is what we are supposed to do. When receive a new supply we check dates and sometimes the product is expired. We have to keep our eyes open for this. If items are expired, we throw them away because they cannot give expired product to the residents. On [DATE] at 04:02PM, an interview was conducted with the Central Supply Supervisor (CSS) who stated they are in charge of the delivery of enteral feedings. They check the stock every 2 weeks and need to send an inventory to the enteral feeding company to let them know what feedings they have on hand, They inventory the emergency stock and go thru the stock thoroughly. They look for expired items every 2 weeks. The CSP delivers enteral feeding to the storeroom and looks at the enteral feeding on the units and removes items that are expired. They have been expired items found in the 2nd floor closet. They pay attention to what is printed on each bottle with the date. The ordered enteral feeding that was expired was received in [DATE], and it was specially ordered for the resident. It should have been removed, and it is no longer part of their ordering template. 415.14 (h)

Based on observation, record review, and interviews conducted during an abbreviated survey, (Complaint NY 601), the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent elopement. This was evident in 1 of 1 resident sampled (Resident #1). Specifically, on 7/6/2022 at 2:06 PM, Resident #1, at risk for elopement, with a wander-guard in place, was seen on the facility's surveillance camera, walked out of the facility lobby, and was found by the police (NYPD) on 7/7/2022. The findings are: The facility's policy entitled Elopement Risk Assessment & Prevention Plan last revised 7/2022, documented: Resident's whereabouts must be always known. All residents are considered potential risks for elopement. Haym [NAME] Home is responsible for evaluating each resident's level of risk and to provide a secure environment to prevent elopement. The Facility's Accident/ Incident Report dated 7/6/2022, and internal Investigative Summary documented that Resident #1 attended an off-unit luncheon event in the facility's lobby. At 4:00 PM, a 2-10 PM Certified Nursing Assistant (CNA) asked the Recreation Leader about Resident #1 whereabouts, Code M (Elopement) was initiated, and a search of the facility was unsuccessful. The facility's surveillance camera revealed that Resident #1 exited the building via the front entrance at 2:06 PM. The Facility administration and Resident #1's family were alerted. The Police, and community advocates arrived at the facility 4:30 PM to determine plans to find Resident #1. Resident #1 was located by police on 7/7/2022 and transported to a local hospital for evaluation. There was no injury and Resident #1 was readmitted to the nursing home on 7/8/2022. The Facility's plan to prevent recurrence include re-educating staff on facility policy /procedures and risk factors to be aware of when residents are off their units. The Facility's Surveillance footage was viewed on 7/20/2022 at 2:15 PM, with the Director of Nursing #1 (DON #1), and the Purchasing Coordinator who identified pertinent persons on the footage. There was no audio, and the recorded tape was dated 7/6/2022, and started at 2:05 PM.The scene was the Facility's lobby area. Several Residents were seated in wheelchairs in the lobby to the left of the viewer. A person identified as the person fixing the fire alarm was seen to the right of the security guard's station. The security guard is not clearly visible on the footage, only the area where the guard is usually seated. Resident #1 was seen exiting a room located towards the rear of the lobby and walked on the ride side of the viewer, away from the seated residents, on a clear pathway to the entrance door of the facility and exits the facility at 2:06 PM. Resident #1 stops briefly in front of the facility before disappearing to the right and off the camera. An occasional visitor is seen on camera. Resident # 1 with diagnoses that included Alzheimer's Dementia, and [CONDITION(S)]. The Minimum Data Set assessment (MDS, a resident assessment tool) dated 5/15/2022, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 10 out of 15, indicating that Resident #1 had moderate impaired cognition. Resident #1 ambulates with a steady gait. A Behavior Care Plans, dated 12/23/2020, documented that Resident #1 exhibited wandering and exit seeking behavior on 12/23/2020. A wander-guard and elopement risk interventions were initiated. There was no intervention for staff monitoring off the resident's unit. A Resident's Treatment Administration Record dated July 1- July 2022,documented that Resident #1 was wearing a wander guard on the right ankle up to 7/6/2022. The wander guard was checked every shift for placement. The expiration date on the wander guard was checked weekly. On 7/4/2022, the last weekly check was documented and verified by staff signatures. On 7/8/2022, a new wander-guard was applied on readmission. The Assistant Director of Nursing (ADON) note dated 7/7/2022, documented that on 7/6/2022, around 4:20 PM, an employee from the recreation department informed them that Resident #1 was missing from the facility. A facility wide search followed the Missing Resident Protocol was implemented, and Resident #1 was not found. The police, family, and Department of Health (DOH) were notified. During an interview on 7/20/2022 at 11:50 AM, the assigned Certified Nursing Assistant #1, (CNA #1), stated that about 10:45 AM, residents were moved to the lobby for lunch. Resident #1 was last seen about 1:40 PM -1:45 PM. At about 1:15 PM, the staff started to move residents to another room for music. Resident #1 was standing in the room adjoining the lobby at 1:40 PM. CNA #1 was then relieved by another CNA and returned to the unit. Also stated, Resident #1 was never seen going to the elevators or the stairs. Resident #1 usually walked around the unit or stayed in his/her room. Added, nothing like this ever happened before. During an interview on 7/20/2022 at 11:45AM, Licensed Practical Nurse #1, (LPN #1 from agency), stated: worked as a float nurse for 3 years on the day shift. On 7/6/2022 (day of elopement), rounds were done, and medications were administered. Resident #1 walked around the unit as usual. There was an issue with the air conditioner. The Assistant Director of Nursing (ADON) came to the unit and informed staff that residents had to be transported to the lobby, near security. Other staff from another floors and recreation staff were there and they had activities for the residents. CNAs took turns to take residents downstairs to monitor them. They stayed on the unit doing documentation and never heard any overhead announcement that a resident was missing. The surveillance camera reviewed later showed the time that Resident #1 left the facility. Visual checks are now every 15 minutes, prior to this the checks were every 30 minutes. There was a picture of the Resident #1 at the nursing station and one in the lobby. During an interview on 7/20/22 at 1:00 PM, the Recreation Coordinator/Asst Director #1 stated: worked for 15 1/2 years at the facility and nothing like this ever happened. The party was pre-arranged in the lobby, usually residents at high risk for elopement are not in the lobby unless they are monitored 1:1. The team decided to have Resident #1 come down to the lobby because he/she always stayed in his/her bedroom. The Recreation staff and CNAs were in the lobby monitoring residents, and residents were seated in their wheelchairs, there were no reported issues. At 4:00 PM, received a phone call from the Recreation Leader asking whether he/she had seen Resident #1 because they are looking for him/her. Code M (Elopement Code) was called, the facility search began, and the police were called. Staff used their cars in the community and asked the community for assistance with the search for Resident #1. On 7/7/2022 a text was received that Resident #1 was located. During an interview on 7/20/22 at 2:30 PM, the Recreation Leader #1 stated that he/she has been worked at the facility since 2004. On 7/6/22 there was an event for residents in the lobby. Resident #1 was in a room off the lobby, placed closer to the wall in an adjoining room. There were residents from 2 floors in the lobby. There was music and a lot of people, the security person was at their station and left at 3:00 PM. Also stated that Resident #1 was always just walking around, CNAs and recreation staff were monitoring residents. Everyone was just assisting everyone, there was no specific person assigned to monitor the room where Resident #1 was. Also stated, if I didn't see Resident #1, it was assumed that a CNA had taken him/her to the bathroom. Also stated CNA, on the evening shift approached and asked for Resident #1 and was told that Resident #1 was probably upstairs. Everyone started searching the building. The Recreation Coordinator was informed, and searched room to room on the 4th floor, looked in bathrooms and could not find Resident #1. Staff went driving around the area. During an interview on 7/20/22 at 4:15 PM, the DON, stated, there were about 80 residents from 2 floors in the lobby area, there was music and fire alarms were being fixed by an outside company. The wander guard alarm was not heard. As part of the corrective action the volume on the exit door has been increased and lights are now flashing at the doors when a resident with a wander guard approaches. Also, anyone entering or leaving the facility are buzzed in and out at the front door. All staff have been re-in-serviced on the new policy. During an interview via telephone on 7/21/2022 at 2 PM, the Security Guard (SG) stated, he/she had worked via an agency on the 7-3 PM shift Monday-Saturday since 2007. The only SG on the day shift was seated near the front exit doors. Monitored the floors, lobby and outside the building intermittently via the cameras on the monitoring screen. The cameras are moved to focus on different areas at different times. No one mentioned that Resident #1 was missing and did not see the Resident #1 leaving the facility. There was a photograph of the Resident #1 at the desk, but the Resident in the photograph at the desk is clean shaven and has no cap on. Resident #1 on 7/6/2022 had a hoodie on, a moustache and a cap on. Also stated that the wander-guard kept alarming when the residents came down to the lobby and so Resident #1 was moved to the room adjoining the lobby along with some other residents. Stated his/her back was towards the residents in the lobby, facing the front exit door. Could not hear the wander-guard alarm as there was music and someone was checking the fire alarms near the front door. SG also stated, he/she did not realize Resident #1 left the facility. Received a call from the Administrator that Resident #1 left at about 3:15 PM. Also stated that the recreation staff was monitoring the room where the Residents #1 was, and the other residents were all in the lobby when he/she left for the day. Stated that since the incident, the volume of the wander guard alarm at the door has been increased and anyone entering or leaving the lobby is buzzed in and out. Also stated that prior to the incident, the photograph at the front desk showed a clean, shaven resident and no hoodie. The photograph had since been updated and he/she has been re-in-serviced on abuse /neglect. 10 NYCRR: 415.12(h)(1)(2)

Based on observation and staff interviews during recertification survey, the facility did not ensure that raw food was handled appropriately during food preparation in accordance with professional standards for food service safety. Specifically, potentially hazardous raw chicken and raw fish were handled with bare hands during food preparation. This was evident during the Kitchen Observation facility task. The findings are: 1) The policy and procedure titled Handwashing Policy For All Employees last reviewed 11/01/2019, documented the purpose of the handwashing was to prevent of spread of microorganisms, to prevent incidence of cross-contamination and to remove dirt and possible pathogenic organisms present on skin. The policy and procedure titled Safe Food handling effective 1/31/2019 documented gloves and hairnets will be worn when handling food. Hands will be washed prior to putting on gloves and changed each time a task is changed. On 12/04/2019 between 9:12 AM and 10:37 AM, Cook #1 was observed preparing and chopping raw chicken in the cook's area with bare hands in metal pans on the metal counter top and on a metal cart. Cook #1 was not wearing gloves while preparing the raw chicken. Raw chicken was noted in the sink under running water. Cook #1 covered the raw chicken in the metal pan with a piece of cardboard. Cook #1 donned gloves, placed chicken in metal pans, and Butcher's paper was observed touching the cooks chef [NAME]et. The pan was covered with aluminum foil, dated and placed in the meat refrigerator. The metal pan was taken to the dish washing area behind cook's area before dish washing area on meat side of kitchen gloves removed and metal pan touched with bare hands that had chicken remnants on it. The Cook was noted touching the metal edge of the sink that had the raw chicken with bare hands when wiping it down with cloths and dish washing soap. The Cook then picked cardboard off the floor and placed it in a plastic bag. The cardboard was then taken to the trash bin outside the kitchen door. Cook # 1 returned to the kitchen after disposing of the cardboard in the trash bin outside of the kitchen. The Cook then proceeded to move the Wet Floor and mopped the kitchen floor with a mop. Cook #1 was not observed performing hand hygiene after handling the raw chicken and upon return to the kitchen after disposing of the cardboard trash. On 12/04/2019 at 10:27 AM, Cook # 1 was observed opening a cardboard box that contained raw fish. The cook removed the fish from the box with his bare hands, opened the refrigerator, took out 2 lemons, cut them in half and squeezed them over the raw fish. He then added water to the fish, threw off the water and rinsed his hands in the sink. The cook then mixed pureed garlic, paprika, onion, pureed ginger in a metal cup and added to the raw fish. He then placed the fish on a metal pan and placed it in the oven. Cook #1 was not observed wearing gloves when handling the raw fish and the seasoning containers. In addition, no hand washing was observed before or after handling the raw fish. Record Review of Training Record for Cook # 1 documented that Competency Validation on hand hygiene was completed on 01/16/2019. On 12/04/2019 at 10:27 AM, an interview was conducted with Cook # 1. Cook #1 stated when he is cleaning the chicken, he does not use gloves as it is difficult to remove the feathers and when he is finished prepping the chicken he puts on gloves. Cook #1 also stated that raw meat including chicken should be handled with gloved hands. He stated that gloves are used so you do not contaminate anything and get residents sick. On 12/09/2019 at 2:38 PM, an interview was conducted with the Director of Nutrition (DON). The DON stated that she provides job specific training for staff and handwashing in-service is done yearly by Nursing. Staff should be wearing gloves in the kitchen and if hands are dirty the are expected to change gloves and wash hands as necessary. Gloves should be worn when handling chicken and when gloves are removed hands should be washed. 415.14(h)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. Specifically, 1). care plans were not developed to address Diabetes Mellitus and the use of anticoagulant, anti-hypertensive medication, and diuretic medication, and 2). Care plans were not developed to address the use of anticoagulant and diuretic medication. This was evident for 2 of 5 residents reviewed for Unnecessary Medications out of a sample of 39 residents. (Resident #110 and #610) The findings are: The undated facility policy and procedure titled Comprehensive Care Plan documented the care plan shall be initiated by a professional nurse upon admission of the resident/patient; must be a current reflection of the needs, problems, concerns, strengths, and plan of care; and shall be revised and updated on an ongoing basis by the interdisciplinary team, as appropriate. 1. Resident #110 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident received 3 insulin injections during the last 7 days, received an anticoagulant on 1 of 7 days and a diuretic on 4 of 7 days. physician's orders [REDACTED]. Orders also included: Finger sticks three times a day, Monitor BP and Pulse weekly on Sunday, Orthostatic BP monthly and notify MD if systolic BP 160 or below 100 and pulse below 50. There was no documented evidence that comprehensive care plans had been developed to address the condition of Diabetes Mellitus and the use of anticoagulant, anti-hypertensive medication, and diuretic medication. 2. Resident #610 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident received an anticoagulant on 7 of 7 days and a diuretic on 6 of 7 days. Physicians Order dated 11/18/2019 documented resident was ordered [MEDICATION NAME] 40 mg daily and Eliquis 5 mg daily. There was no documented evidence that a comprehensive care plan had been developed to address the use of anticoagulant or diuretic medication. On 12/5/2019 at 9:46 AM, the Registered Nurse (RN) #1 (Unit Manager) was interviewed. RN #1 stated care plans are initiated on admission and the Unit Manager is responsible for checking and completing the care plans. All diagnoses, medications and other patient conditions must have a care plan. The MD progress notes must also be checked for additional pertinent resident information. The RN reviewed the electronic medical record and acknowledged that Resident #110 has missing care plans implemented, which includes anticoagulant, diabetes, hypertension and constipation and Resident #610 had missing care plans for use of an anticoagulant and a diuretic medication. The RN also stated this was an oversight and all nurses should be checking to ensure that all care plans are done as this is a busy floor and it is possible for things to be missed. On 12/5/19 at 10:46 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that she provides supervision for the entire building. When new admissions come in, I look over care plans to see the care plan has been developed and even created a tool for the supervisors to make sure that the care plan is done. The ADON also stated there is only one RN Unit Manager per floor and that RN is responsible for ensuring all care plans are done in addition to other duties. MDS staff also check the care plans and let us know what is done and what needs to be done. On 12/05/19 at 02:59 PM, the RN- MDS coordinator was interviewed. The MDS Coordinator stated the RN on- duty is responsible for admission of the resident and initiating the care plan. The Unit Manager continues the care plan the next day. All disciplines complete their pertinent sections of the MDS assessment and initiate their respective care plan. The MDS Coordinator stated that his department is not involved in the creation of care plans after the MDS is completed. 415.11 (c)(1)

Based on record review and interview conducted during recertification survey, the facility did not ensure cognitively intact residents were afforded the opportunity to participate in care planning meetings. This was evident for 2 of 3 residents reviewed for Care Plan out of a sample size of 39 residents. (Resident #176 & #107) The findings are: The undated facility policy and procedure titled Care Planning and Notification of Care Plan meetings to Families and Residents documented the Social worker will encourage resident/designated representative attendance in the CCP meeting and will emphasize the importance of resident/family involvement in resident care planning. The CCP meetings attendance sheet will indicate the responses of resident/designated representative to said invitation. 1). Resident #176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented resident with intact cognition and required extensive assistance of one staff with Activities of Daily Living. The MDS also documented that resident was receiving [MEDICAL TREATMENT] treatment. On 12/3/19 at 11:00 AM, during an interview Resident #176 stated that she wanted to attend the Care planning meeting but was not able to do so as it was held on a day that she was scheduled to receive [MEDICAL TREATMENT] treatment. The resident further stated that the meeting was held without her. The facility document Invitation to Comprehensive Care Plan (CCP) Meeting form signed by the Social Worker and dated 5/23/2019 documented resident was invited to attend initial/readmission meeting on 5/29/2019. The form further documented the resident did not attend the meeting and resident's spouse attended the CCP meeting. A handwritten note on the form documented will meet with resident on 5/30 as per resident request. There was no documented evidence that any other meeting occurred with the resident. On 12/05/2019 at 11:31 AM, Social Worker (SW) #3 was interviewed. SW #3 stated that upon admission residents are invited to attend the care planning meeting. A letter of invitation is usually sent a week in advance of the meeting. SW #3 also stated that if the resident is not able to attend on that date, the meeting would be rescheduled to accommodate the resident. SW #3 stated that care plan meetings were scheduled on that unit on Mondays, Wednesdays and Fridays and so was planned for 5/29/19. SW #3 could not provide a reason why the meeting was not rescheduled to accommodate the resident's [MEDICAL TREATMENT] schedule and stated that she planned to meet with the resident on the following day. SW#3 could not confirm whether or not the meeting had occurred and could not provide documented evidence of the meeting. 2). Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission MDS dated [DATE] documented resident with intact cognition. On 12/02/19 at 10:26 AM, during an interview the resident stated that he had not attended the care-planning meeting. The resident also stated they told me there will be a meeting, but they didn't invite me to come and I did not hear anything else about it The Invitation to Comprehensive Care Plan meeting form dated 11/4/19 documented the initial meeting was scheduled for 11/12/19. The Social Service section of the form dated 11/12/19, contained a check mark for yes response for resident attended meeting. In addition, the form was signed by the resident's representative. There is no documented evidence in the medical record that the resident attended the care planning meeting. On 12/5/2019 at 10:11 AM, Social Worker (SW) #2 was interviewed. SW #2 stated on short term units the resident and family are invited. The invitation is also sent by mail to representative; representatives are invited regardless of the cognitive status of the residents. The resident is physically invited to attend. SW#2 also stated that the representative for Resident #107 attended the care planning meeting, but did not offer an explanation as to why the resident had not been included in the meeting. 415.11(c)(2)(i-iii)

Based on observation and staff interview, the facility did not ensure that residents who have limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with contractures was not observed wearing a hand splint device as ordered by the physician. This was evident for 1 of 3 resident reviewed for Position/Mobility out of a sample of 39 residents. (Resident #135) The findings are: Resident # 135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/02/2019 at 02:42 PM and on 12/03/2019 at 02:32 PM, resident was observed in the dining area sitting in a wheel chair, engaged in a music activity. Resident was observed with right hand contracture without a hand splint or hand roll. Resident was observed with right elbow brace only. On 12/4/2019 at 2:32 PM, resident was observed in the Day room during lunch time. Resident was observed with other residents watching TV and being monitored by a Certified Nursing Assistant. Resident was observed without right hand splint or hand roll. Resident was only observed with right elbow brace. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented resident with severely impaired cognition, required extensive assistance of staff for Activities of Daily Living and had functional limitation on one side for both upper and lower extremity. The MDS also documented resident received Occupational Therapy, Restorative Nursing program and used a splint device. physician's orders [REDACTED]. The Activities of Daily Living (ADL) Impaired Physical Mobility Care plan dated 7/17/2019 documented resident has impaired physical mobility related to poor balance as decreased strength. Interventions include Adaptive/Assisted device to apply hand roll at all times except removal for ROM, hygiene and skin inspection daily. On 12/3/2019 at 3:48 PM, Certified Nursing Assistant (CNA) #2 was interviewed. CNA# 2 stated she is responsible for providing ADL care to the resident and Range of Motion activities which include applying splint devices. CNA#2 also stated that she provides range of motion exercises with his arms and hands during daily ADL and applies an elbow brace to better support his arm and for better positioning in his chair. CNA #2 further stated that the resident uses a hand splint to keep his hand open and this is applied in the morning and is removed when resident is in bed and during sleeping hours. On 12/4/2019 at 5:30 PM, State Agent and Licensed Practical Nurse (LPN) #4 observed the resident in bed without hand device. State Agent inquired about the resident's splint device. LPN #4 looked in the resident's dressing drawer and clothing cabinet but could not locate any hand splint or hand roll device in the resident's room. 415.12(e)(2)

Based on observation, and staff interviews during the re-certification survey, the facility did not ensure medical supplies containing biologicals were stored with appropriate pharmacy labels, following cautionary and expiration instructions. Specifically, 2 insulin pens were observed in a plastic bag with the name and room number of a resident. There were no pharmacy issued labels affixed and pens did not contain an opened or discard date. This was evident for 1 medication cart on the 6th Floor during the Medication Storage Task. The undated facility policy and procedure titled Medication Storage documented prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. On 12/04/19 at 02:39 PM, during the Medication Observation task, a clear plastic bag containing 1 [MEDICATION NAME] Flex Pen 70/30 and 1 Tresiba U-100 Flex Touch pen was observed in a medication cart on Unit 6. Affixed to the bag was a hand-written label with the resident's last name and room number. Neither pen had a pharmacy label attached and there was no labeling that documented when the pens were opened and needed to be discarded. An interview was conducted immediately with Licensed Practical Nurse (LPN#1). LPN #1 stated the insulin pens should have name of the resident, date opened and date to be discarded. Oncoming shift must check the medication cart. LPN #1 also stated she was not the one who signed off and check the medication cart, so she did not see the unlabeled flex pens. LPN #1 stated that there is a task sign-off in the Electronic Health Record (EHR) for medication storage which she showed to State Agent. The task sign-off did not include a field for checking of medications. On 12/4/2019 at 3:03 PM, an interview was conducted with Registered Nurse (RN #1). RN#1 stated medication carts should be checked daily by the medication nurses. Nurses should be checking for expired medications and ensuring that medications are labeled and dated. RN #1 stated that she does not usually check the medication carts unless she is giving medications. Insulin pens should be labeled and dated when opened. Unlabeled insulin pens must be discarded and reordered. On 12/5/19 at 3:56 PM, an interview was conducted with the Assistant Director of Nursing (ADN). The ADN stated she checks the medication carts and refrigerators from time to time for expired medications and to ensure that medication is labeled properly. Pharmacy also checked the carts for expired medications. The ADN also stated the nurses are supposed to check the medication carts every shift before they start giving medications. Insulin pens are for individual patient use and have to be labeled individually and dated when opened. the ADN further stated all medication should contain labeling from the pharmacy and not just be handwritten on the plastic bag. 415.18 (e)(1-4)

Based on observation and staff interview during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a housekeeper was observed removing waste from the rooms of residents who were maintained on Contact Precautions and did not perform hand hygiene. This was observed during the Infection Control task. The findings are: The facility policy and procedure Infection Prevention and Control Program Title: Hand Hygiene dated 11/01/2019 documented hands must be washed before and after administering care and services and should be washed before and after entering isolation precaution settings. On 12/04/2019 at 08:30 AM, Housekeeper # 1 was observed on the 5th Floor collecting waste from isolation rooms on the floor. He donned Personal Protective Equipment (PPE) which included a blue plastic gown, gloves and a blue mask with nose bridge. Staff was observed at room [ROOM NUMBER] P where a resident was maintained on Contact Precautions removing Personal Protective Equipment (PPE) except mask and handling red bag with bare hands after gown and gloves were removed. The red bag was placed on top of a large black trash container. The housekeeper then proceeded to room [ROOM NUMBER] where a resident was maintained on Contact Precautions and donned a blue gown and gloves. He removed 2 red bags from room and removed PPE at door way of the room. The Housekeeper proceeded to take the isolation waste to the basement area of the facility, where he again donned PPE. He prepared cardboard boxes, placed 3 bags of waste in the boxes, sealed them with tape. He then discarded 5 other bags of the isolation waste. The Housekeeper was not observed performing hand hygiene before entering or leaving multiple rooms of residents maintained on contact precautions, and before donning and after doffing PPE. On 12/04/2019 at 08:37 AM, Housekeeper (HSK) #1 was interviewed. HSK #1 stated he has received training on the handling of waste from isolation rooms but was not here when training was done recently, however his supervisor reviewed the training with him when he returned. He also stated that after he finishes collecting the infectious waste, he washes his hands and proceeds with his other duties On 12/04/2019 at 09:00 AM, the Director of Housekeeping (DOH) was interviewed. The DOH stated he in-services his staff every 6 months and instructs all staff to use mask, protective gloves, and gowns. He stated that staff are required to complete a training to handle biohazardous waste. He also stated that the housekeeper should be wearing PPE when handling biohazardous waste. Staff is expected to use hand sanitizer and wash their hands before and after picking up hazardous waste. On 12/04/2019 at 2:30 PM, the Director of Nursing Services/Infection Control Manager was interviewed. The DNS stated she does environmental rounds and has started doing isolation rounds to make sure rooms are set up properly in relation to PPE and signage. She stated staff are to put on PPE, wash hands, do gloves when precaution signs are posted. She stated that she has observed Housekeeping staff pick up and dispose of isolation waste and did not observe any breaks in infection control. She stated that hands should be washed in between handling the red bags, and hand hygiene should be performed when staff move from one room to the next. 415.19 (b)(4)

Based on observation, record review and interview conducted during a Recertification survey and abbreviated survey (NY 875), the facility did not ensure that the resident received adequate supervison to prevent accidents. Specifically, a Certified Nurse Assistant (CNA) did not follow the plan of care and provide necessary supervision to a resident during a shower. The CNA showered a confused resident alone when the plan of care required a two-person assist for showers. The CNA left the resident alone in the shower room, and the resident fell from the shower chair. After the resident fell , the CNA did not call for the assistance of a nurse, picked the resident up alone, and placed the resident back onto the shower chair. The resident sustained [REDACTED].#129). The findings are: The facility policy and procedure for Accident/Incident Reporting dated 11/2017 documented the following: It is the policy of the facility to promote resident safety through staff education and provide a safe environment by identifying and eliminating risk without compromising independence. The facility shall ensure the that the facility environment remains free of accident hazards as possible and each resident receive adequate supervision and assistive devices to prevent occurrences. All accident/fall must be reported to the nurse or physician and their family member as soon as possible. The facility policy and procedure for accident/incident further documented that the Certified Nursing Assistant (CNA) must notify a charge nurse for any fall or accident immediately. The Registered Nurse (RN) must respond immediately and remove the resident from danger and/or assure resident safety. The RN should assess the resident's condition, render emergency treatment, and notify the nursing supervisor and physician. Resident #129 is a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition with short and long-term memory problems. The resident had unclear speech and sometimes understands/understood. The MDS further documented the resident required the total assist of two persons for transfers and toileting. The resident required two people to provide physical help in part of bathing activity. The MDS documented the resident did not ambulate and required total assist for locomotion on the unit. The resident weighed 155 pounds (lbs.). On 06/05/18 at 12:45 AM, the resident was observed in the day room. The resident was alert, awake, and confused. Casts were on his left arm and right leg, and there were black and blue marks on the right arm. On 06/05/18 at 12:43 PM, the resident's daughter was interviewed stated that her dad fell recently and sustained multiple fractures. The Comprehensive Care Plan (CCP) for At Risk for Accidents/Falls/Injury, effective 7/15/17 and last reviewed 4/16/18, documented the resident was at risk secondary to confusion, vision/hearing impairment, psychoactive drug use, poor communication/comprehension, and fragile skin. The CCP for ADL: Self Care Deficit effective 7/15/17 and last reviewed 4/12/18 documented the resident was dependent on staff for transfer, bathing, toileting, and dressing. The CCP included the intervention: Provide necessary support as per ADL directive. The CNA Accountability Record (CNAAR) dated (MONTH) (YEAR) documented that the resident required total assist of 2 persons using a Hoyer lift for transfers. On 5/27/18 the CNA documented that the resident was provided with total assist of 2 persons for transfer and physical help of two persons for bathing. The CNA assignment sheet dated 5/27/18 documented CNA #1 was assigned to Resident #129. A Nursing Note dated 5/27/18 at 2:16 PM, written by the Registered Nurse Supervisor (RNS), documented that RNS was called to the floor by nursing staff to investigate a fall. Upon arrival, the RNS observed the resident sitting in a shower chair with a strap across the waist. There was a bump and a small cut across the middle of his forehead. The RNS also noticed a small cut and redness across the resident's nostril. There were scattered areas of redness on bilateral knees. The resident's left wrist had a small reddened area. The RNS documented she did not notice any bleeding and the resident was able to move all 4 extremities. The Physician (MD) was called and orders were given to transfer the resident to the hospital for evaluation. The resident's daughter was informed of the occurrence. The Nursing Note dated 5/27/18 at 2:40 PM documented the resident was status [REDACTED]. The note further documented that telephone orders were received to transfer the resident to the hospital to rule out (r/o) fracture. The ambulance arrived at 1:30 PM to transport the resident to the hospital. The Accident/Incident Report dated 5/27/18, documented the time of the incident as 1:00 PM. The RNS documented she was called to the shower room to investigate a fall. The resident was observed sitting in the shower char with a seat belt in place. There was a bump and cut on the mid-forehead, small cut and redness on the nose, redness on B/L knees, and L wrist redness. No active bleeding was present. Staff reported to her that the resident fell forward from the shower chair. The resident was unable to verbalize what occurred. The resident was alert and oriented x (times) 1. The Accident/Incident Follow-up Investigation sheet, completed by the RNS, documented the CNA was showering the resident and the resident fell forward in the shower chair. The resident's condition was described as Pt (Patient)in pain. The Evaluation/Outcome portion documented the CNA was in the shower room with the patient and left to go ask for help. When the CNA came back, the resident was face down sitting in his shower chair. The CNA picked up the resident and positioned him in an upright position. He left the shower room to ask another CNA to get help. The Certified Nursing Assistant (CNA #1) written statement dated 5/29/18 documented that he showered the resident, and he left the shower room to look for help for the Hoyer lift transfer. He did not receive any help, so he left the shower room a second time to get help. When he returned to the shower room, the resident was on the floor. He ran to help the resident on first impulse. He was screaming for help and he lifted the resident up. The written statement by CNA #3 dated 5/27/18 documented she was distributing lunch to resident rooms when CNA #1 stated he needed help with the resident in the shower room. CNA #3 was giving the tray to the resident in 319B when she heard Resident #129 screaming. She told CNA #1 not to leave the resident and she was coming in to help. CNA #3 went to the shower room and saw Resident #129 with a bruise on the forehead and blood on his nose. CNA #1 was next to him, and she asked CNA #1 what happened. CNA#1 asked her to give him a few minutes. She told him she was going to call the nurse, and she called the nurse immediately. CNA#1 later stated that the resident fell and he picked him up. The Registered Nurse Supervisor (RNS) statement dated 5/27/18 documented that she was called to the shower room and found the resident sitting in the shower chair strapped in with a cut and lump on the forehead. Also noted a cut across the top of his nose and redness, scattered redness on bilateral knees and redness on left wrist radial bone. The CNA # 1 was standing next to the resident. CNA # 1 stated that he left the resident when he came back he found the resident faced down with the shower chair and immediately picked the resident up and sat him in an upright position. She asked him why he did not call for help instead of leaving the resident alone. He could not answer her. The RNS asked CNA #1 why was he giving a resident a shower during lunch time, and he replied that he was behind schedule on his assignment because he had 3 residents to shower. The RNS told CNA #1 that he should not be giving a shower during lunch time. The hospital discharge summary dated 5/29/18 documented that the resident was diagnosed with [REDACTED]. The hospital discharge papers also documented that the resident had an X-Ray of the R knee on 5/27/18 that showed a [MEDICAL CONDITION] fibula. The Nursing Note dated 5/30/18 at 6:49 AM documented the resident was readmitted to the facility with Primary [DIAGNOSES REDACTED]. The resident was observed with Deep Tissue Injury (DTI) to Coccyx and Stage 1 on the L heel. There was ecchymosis (discoloration of the skin due to ruptured blood vessels) to right forehead, upper extremities and lower extremities. The left knee was swollen, and there was [MEDICAL CONDITION] (swelling due to excess fluid) in the left foot. The note documented resident had a soft cast to the left upper extremity, and a soft cast to the left lower extremity. There was a dry scab on the right nostril. The nurse further documented the resident required the total assist of two or more persons using a hoyer lift for transfers. The Nursing Note dated 5/30/18 at 11:23 AM documented the resident had a cast to Left arm and Right lower leg. The Internal Investigation Report, signed by the DNS, documented a summary of the investigation. The report documented on Saturday 5/27/18, at approximately 12:40 PM, the resident was showered by CNA #1, a floating CNA. Upon completion of the shower, CNA #1 left the resident seated in the shower chair with the safety belt while seeking help to transfer the resident from the shower chair to the wheelchair. When CNA #1 returned to the shower room, the resident was observed on the floor with bruises to his face and redness to both knees. The resident was assessed by the RNS. The MD and family were informed. CNA #1 stated he got very nervous and picked up the resident, and CNA #3 came and got the nurse. The report documented that CNA #1 violated facility policy for failure to use the call light in the shower room to ask for help. The caregiver failed to follow the accident/incident protocol of not moving the resident until they are assessed by an RN. The Caregiver failed to use good judgement while providing care, and he did not seek another staff to assist with providing the shower. The facility determined that there was no abuse, neglect, or mistreatment. The Report documented a plan of correction that included in-services for staff and review of policies for Accident Prevention and Accident/Incident. Competency skills checks for CNAs will be started 6/18/18. Monitoring of staff performance for compliance with safety measures will also be added 6/30/18, and the results will be reported to the Quality Assurance Performance Improvement (QAPI) Team. On 6/7/18 at 11: 20 AM, an interview conducted with CNA # 2, who stated that she has been working on the unit for almost 3 years. She stated the CNAs should check the CNA Accountability Records for their assigned residents daily to see what the ADL needs are for the residents. CNA #2 stated that they are supposed to call for another CNA when two persons are needed for care, such as with Hoyer lift transfers. If there is no CNA available, the nurse can be called to assist. On 5/27/18, she assisted CNA #1 with transferring the resident to the shower chair in the bedroom, using the hoyer lift. She did not go with CNA #1 to the shower room because she went on a lunch break. She was on break at the time of the incident. On 6/7/18 at 11:30 AM, an interview conducted with CNA #3 who stated that she has been working on the unit for 6 years. She stated that she knows how much assist is needed for transfer and ADLs from the CNAAR, and she will call another CNA or the nurse if she needs another person to assist with care. On the day of the fall, CNA #1 called her to the bathroom, and she responded in minutes. When she arrived at the bathroom, she saw the resident sitting on the shower chair sitting upright. She asked CNA #1 what happened because she was confused. The resident was bleeding on top of the nose and moaning. CNA #1 told her to wait and give him a few minutes before calling the nurse, but she called the nurse. She stated she did not touch the resident. On 6/7/18 at 11:45, the RN Manager was interviewed and stated that she has been working on the unit since Jan (YEAR). She stated that the resident is confused and Russian speaking. The resident has always required two persons total assist for toileting and dressing. The resident requires two-person physical assist for bathing. Usually, the primary aide assigned to the resident seeks assistance from another CNA when two people are needed. If the aide cannot get someone, he or she needs to call the nurse. She was on vacation at the time of the incident. On 6/7/18 at 12:00 PM, the Licensed Practical Nurse (LPN) was interviewed and stated she has been working on the 3rd floor for about 7 years. She stated that the CNAs are told to refer to the CNAAR to know the residents' ADL status. If they need help, they ask for it. She stated CNA # 3 called her and asked her to go shower room. When she arrived at the shower room, she saw the resident sitting on the shower chair with the seat belt on. There was a laceration on the head. CNA #1 was with the resident. She told CNA #1 to stay with the resident while she called the supervisor. On 6/7/18 at 12:20 PM, the resident's daughter was interviewed and stated she was notified around 1pm that her dad fell in the shower room. The facility staff told her the ambulance was coming, and she went straight to the hospital. She saw her dad on the stretcher. He was vomiting, had multiple bruises all over his face, and fractures in his leg and left arm. He was crying at that time. No one could touch him, and he screamed. She was very angry. She went to the facility on the following Wednesday to meet the Director of Nursing (DNS), to find out what happened. The DNS told her the CNA made a bad decision and her dad fell . The DNS didn't provide any further information. The daughter stated she never met CNA #1; he is not a regular worker. Her dad had multiple fractures due to the fall, and he was in severe pain. On 6/7/18 at 1:30 PM an interview conducted with the Director of Nursing (DNS) who stated that she has been working here for over [AGE] years. She stated that she was called by the weekend supervisor about the incident, and got the details of the incident and statements from staff. The resident was sent to the hospital. She said that CNA #1 admitted that he walked away from the resident, and the resident fell . CNA #1 was suspended immediately, and she met with the resident's daughter. The DNS stated she discussed pain management with the daughter, and the daughter agreed to pain management. The DNS further stated that she thinks this was human error, like poor judgement. The staff should always call for help when they see a resident fall, and they should call the nurse. CNA #1 should not have left the resident alone or picked the resident up off the floor. He should have used the call light. On 6/8/18 at 1:42 PM, the Administrator was interviewed and stated that he found out about the fall in the morning on 5/29/18. The fall was investigated and all staff were spoken to. The Administrator also stated that he was fully aware that the incident should be reported to the state, and the facility reported it on 6/4/18. He did not see the accident as abuse or neglect. He stated the DNS and himself re-educated the staff to prevent further problems. The call bell in that bathroom was working very well. The CNA should not have left the resident alone. He should have used the call bell. CNA #1 and the RNS were unavailable for interview. 415.12(h)(1)

Based on observation, record review and interview conducted during a Recertification survey and abbreviated survey (NY 875), the facility did not ensure a resident was free from neglect. Specifically, a Certified Nurse Assistant (CNA) did not follow the plan of care and provide necessary supervision to a resident during a shower. The CNA showered a confused resident alone when the plan of care required a two-person assist for showers. The CNA left the resident alone in the shower room, and the resident fell from the shower chair. After the resident fell , the CNA did not call for the assistance of a nurse, picked the resident up alone, and placed the resident back onto the shower chair. The resident sustained [REDACTED].# 129). The findings are: The undated facility policy and procedure for Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Resident Property. Investigating and Reporting documented that the facility will protect its residents from abuse and neglect. Neglect is failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The policy also documented that neglect also occurs when the facility fails to provide necessary care for a resident, such as a situation where a resident is left to lie in urine or feces. The facility policy and procedure for Accident/Incident Reporting dated 11/2017 documented the following: It is the policy of the facility to promote resident safety through staff education and provide a safe environment by identifying and eliminating risk without compromising independence. The facility shall ensure the that the facility environment remains free of accident hazards as possible and each resident receive adequate supervision and assistive devices to prevent occurrences. All accident/fall must be reported to the nurse or physician and their family member as soon as possible. The facility policy and procedure for accident/incident further documented that the Certified Nursing Assistant (CNA) must notify a charge nurse for any fall or accident immediately. The Registered Nurse (RN) must respond immediately and remove the resident from danger and/or assure resident safety. The RN should assess the resident's condition, render emergency treatment, and notify the nursing supervisor and physician. Resident #129 is a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition with short and long-term memory problems. The resident had unclear speech and sometimes understands/understood. The MDS further documented the resident required the total assist of two persons for transfers and toileting. The resident required two people to provide physical help in part of bathing activity. The MDS documented the resident did not ambulate and required total assist for locomotion on the unit. The resident weighed 155 pounds (lbs.). On 06/05/18 at 12:45 AM, the resident was observed in the day room. He was alert, awake, and confused. Casts were on his left arm and right leg, and there were black and blue marks on the right arm. On 06/05/18 at 12:43 PM, the resident's daughter was interviewed and stated that her dad fell recently and sustained multiple fractures. She also stated that her dad really declined after he was admitted to this nursing home a few years ago. The Comprehensive Care Plan (CCP) for At Risk for Accidents/Falls/Injury effective 7/15/17 and last reviewed 4/16/18 documented the resident was at risk secondary to confusion, vision/hearing impairment, psychoactive drug use, poor communication/comprehension, and fragile skin. The CCP for ADL: Self Care Deficit effective 7/15/17 and last reviewed 4/12/18 documented the resident was dependent on staff for transfer, bathing, toileting, and dressing. The CCP included the intervention: Provide necessary support as per ADL directive. The CNA Accountability Record (CNAAR) dated (MONTH) (YEAR) documented that the resident required total assist of 2 persons using a Hoyer lift for transfers. On 5/27/18 the CNA documented that the resident was provided with total assist of 2 persons for transfer and physical help of two persons for bathing. The CNA assignment sheet dated 5/27/18 documented CNA #1 was assigned to Resident #129. A Nursing Note dated 5/27/18 at 2:16 PM, written by the Registered Nurse Supervisor (RNS), documented that RNS was called to the floor by nursing staff to investigate a fall. Upon arrival, the RNS observed the resident sitting in a shower chair with a strap across the waist. There was a bump and a small cut across the middle of his forehead. The RNS also noticed a small cut and redness across the resident's nostril. There were scattered areas of redness on bilateral knees. The resident's left wrist had a small reddened area. The RNS documented she did not notice any bleeding and the resident was able to move all 4 extremities. The Physician (MD) was called and orders were given to transfer the resident to the hospital for evaluation. The resident's daughter was informed of the occurrence. The Nursing Note dated 5/27/18 at 2:40 PM documented the resident was status [REDACTED]. The note further documented that telephone orders were received to transfer the resident to the hospital to rule out (r/o) fracture. The ambulance arrived at 1:30 PM to transport the resident to the hospital. There was no documented evidence in the medical record that the resident was assessed for pain by the nurse. The Medication Administration Record [REDACTED]. The Accident/Incident Report dated 5/27/18, documented the time of the incident as 1:00 PM. The RNS documented she was called to the shower room to investigate a fall. The resident was observed sitting in the shower char with a seat belt in place. There was a bump and cut on the mid-forehead, small cut and redness on the nose, redness on B/L knees, and L wrist redness. No active bleeding was present. Staff reported to her that the resident fell forward from the shower chair. The resident was unable to verbalize what occurred. The resident was alert and oriented x (times) 1. The Accident/Incident Follow-up Investigation sheet, completed by the RNS, documented the CNA was showering the resident and the resident fell forward in the shower chair. The resident's condition was described as Pt (Patient)in pain. The Evaluation/Outcome portion documented the CNA was in the shower room with the patient and left to go ask for help. When the CNA came back, the resident was face down sitting in his shower chair. The CNA picked up the resident and positioned him in an upright position. He left the shower room to ask another CNA to get help. The Certified Nursing Assistant (CNA #1) written statement dated 5/29/18 documented that he showered the resident, and he left the shower room to look for help for the Hoyer lift transfer. He did not receive any help, so he left the shower room a second time to get help. When he returned to the shower room, the resident was on the floor. He ran to help the resident on first impulse. He was screaming for help and he lifted the resident up. The written statement by CNA #3 dated 5/27/18 documented she was distributing lunch to resident rooms when CNA #1 stated he needed help with the resident in the shower room. CNA #3 was giving the tray to the resident in 319B when she heard Resident #129 screaming. She told CNA #1 not to leave the resident and she was coming in to help. CNA #3 went to the shower room and saw Resident #129 with a bruise on the forehead and blood on his nose. CNA #1 was next to him, and she asked CNA #1 what happened. CNA#1 asked her to give him a few minutes. She told him she was going to call the nurse, and she called the nurse immediately. CNA#1 later stated that the resident fell and he picked him up. The Registered Nurse Supervisor (RNS) statement dated 5/27/18 documented that she was called to the shower room and found the resident sitting in the shower chair strapped in with a cut and lump on the forehead. Also noted a cut across the top of his nose and redness, scattered redness on bilateral knees and redness on left wrist radial bone. The CNA # 1 was standing next to the resident. CNA # 1 stated that he left the resident when he came back he found the resident faced down with the shower chair and immediately picked the resident up and sat him in an upright position. She asked him why he did not call for help instead of leaving the resident alone. He could not answer her. The RNS asked CNA #1 why was he giving a resident a shower during lunch time, and he replied that he was behind schedule on his assignment because he had 3 residents to shower. The RNS told CNA #1 that he should not be giving a shower during lunch time. The hospital discharge summary dated 5/29/18 documented that the resident was diagnosed with [REDACTED]. The hospital discharge papers also documented that the resident had an X-Ray of the R knee on 5/27/18 that showed a [MEDICAL CONDITION] fibula. The Nursing Note dated 5/30/18 at 6:49 AM documented the resident was readmitted to the facility with Primary [DIAGNOSES REDACTED]. The resident was observed with Deep Tissue Injury (DTI) to Coccyx and Stage 1 on the L heel. There was ecchymosis (discoloration of the skin due to blood from ruptured blood vessels) to right forehead, upper extremities and lower extremities. The left knee was swollen, and there was [MEDICAL CONDITION] (swelling caused by excess fluid) in the left foot. The note documented resident had a soft cast to the left upper extremity, and a soft cast to the left lower extremity. There was a dry scab on the right nostril. The nurse further documented the resident required the total assist of two or more persons using a hoyer lift for transfers. The Nursing Note dated 5/30/18 at 11:23 AM documented the resident had a cast to Left arm and Right lower leg. The Internal Investigation Report, signed by the DNS, documented a summary of the investigation. The report documented on Saturday 5/27/18, at approximately 12:40 PM, the resident was showered by CNA #1, a floating CNA. Upon completion of the shower, CNA #1 left the resident seated in the shower chair with the safety belt while seeking help to transfer the resident from the shower chair to the wheelchair. When CNA #1 returned to the shower room, the resident was observed on the floor with bruises to his face and redness to both knees. The resident was assessed by the RNS. The MD and family were informed. CNA #1 stated he got very nervous and picked up the resident, and CNA #3 came and got the nurse. The report documented that CNA #1 violated facility policy for failure to use the call light in the shower room to ask for help. The caregiver failed to follow the accident/incident protocol of not moving the resident until they are assessed by an RN. The Caregiver failed to use good judgement while providing care, and he did not seek another staff to assist with providing the shower. The facility determined that there was no abuse, neglect, or mistreatment. The Report documented a plan of correction that included in-services for staff and review of policies for Accident Prevention and Accident/Incident. Competency skills checks for CNAs will be started 6/18/18. Monitoring of staff performance for compliance with safety measures will also be added 6/30/18, and the results will be reported to the Quality Assurance Performance Improvement (QAPI) Team. On 6/7/18 at 11: 20 AM, an interview conducted with CNA # 2, who stated that she has been working on the unit for almost 3 years. She stated the CNAs should check the CNA Accountability Records for their assigned residents daily to see what the ADL needs are for the residents. CNA #2 stated that they are supposed to call for another CNA when two persons are needed for care, such as with Hoyer lift transfers. If there is no CNA available, the nurse can be called to assist. On 5/27/18, she assisted CNA #1 with transferring the resident to the shower chair in the bedroom, using the hoyer lift. She did not go with CNA #1 to the shower room because she went on a lunch break. She was on break at the time of the incident. On 6/7/18 at 11:30 AM, an interview conducted with CNA #3 who stated that she has been working on the unit for 6 years. She stated that she knows how much assist is needed for transfer and ADLs from the CNAAR, and she will call another CNA or the nurse if she needs another person to assist with care. On the day of the fall, CNA #1 called her to the bathroom, and she responded in minutes. When she arrived at the bathroom, she saw the resident sitting on the shower chair sitting upright. She asked CNA #1 what happened because she was confused. The resident was bleeding on top of the nose and moaning. CNA #1 told her to wait and give him a few minutes before calling the nurse, but she called the nurse. She stated she did not touch the resident. On 6/7/18 at 11:45, the RN Manager was interviewed and stated that she has been working on the unit since Jan (YEAR). She stated that the resident is confused and Russian speaking. The resident has always required two persons total assist for toileting and dressing. The resident requires two-person physical assist for bathing. Usually, the primary aide assigned to the resident seeks assistance from another CNA when two people are needed. If the aide cannot get someone, he or she needs to call the nurse. She was on vacation at the time of the incident. On 6/7/18 at 12:00 PM, the Licensed Practical Nurse (LPN) was interviewed and stated she has been working on the 3rd floor for about 7 years. She stated that the CNAs are told to refer to the CNAAR to know the residents' ADL status. If they need help, they ask for it. She stated CNA # 3 called her and asked her to go shower room. When she arrived at the shower room, she saw the resident sitting on the shower chair with the seat belt on. There was a laceration on the head. CNA #1 was with the resident. She told CNA #1 to stay with the resident while she called the supervisor. On 6/7/18 at 12:20 PM, the resident's daughter was interviewed and stated she was notified around 1pm that her dad fell in the shower room. The facility staff told her the ambulance was coming, and she went straight to the hospital. She saw her dad on the stretcher. He was vomiting, had multiple bruises all over his face, and fractures in his leg and left arm. He was crying at that time. No one could touch him, and he screamed. She was very angry. She went to the facility on the following Wednesday to meet the Director of Nursing (DNS), to find out what happened. The DNS told her the CNA made a bad decision and her dad fell . The DNS didn't provide any further information. The daughter stated she never met CNA #1; he is not a regular worker. Her dad had multiple fractures from the fall, and he was in severe pain. On 6/7/18 at 1:30 PM an interview conducted with the Director of nursing (DNS) who stated that she has been working here for over [AGE] years. She stated that she was called by the weekend supervisor about the incident, and got the details of the incident and statements from staff. The resident was sent to the hospital. She said that CNA #1 admitted that he walked away from the resident, and the resident fell . CNA #1 was suspended immediately, and she met with the resident's daughter. The DNS stated she discussed pain management with the daughter, and the daughter agreed to pain management. The DNS further stated that she thinks this was human error, like poor judgement. The staff should always call for help when they see a resident fall, and they should call the nurse. CNA #1 should not have left the resident alone or picked the resident up off the floor. He should have used the call light. On 6/8/18 at 1:42 PM, the Administrator was interviewed and stated that he found out about the fall in the morning on 5/29/18. The fall was investigated and all staff were spoken to. The Administrator also stated that he was fully aware that the incident should be reported to the state, and the facility reported it on 6/4/18. He did not see the accident as abuse or neglect. He stated the DNS and himself re-educated the staff to prevent further problems. The call bell in that bathroom was working very well. The CNA should not have left the resident alone. He should have used the call bell. CNA #1 and the RNS were unavailable for interview. 415.4(b)

Based on observation and interview conducted during the recertification survey, the facility did not ensure that a resident's dignity was maintained. Specifically, a resident was observed multiple times, in the public areas, wearing a hospital-type gown. This was evident for1 of 3 residents reviewed for Dignity (Resident #202). The findings are: The facility policy regarding clothing needs dated 11/2017 documented the following: In the event that a resident does not have clothing, the nursing staff will inform the social worker verbally at which point the social worker will contact family member/designated representative and ask them to bring in clothing. If the family/designated representative is unable to bring clothes in a timely manner, residents are provided with clothing from the facility donation supply. Resident #202 is a resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident required total assistance in performing Activities of Daily Living (ADLs), and the resident was incontinent of bowel and bladder. On 6/05/17 at 11AM, the resident was observed being wheeled through the hallway by a Certified Nursing Assistant (CNA). The resident was wearing a hospital gown. The resident was observed on several occasions being transported back and forth from different locations. On 6/07/18 at 11:45AM, the resident was observed sitting in a Geri chair in the dining area wearing a hospital gown. On 6/8/18 at 11: 00AM, the resident was observed in the bedroom sleeping. The resident as still wearing a hospital gown. The resident's wardrobe was checked for clothing, and there was one heavy blanket and one winter jacket inside. The CNA informed the State Agent (SA) that the jacket belonged to the resident's daughter. On 6/8/18 at 11:15 AM, CNA #1 was interviewed and stated she is from an agency has been working on the unit for a while. She stated she works in the facility at least 3 days per week. The CNA stated that had never informed anyone about lack of clothing because if a resident does not have clothing, they are dressed in a gown from the laundry cart. The laundry department always provides hospital gowns to the unit on a daily basis. On 6/8/18 at 11:37 AM, CNA #2, the assigned CNA, was interviewed and stated that if a resident doesn't have clothing, we ask the family member to bring clothes, but we always have gowns from the laundry. CNA #2 further stated that they also use gowns for residents who have impairments like contractures or pain. She said she never reported a shortage of clothing for the resident to the supervisor because they always have hospital gowns in the linen carts. On 6/8/18 at 11:43 AM, CNA #3 was interviewed and stated that she uses a hospital gown for residents who do not have clothing. The hospital gowns are supplied by the laundry. She further stated she has never reported a clothing problem to anyone. On 6/7/18 at 11:54 AM, the Director of Social Work (DSW) was interviewed and stated that the housekeeping and the social service department are responsible for clothing issues. She stated they contact the family member to bring clothes, and they also get clothing donations from outside sources. The DSW further stated they rarely have problems getting clothes from families. She said she was not aware that the resident was having clothing problems and could not explain the reason why the laundry was supplying the hospital gowns. The DSW stated sometimes she receives calls from the rehab unit informing her of resident clothing needs and clothing is then provided. She stated the department has never heard any issues from the unit. On 6/8/18 at 12:27 PM, the Registered Nurse was interviewed and stated usually residents are admitted from the hospital with a hospital gown. If the resident does not have clothes, Social Services will work with the family. The RN stated the hospital gowns on the laundry carts are used during showers. Residents are put into a gown after a shower to cover them while they are being transported back to their room. The family members are very involved. 415.5(a)