Every finding on record at Hollis Park Manor Nursing Home

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that all drugs and biological were stored in accordance with currently accepted professional principles. This was evident in 1 (Unit C) of 2 units observed. Specifically, expired medications were stored in Unit C medication cabinet. The findings are: The facility policy and procedure titled Medication Administration with a revision date of 09/2024 stated over the counter drugs should be labeled clearly and monitored regularly. The labels should include expiration dates and any specific storage instructions. During observation on 05/13/2025 at 2:23 PM, Unit C medication cabinet was observed with 2 bottles (100 tablets in each bottle) of Zinc Sulfate - 220 milligram per tablet, with expiration date of 09/2024, 1 bottle (200 tablets in a bottle) of Iron tablet - 325 milligrams per tablet, with expiration date of 09/2024, and a bottle of liquid Vitamin C - 473 cubic centimeter with an expiration date of 03/2025. On 05/13/2025 at 2:59 PM, the Central Supply Room staff was interviewed and stated their responsibility is to deliver the medications in the unit. They stated, it is the nurse's responsibility to store them. They stated they do not check the medications for expiration date. On 05/13/2025 at 2:30 PM, Registered Nurse #1 was interviewed and stated it is the nurse's reposnibility to check for expiration dates. They stated they did not check the medication expiration dates today. On 05/13/2025 at 2:49 PM, the Assistant Director of Nursing was interviewed and stated it is the responsibility of the night shift Licensed Practical Nurse to check the medication stock nightly for expired medications. They stated it is also the Central Supply Room person in charge's responsibility to check and replace the expired medications in the medication cabinet. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews conducted during the recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure a resident's right to receive services with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #15) of 21 total sampled residents. Specifically, Resident #15 was prevented from using their room's bathroom due to the door being locked. The findings are: Resident #15 was admitted on [DATE] with diagnoses of cerebral vascular accident with left hemiplegia and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #15 was cognitively intact, required substantial to maximal assistance with toileting, and had episodes of bladder incontinence. On 01/16/2024 at 10:20 AM and 01/17/24 at 10:17 AM, Resident #15 was interviewed and stated they were unable to use the bathroom in their room. The bathroom was shared between Resident #15's room and the room next to theirs. The resident in the adjoining room locked Resident #15's bathroom door from inside the bathroom preventing Resident #15 from accessing the bathroom. The toilet was consistently clogged, unable to be flushed, and not functional. Resident #15 stated this was an ongoing problem since they were admitted to the facility. Resident #15 used their cane to walk to the unit bathroom in the hallway or ask other residents to use their toilet. Resident #15 stated they felt embarrassed because they soiled themselves when they were unable to reach the bathroom on time. Their bathroom concerns were reported to the Social Worker and the Housekeeper but Resident #15 stated nothing was done. On 01/16/2024 at 10:45 AM, the bathroom door in Resident #15's room was locked and could not be opened. The bathroom door in the adjoining room that shared the bathroom was open. The toilet did not flush when the handle was pushed. On 01/17/2024 at 9:25 AM, Resident #15 was observed ambulating with their cane from their room to the unit bathroom in the hallway. Resident #15 was unable to use the hallway bathroom because it was occupied and proceeded to another resident's room on the unit. Resident #15 knocked on the other resident's door, asked to use the bathroom, and was observed walking into the bathroom in the other resident's room. On 01/19/2024 at 08:15 AM, Resident #15 was observed using a rolling walker to ambulate from their room and use the unit bathroom in the hallway. There was no documented evidence Resident #15's need and preference to use the bathroom in their room was accommodated by the facility. On 01/19/2024 at 10:45 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #15 used their cane to ambulate to the unit bathroom in the hallway. Certified Nursing Assistant #1 did not ask Resident #15 the reason they used the hallway bathroom. Certified Nursing Assistant #1 knew the toilet in Resident #15's shared bathroom did not flush, reported the issue to the Director of Environmental Services, and did not log the broken toilet in the maintenance logbook. On 01/19/2024 at 11:18 AM, [NAME] #1 was interviewed and stated the toilet in Resident #15's shared bathroom was working before they went on vacation in 12/2023. [NAME] #1 returned from vacation on 1/18/2024 and noticed Resident #15's toilet did not flush but did not report the broken toilet to their supervisor. On 01/19/2024 at 12:55 PM, Licensed Practical Nurse #1 was interviewed and stated they were not aware Resident #15's toilet did not flush, and Resident #15 did not have access to their bathroom because the door was locked. Unit staff should have reported the issue to Licensed Practical Nurse #1 so they could immediately alert the Maintenance Department. Licensed Practical Nurse #1 stated they did not ask Resident #15 the reason they did not use the toilet in their room and assumed Resident #15 chose to use the unit hallway bathroom because their roommate also used the bathroom in the hallway. The resident in Resident #15's adjoining room locked the shared bathroom door for privacy and stuffed paper down the toilet causing it to clog and overflow. On 01/19/2024 at 11:34 AM, the Director of Environmental Services was interviewed and stated they were aware the resident in Resident #15's adjoining room had a recurrent behavior of causing the toilet to clog by stuffing it with paper and objects. The maintenance logbook was available on each unit and [NAME] #1 should have made the Director of Environmental Services aware this was an issue. On 01/22/2024 at 11:12 AM, the Director of Social Services was interviewed and stated they were not aware Resident #15 did not have access to the shared bathroom in their room. The Director of Nursing was interviewed on 01/22/2024 at 08:14 AM and stated staff on Resident #15's unit should have made rounds more frequently to ensure the resident had access to their bathroom and the toilet was functional. 10 NYCRR 415.5(e)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not services provided met professional standards of quality. This was evident for 1 (Resident #16) 18 total sampled residents. Specifically, the nurse did not inform Physician #1 of Resident #16's high fingerstick blood sugar readings in accordance with Physician's Orders. The findings are: The facility policy titled Long-term Diabetic Care dated 07/2017 documented the Physician will confirm factors that may influence glucose tolerance. Resident #16 had diagnoses of diabetes mellitus and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #16 was moderately cognitively impaired. The Comprehensive Care Plan related to diabetes mellitus dated 11/10/2023 documented Resident #16 was at risk for abnormal glucose levels and blood glucose levels were monitored according to physician's order. Physician's Orders dated 12/18/2023 documented Resident #16 received Basaglar insulin 26 units at bedtime and Admelog insulin 16 units before each meal for diabetes mellitus. Resident #16 was ordered to have fingerstick blood sugar testing 3 times daily and staff were ordered to inform the physician if Resident #16's blood sugar reading was more than 350. Resident #16 had fingerstick blood sugar readings above 350 on the following dates: 12/01/2023 = 392 12/04/2023 = 357 01/14/2023 = 383 01/15/2024 = 375 01/15/2024 = 362 There was no documented evidence the nurse informed Physician #1 when Resident #16's fingerstick blood sugar readings were above 350. On 01/19/2024 at 3:15 PM, an interview was conducted with Licensed Practical Nurse #2 who stated they did not recall contacting Physician #1 when Resident #16's fingerstick blood sugar readings were above 350. Licensed Practical Nurse #2 would administer Resident #16's ordered medications and did not retest the resident's blood sugar after high blood sugar readings. On 01/22/2024 at 2:00 PM, Physician #1 was interviewed and stated they chose not to take an aggressive approach with adjusting Resident #16's insulin orders because they were unsure how it would affect the resident's blood sugar. Physician #1 stated they should have ordered for Resident #16 to be evaluated by an Endocrinologist to address the Resident #16's persistently high blood glucose levels. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident in 1 (Resident #30) of 18 total sampled residents. Specifically, Resident #30 fall resulting in spinal fracture was not reported to the New York State Department of Health. The findings are: The facility policy titled Accidents and Incidents Investigation and Reporting dated 12/2023 documented all accidents and incidents shall be investigated and reported to the Administrator and Director of Nursing. Resident #30 had diagnoses of dementia and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #30 was severely cognitively impaired. Nursing Note dated 12/17/2023 documented Resident #30 was found on the floor in their room and no apparent injury was noted. Resident #30's heart rate was later elevated, and the Medical Doctor ordered for the resident to be transferred to the hospital for computerized tomography of the head. Nursing Note dated 12/20/2023 documented Resident #30 was readmitted from the hospital with diagnosis of cervical spinal fracture. There was no documented evidence Resident #30's unwitnessed fall resulting in a spinal fracture was reported to the New York State Department of Health. On 01/18/2024 at 11:30 AM, an interview was conducted with the Acting Director of Nursing who stated the Director of Nursing at the time of the incident no longer works at the facility and they were unable to provide an explanation the facility did not report Resident #30's fall and fracture to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, interviews, and record review conducted during the Recertification Survey from 01/16/2024 to 01/23/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit C) of 3 units. Specifically, resident rooms had loose wires and dusty, dirty equipment, and the floor dining room had dirty window shades. The findings are: 1) Unit C was observed multiple times from 01/16/2024 at 8:00 AM to 01/23/2024 at 12:00 PM with the following: 1- Room C05 had a wheelchair and seat cushion with crusty brown stains, food particles, and dust and dirt on the metal frame and wheel spokes. 2- Room C06 had a dusty wheelchair with brown stains and a tube feeding pump and pole with crusty brown stain. The dusty, dirty clothing hamper had brown stains. 3- Room C10 had a recliner chair and stained cushion with food particles and layers of dirt and dust. 4- Room C11 had a dirty and dusty wheelchair and a dusty, dirty clothing hamper with brown stains. 5- Room C12 had a tube feeding pump pole and power cord with dried brown stains. 6- The unit chair scale frame and footrest were dusty and dirty. 7- The floor dining room window shades were splattered with dried brown stains. On 01/19/2024 at 11:34 AM, the Director of Environmental Services was interviewed and stated they made daily rounds to ensure the facility was clean. They were responsible for power washing wheelchairs daily according to the cleaning schedule posted on each unit. The nursing staff reported to them when wheelchairs were dirty and required immediate attention. The nursing staff were responsible for wiping down the tube feeding pumps. Housekeeping was responsible for cleaning the tube feeding poles and the chair scales. There was a maintenance logbook on each unit that was checked daily to ensure resident equipment was in good working condition. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #16) 18 total sampled residents. Specifically, Physician #1 did not address Resident #16's consistently high blood glucose levels. The findings are: The facility policy titled Long-term Diabetic Care dated 07/2017 documented the Physician will confirm factors that may influence glucose tolerance. Resident #16 had diagnoses of diabetes mellitus and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #16 was moderately cognitively impaired. The Comprehensive Care Plan related to diabetes mellitus dated 11/10/2023 documented Resident #16 was at risk for abnormal glucose levels and blood glucose levels were monitored according to physician's order. Hemoglobin A1c laboratory results for Resident #16 dated 10/3/2023 documented a 12.8% result above the normal reference range of 5.6% and below. Physician's Orders dated 12/18/2023 documented Resident #16 received Basaglar insulin 26 units at bedtime and Admelog insulin 16 units before each meal for diabetes mellitus. Resident #16 was ordered to have fingerstick blood sugar testing 3 times daily and staff were ordered to inform the physician if Resident #16's blood sugar reading was more than 350. Hemoglobin A1c laboratory results for Resident #16 dated 1/2/2024 documented a 12.2% result above the normal reference range of 5.6% and below. Resident #16 had fingerstick blood sugar readings above 350 on the following dates: 12/01/2023 = 392 12/04/2023 = 357 01/14/2023 = 383 01/15/2024 = 375 01/15/2024 = 362 The Physician's Note dated 1/8/2024 documented Resident #16 was evaluated for their monthly review and did not document the resident's laboratory results or elevated blood glucose readings. There was no documented evidence Physician #1 addressed Resident #16's high blood glucose levels in relation to their diagnosis of diabetes mellitus. On 01/22/2024 at 2:00 PM, Physician #1 was interviewed and stated they chose not to take an aggressive approach with adjusting Resident #16's insulin orders because they were unsure how it would affect the resident's blood sugar. Physician #1 stated they should have ordered for Resident #16 to be evaluated by an Endocrinologist to address the Resident #16's persistently high blood glucose levels. 10 NYCRR 415.15(b)(1)(i)(ii) 48876 Based on observation, record review and interviews conducted during the Recertification and Complaint survey from 01 01/16/2024 to 01/23/2024 , the facility did not ensure that a fall that resulted to an injury was reported immediatlet , but no later than 2 hours , to the New York State Department of Health . This was evident in 1 of 1 reviewed for accident out of 18 total sampled residents The findings are: The facility policy titled Accidents and Incidents -- Investigation and Reporting with a review date -*Resident Abuse, Neglect, and Exploitation dated 10/2023 documented all employees and contractors must report any allegation of abuse to the Administrator and Director of Nursing immediately, but not later than two hours after being informed of the allegation. Resident #106 had diagnoses of schizoaffective disorder and mood disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #106 had intact cognition. Resident #167 had diagnoses of major depressive disorder and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #167 had mild cognitive impairment. Nursing Note dated 02/02/2023 at 5:37 PM documented Residents #106 and #167 had an altercation. Resident #106 had a bump on their forehead and scratches to their chin and cheek. Resident #167 was transferred to the hospital for a psychiatric evaluation. The Aspen Complaint Tracking System intake dated 2/6/2023 at 12:39 PM documented the facility reported the resident-to-resident altercation between Residents #106 and #167, more than 2 hours after the occurrence. There was no documented evidence the facility reported the altercation between Resident #106 and #167 to the New York State Department of Health within 2 hours of occurrence. On 01/23/2024 at 02:44 PM, an interview was conducted with the Director of Nursing who stated the facility only reported resident-to-resident altercations to the New York State Department of Health when it resulted in a resident being seriously injured. Residents #106 and #167 had psychiatric histories and the facility did not look at their incidents as possible abuse. 10 NYCRR 415.4(b)(2) Resident #30 Abuse 01/19/24 11:23 AM OBSERVATION: Resident was observed several times during the recertification survey seated in her WH in the room [ROOM NUMBER] bedded with daughter visiting , appropriately dressed , neat and clean in appearance with soft cervical collar intact . Denies any pains . resident with dressing on both lower extremities . On eating assisted and frequent encouragement . RECORD REVIEW: DOB:03/27/1942 --- 82 Y/O F DOA: 12/15/2023 FLU: 12/16/2023 ATTENDING MD: [NAME]. [NAME] DX: HTN /PVD/NON ALZHEIMER' DEMENTIA /ATRIAL FIB /S/P SURGERY / MDS: 12/17 /2023 -- INITIAL HEARING -- 0/0 -- SPEECH -- 0/2-- VISION --0/0-- MODEREATELY IMPAIRED-- MOOD/ BEHAVIOR ---0/0-- FUNCTIONAL STATUS -- USES WALKER -- ROM --0/0--EATING --2-- TOILETING --2--DEPENDENT --1--SHOWER --1--UPPER BODY -- 2/1-- ROLL LEFT /RIGHT --2/2--CHAIR --1AMBULATION -- UNABLE --BLADDER /BOWEL -- 3/3-- SECTION J -- PAIN YES -- FALL -- YES -- HEIGHT -- 64 -- WEIGHT --142 --MECHANICALLY ALTERED MEALS -- SECTION M -- SURGICAL WOUNDS X 2 MD ORDERS: 01/02/2024 Clopidogrel 75 mg OD /Donepezil 5 mg OD /Dorzolamide 2-0.5 % 1 gtt OU BID /Enoxaparin 60 mg --0.6 ml SQ BID /Gabapentin 100 mg q 8 hrs /Lasix 20mg OD /Lisinopril 20 mg OD /Memantine 5 mg OD /Metoprolol 25 mg BID /Norvasc 10 mg OD /Polyethylene glycol 17 grams q 12 hrs /Senna 8.6 mg 2 tabs HS /Simvastatin 40 mg HS /Tylenol 325 mg 2 tabs PRN q 6 hrs and 30 minutes prior to dressing change / Bil floor mat WOUND CARE : LEFT /Right LATERAL SHEEN --- nss -- santyl --- dpd -- OD and prn ADVANCE DIRECTIVE : DNR/DNI DIETARY: Chopped / NAS / thin liq COMPREHENSIVE CARE PLANS : 12/22 2023 1.FALL-- resident with hx of fall with Fx of femur . Actual fall in the facility 12/17/2023 -- Fx of cervical 6-7 and 11 . GOAL: resident will be free from complications and discomfort due to fx . APPROACHES : cervical collar as per MD order . skin check q shift /Pain assessment q shift / administer pain medications as per MD order 2. PRESSURE ULCER --resident with surgical wounds : GOALS : Resident will be fee from infection at surgical sites and will heal without difficulty . APPROACHES : wound dressing as per MD order / Monitor and report to MD any signs of infection or changes in surgical sites / F/U with surgeon and weekly wound rounds 3. PSCYHOTROPICS -- UNNECESSARY MEDS -- rt resident receives antidepressant . GOAL: Resident will not exhibit signs of drug related: sedation, hypotension or anticholinergic symptoms, EPS, daily x 3 months APPROACHES: Monitor for adverse effects/reactions to medications./Approach: Attempt dosage reduction to lowest possible therapeutic level as indicated by IDT, MD, Psychiatry./Follow up with psychiatrist as indicated./Monitor/record/report mood and response to medication. IDT NOTES : NURSES NOTES : 12/15/2023 -- Bertilia [NAME]- [NAME] RN -- Admission notes -- admitted 81 y/o female from Northwell LIJ -- dx : acute occlusion of aortoiliac artery due to thromboembolism , Verbally responsive but confused With surgical wounds on both legs and staples on both sides of lower abdomen . Incontinent of bowel/bladder . fall and safety precautions , 12/17/2023 -- [NAME] Darby RN -- Staff making rounds at 1:40 am . At about 1;45 AM , Charge Nurse heard a noise the resident was laying on her right side on the floor She was assisted back to bed /Full body check done / no apparent injuries notes . Resident has periods of confusion on admission and is unable to state exactly what happened . denies any pains . denies hitting her head ROM done to all extremities . no limitations , Neuro check done Dr. [NAME] notified . will monitor . 12/17/2023 -- Resident is constantly getting out of bed , despite being encouraged not to get out of bed and instead use the call bell . Resident transferred to reclaimer and placed near the nursing station . 12/17/2023 --11:31AM -- Rupinder [NAME] RN -- LPN notified writer that resident has elevated HR an, d delayed response to pupillary light reflex . S/P fall Dr . [NAME] was notified with order to transfer to LIJ for Head scan . Dtr notified . 12/20/2023 -- Sumintra [NAME] RN DON -- Spoke with RN Kelsy from LIJ . resident was admitted with dx of back pain m FX of cervical spine C6-7 and 11 12/22/2023 -- Bertillia [NAME] RN -- Resident re - admitted from Northwell LIJ , with dx of s/p syncope , wound dehiscence , cervical Spine FX . with cervical collar / Medication reconciliation done by MD / Dtr informed of readmission . Fall/safety protocol in place . 12/23/2023 -- Marcena [NAME] RN -- OT/PT evaluation for increase adl function . PSYCHE CONSULTATION --01/08/2024 -- Dr. Khaldarov -- Resident alert x 1 . no psychiatric hx / dx of dementia without behavioral disturbance , Resident not capable of making medical and financial decisions . To continue current medications aricept, memantine and Gabapentine . No GDR done -- recent admission . Memory -- decreased/concentration fair MEDICAL NOTES 01/09/2024 -- Dr. Kamyar [NAME] -- MD notes mostly on resident's surgical wounds , bil . seen and bil. inguinal hernia , s/p surgery fasciotomy . wound care done daily and seen by wound team weekly . No s/sx of infection . Wound care with betadine paint Surveyor notes -- resident seen by MD , No neuro follow up and still using hard cervical collar . STAFF INTERVIEWS: 01/20/24 1:15 AM -- [NAME] Bah CNA -- 718 -- 666 -1471 -- Telephone interview with the staff was done . During the interview , she stated at the beginning of the shift , we received the endorsement from the outgoing that resident was agitated. During the rounds , she was sleeping . I saw her last at around 1:40 , then while seated in the Nurses station , we heard a bang coming from her room , room [ROOM NUMBER] , we went and found her on the floor . She has floor mat , but her body was halfway touching the floor mat and the floor . We immediately called the Nursing Supervisor and transferred her to the bed . Then we transferred her to a geri chair and moved it in front of the nursing station . Staff was asked about monitoring of residents . She stated we do frequent monitoring , some residents are on q 30 minutes / hourly . There is no documentation made unless the resident has a specific order for monitoring . No I did not document , the time I went or the other CNA making the rounds . 01/20/24 1:20 AM --- [NAME], [NAME] CNA -- T/c # same as above -- Telephone interview with the staff was done. During the interview , she stated has been working as a CNA in this facility x 37 + years . Resident is new admit , maybe 2-3 days . We were seated in the Nursing station and heard a bang from her room . We run and found the resident lying on the floor . She likes to move around her bed , cannot remember if resident has any side rails , but states , the is bed . She stated , there is no documentations done on rounding except when there is a MD order for frequency , then they will document . 01/20/24 1:30 AM --- [NAME] , [NAME] LPN -- tele. # same as above -- during the Telephone interview , the staff stated Resident likes watching TV . The CNAS made their round about 1:40 am and found resident sleeping .Between 1;45 -2 :00AM , while in the nursing station , she heard a bang and immediately went inside the room and found the resident lying on the floor . Immediately , the RN Supervisor was called in . Resident was then transferred to the her bed , assessment and VS taken , resident denies any pains and if she hit her head . Neuro check was started. She further stated , it is the Supervisor responsibility to inform and call the physician . 01/23/24 12:31 PM [NAME] Darby RNS Pt/Ot MD need ccp for psycho tropics and htn medications

Based on record review and interviews, during the Recertification/Complaint Survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a resident's Discharge Assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for 1 of the 2 residents reviewed for Resident Assessment, out of a sample of 23 residents. (Resident #2). The CMS RAI Version 3.0 Manual (Dated October 2017) was referenced. Chapter 5 titled Submission and Correction of the MDS Assessments was reviewed. The MDS completion date must be no later than 14 days after the ARD for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. The findings are: The facility policy and procedure titled MDS Completion, Submission Timeframe's and Electronic Transmission dated 01/2017 documented: Facility will conduct and submit resident assessments in accordance with current Federal and State submission timeframe's. All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Resident #2 was admitted to the facility on [DATE] and discharged [DATE]. The Facility's MDS Submission Reports printed 02/14/2022 documented that resident's Discharge Assessment MDS of Target Date 12/24/2021 was submitted 02/14/2022. The submission date is more than 14 days after the assessment. On 02/14/22 at 11:10 AM, an interview was conducted with the MDS Coordinator, (MDSC). The MDSC stated that each interdisciplinary team member completing the MDS book checks for accuracy of the sections completed, the MDS Coordinator will validate and finalize the assessments before submission. MDSC also stated that they are responsible to ensure timely submission of the assessment but could not understand why there was that delay error in the submission of the resident's Discharge MDS. On 02/16/22 at 12:25 PM, the Administrator was interviewed, stated that the MDS Coordinator is a Registered Nurse, trained, and Certified on MDS assessments, and is responsible for completion and timely submission of the MDS. The Administrator stated that MDS Coordinator is supposed to make sure that the MDS is accurately completed and submitted on time. The Administrator further stated that they never heard before now that there has been error in MDS assessment and was not also aware of the late submission of the MDS. 415.11

Based on observation, record review and staff interviews during the recertification survey , the facility did not ensure that each resident's drug regimen must be free from unnecessary drugs when used in the presence of adverse consequences which indicate the dose should be reduced or discontinued. This was evident in 1 of 1 resident reviewed for change in condition in a sample of 16. (Resident #39) The finding is : The facility policy titled, Laboratory (LAB) and Diagnostic Test Results with effective date of 1/2016 documents, Assessment and Recognition: The physician will identify and order diagnostic test and lab testing based on diagnostic and monitoring needs. The staff will process test requisition and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. It further documents on Identifying Situations that Warrant Immediate Notification step #4-- High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. Resident # 39 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified Resident #39 with a score of 14 on the Brief Interview for Mental Status (BIMS). Resident is able to make needs known. On Activities of Daily Living (ADL) resident needs extensive assist of one person including bed transfer, locomotion, transfer and personal hygiene. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) dated 08/23/2021 and last updated on 12/23/2021 titled [CONDITION(S)] states resident at risk for injury secondary to [CONDITION(S)]. The goal was resident will be free from [CONDITION(S)] related injury. Interventions and Approach listed the following: administer medications as per Medical Doctor (MD) order, encourage resident to report any aura headaches, blurred vision or ear pain. Follow up with Neurologist as needed ,keep bed in lowest position, maintain a safe environment, monitor labs as per MD order, observe for any twitching, staring into space and jerking movements. On 11/02/2021 a pharmacy review was done with the recommendation to obtain a [MEDICATION(S)] blood level. This was conveyed to the Nurse Practitioner and Director of Nursing. A [MEDICATION(S)] level was odered. The result was called in to the facility on [DATE] with a result of 37.8 microgram per milliliter (ug/ml ) almost double the normal level of 10-20 ug/ml. Resident # 39 last [MEDICATION(S)] blood level on record was done on 05/06/2021 with a reading of 9.6 ug/ml. The nurses notes dated 11/05/2021 documented lab results received and sent to Primary Medical Doctor (PMD). Will continue to monitor for any changes. Review of the 24 hours Nursing Supervisor Reports documented on 11/05/2021, that lab results were received and sent to the PMD. Further review of the medical record from 11/05/2021 to 12/02 /2021 reveals no documented evidence that the abnormal [MEDICATION(S)] level was addressed by the PMD nor was there any follow up made by the licensed nurses. [MEDICATION(S)] medications was given continuously until 12/03/2021. The Physician notes dated 12/05/2021, documented, [MEDICATION(S)] on hold following a repeat blood test to be done on 12/06/2021. Case was discussed with resident and daughter. Resident has been on long standing [MEDICATION(S)] with no [CONDITION(S)] activities for the last 5 years. Plan of treatment is [MEDICATION(S)] 750 mg BID, will do Neurology follow up, taper [MEDICATION(S)] and discontinue. Review of the repeat [MEDICATION(S)] blood level of 12/06/2021 documented the result as 40 ug/ml. Resident # 39 was monitored and evaluated, with no [CONDITION(S)] activity, no signs and symptoms of lethargy. Electrocardiogram (EKG) done with no arrhythmia. [MEDICATION(S)] was discontinued on 12/05/2021 and [MEDICATION(S)] was started . On 02/15/2022 at 4;45 PM during a telephone interview with the Primary Medical Doctor who stated, The honest truth is that I was not informed about the elevated [MEDICATION(S)] level that was done in November. I was informed about that in December and that is when I stopped the [MEDICATION(S)] and ordered another blood level. The blood level came back very high at 40ug/ml. I spoke with the resident and the daughter and explained my plan of treatment which included the referral to a Neurologist and Cardiologist. The resident did not have any [CONDITION(S)] episodes in the last 5 years. On 02/15/2022 at 5:00PM the Registered Nursing Supervsor (RNS) 3-11 shift was interviwed and stated, When I come to work, my first priority is to look at the lab results and distribute them to the unit. If there is any critical value that the labs called in or the results comes in, I will immediately call the PMD. If I don't get hold of the doctor I will call the Medical Director. I don't remember that I received the result of the [MEDICATION(S)] blood level being high, for I would document that. We have a 24 hour report book. On 02/16/2022 at 2:00PM , the Licensed Practical Nurse LPN #1 was interviewed and stated, I remember that the physician was called, however, it was not clear what laboratory results were reported to the PMD. 415.12(I)(I)

Based on observation and interviews conducted during the recertification and abbreviated survey, the facility did not ensure that drugs and biological's were stored under proper temperature. Specifically an eye drop that was supposed to be kept refrigerated before opening was found sitting in the cart top drawer unopened. This was evident during the facility Medication Storage Task on 1 of 3 units. (Unit A-first floor) The findings are The facility policy Storage of medication effective in January 2017 documented medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications must be stored and labeled accordingly. On 2/11/2022 at 11:21 AM, during the medication storage task, an unopened bottle of [MEDICATION(S)] 0.02%, eye drop was observed in a bag labeled refrigerate. The medication was sitting in the top drawer of the medication cart on unit A, the first floor. A label affixed to the [MEDICATION(S)] bottle documented the medication has been dispensed from the pharmacy on 1/31/2022 The Drug insert documented [MEDICATION(S)], the eye drop, is supposed to be stored in the refrigerator at 36-46 degrees F until opened. After opening, the product may be kept at 36-77F degrees for up to 6 weeks. On 2/15/22 at 10:19 AM, the Director of Nursing (DON) was interviewed and stated that the nurse who receives the medication is supposed to look at the medication information. Everything should be checked by the nurse. If it is done the wrong way, it is not safe for the resident. If the label says refrigerate, it should be refrigerated. On 2/15/ at 10:43AM, the Administrator was interviewed and stated that I understand, this is a problem. For the safety of the residents all nurses should be inserviced. On 2/15/2022 at 11:03AM, LPN #4 was interviewed and stated that medications should be distributed to each floor by the nurses then stored accordingly. On 2/15/22 at 11:13 AM RN #2 was interviewed and stated, I usually receive medications from the pharmacy. Eye drops are dated on the date they are opened. Whatever is supposed to be refrigerated has to be refrigerated. That's the norm. If the unopened medication was supposed to be refrigerated and was found in the cart by the surveyor, that's not safe for the resident. 415.18(e)(1-4)

Based on observation, record review and interview conducted during the Recertification/Complaint Survey, the facility did not ensure that a Significant Change (MDS) Minimum Data Set assessment was completed for a resident within 14 days of determining the status change was significant. Specifically, a resident who had a change in Activity of Daily Living (ADL), in more than 2 care areas did not have a significant change assessment initiated within 14 days. This was evident for 1 of 1 resident reviewed for ADL decline, out of a sample of 23 residents. (Resident #14). The findings are: The Centers for Medicare and Medicaid Services (CMS) Long Term Care Resident Assessment Instrument (RAI) Manual 3.0 documented: A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. The RAI Manual documented a significant change assessment should be completed when there is a decline in two or more areas including but not limited to: - Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual's functioning. Resident #14 was admitted to the facility 01/14/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. MDS documented that resident is extensive assistance of 2 staff for bed mobility and transfer, extensive assistance of 1 staff for eating, toilet use, and personal hygiene. The Annual Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented the resident is total dependence of 2 staff for bed mobility, transfer, toilet use, and total dependence of 1 staff for eating and personal hygiene. The Comprehensive Care Plan (CCP) for Activities of Daily Living-ADL Functional / Rehabilitation Potential dated 01/14/2021, last revised 11/24/2021 documented that Resident requires assist with activities of daily living R/T impaired functional mobility secondary to: Diagnose of [CONDITION(S)], increase fatigue, [CONDITION(S)], generalized weakness chronic left humerus fracture. Goals included: Resident status will not decline x 90 days. Interventions included: - Resident likes to choose his/her clothing and care for his/her personal belongings. Allow to choose bedtime. Initiate PROM of B UE and LE 3 sets 10 reps BID except Left shoulder during ADLs care daily. Provided with Left arm sling all times except during care for safe positioning of shoulder during transfers and positioning. (11/25/21). Resident requires total assist for bed mobility with 2 staff to pull resident up in bed; Total assist x1 for eating; Total assist x1 for hygiene; Bathing with total assist x 2 on Mondays and Thursdays; Total assist via Hoyer lift for transfer; Total assist x 2 staff for toilet use. Encourage resident to participate in ADLS to fullest extent as tolerable. The CCP for ADL Evaluation notes dated 12/02/2021 documented annual POC review no significant change from last assessment. Will continue with CCP daily x 90 days physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Treatment Order: Physical Therapy(PT0: Minimum 3-6x/week x up to 6 weeks; Therapeutic Exercise/Therapeutic Activity/Neuromuscular Re-education/Gait and Stair Training/Hot or Cold Pack/E-Stim/Ultrasound/Other. Treatment Order: Skilled Occupational Therapy (OT): minimum 3x-6x/week x 6 weeks; Therapeutic Exercise/Therapeutic Activity/ADL Training/Wheelchair Management/Neuromuscular Re-education/Other. There was no documented evidence that a significant change MDS assessment was completed within 14 days after a determination was made that the resident had decline in more than two (2) ADLs status. On 02/14/22 at 08:53 AM, an interview was conducted with the Certified Nursing Assistant CNA#1 who stated that resident is now being spoon-fed and has been consuming over 50% of food. The resident was able to feed self with supervision and encouragement to complete meal but is now totally dependent of staff to be fed. The resident used to be extensive assistance of 2 staff to transfer. Hoyer lift with 2 staff are now required to transfer the resident. On 02/14/22 at 02:26 PM, an interview was conducted with the Licensed Practical Nurse Supervisor (LPN#1) who stated that resident used to be able to feed self with supervision, previously required extensive assistance of staff for bed mobility, transfer and toileting, but is now totally dependent of staff for bed mobility, transfer, eating and toileting. LPN #1stated I cannot answer why there is no significant change in MDS, as the assessments for MDS are done by the MDS Coordinator. On 02/15/22 at 08:13 AM, an interview was conducted with the Rehab Director (RD). RD stated that when resident was assessed on 11/15/2021 on readmission from the hospital, the transfer status was total with Hoyer lift, bed mobility: extensive of 1, eating: total, toilet use is total. RD stated that it is the MDS Coordinator that was expected to schedule for the significant change assessmen. The role of rehab is just to document what the findings are. On 02/15/22 at 08:46 AM, MDS Coordinator (MDSC) was interviewed, stated that the significant change MDS is done whenever there is permanent decline or improvement in resident's 2 or more ADLs, any new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDSC stated that the significant change in the resident's ADL documented in MDS of 11/20/2021 was not considered permanent because there was justification to the decline, the resident was transferred to the hospital, and was also noted with poor by mouth(po) intake during that period. On 02/15/22 at 10:57 AM, an interview was conducted with the Director of Nursing who stated, if there are 2 or more declines or improvements in the resident's ADL, a significant change assessment needs to be done within 7 to 14 days of the change in status. DON stated that they just resumed work at the facility and is not aware that there were no significant Change assessments done for the resident. On 02/16/22 at 12:25 PM, the Administrator was interviewed, stated that the MDS Coordinator is a Registered Nurse, trained, and Certified on MDS assessments, and is responsible for completion and timely submission of the MDS. The Administrator stated that MDS Coordinator is supposed to make sure that the MDS is accurately completed and submitted on time. The Administrator further stated that Significant change assessment MDS needs to be done when there are decline or improvement in 2 or more resident's activities of daily living. The Administrator further stated that they never heard before now that there has been error in MDS assessment and was not aware of the late submissions of the MDS. 415.11(a)(3)(ii)

Based on the facility's surveillance camera footage, staff interviews, and record review conducted during an abbreviated survey (NY 426), the facility did not ensure that a resident received adequate supervision to minimize the risk of elopement. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 activated an alarmed door on 10/09/2019 at 8:00PM and was able to elope from the facility undetected by staff. Resident #1 was missing for over three hours before the facility became aware. Resident #1 was readmitted to the facility from the hospital on [DATE]. The findings include: The facility policy and procedure on Alarms / Total Kare Alarm System with a revision date of 04/2019 documented, anytime an alarm sounds, the staff that hear the alarm must respond to the alarm immediately to investigate. A head count of all resident is to be performed if necessary. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 09/04/2019 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 9/15 associated with moderately impaired cognition. Review of the nursing note dated 10/10/2019 at 6:08AM documented that the camera confirmed that Resident #1 eloped at 8:00 PM. Review of a late entry (for 10/09/2019) nurse's note dated 10/12/2019 at 12:43PM, documented that a nursing staff reported that Resident #1 could not be found on the unit. Review of the facility's investigation summary report dated 10/10/2019, revealed that on 10/09/2019 at approximately 8:00 PM, Registered Nurse Supervisor #1 (RNS #1) on duty responded to the basement/parking lot door alarm. The RNS checked the parking lot but did not see anyone and she reset the alarm. Licensed Practical Nurse #1 (LPN #1) conducted a physical count of each resident and reported that all the residents were accounted for. The RNS asked each charge nurses on the units to do a physical count of each resident. All the nurses reported that their residents were accounted for. Certified Nursing Assistant #1 (CNA #1) made rounds at approximately 11:05PM and reported that Resident #1 was not on the unit. The facility staff conducted a search that was unsuccessful and 911 was called. At 9:30AM, Someone from a State Administration Office called the facility and reported that Resident #1 was in their office. Resident #1 was taken to the emergency room (ER) and was admitted to the facility on [DATE]. The facility concluded that abuse, neglect or mistreatment did not occur. Surveyor #1 together with the Administrator and the Director of Nursing Service (DNS) reviewed the facility surveillance camera footage on 12/02/2019 at 12:13PM. On 10/09/2019 at 7:55PM, camera #1 showed Resident #1 exited from an elevator into the basement. Camera #1 showed Resident #1 walking the basement hallway that leads to a stairwell. At 7:56 PM, Camera #2 showed Resident #2 entered a stairwell and walked up the stairs to an exit door (in the basement). At 7:56PM, Camera #3 showed Resident #1 pushed the exit door open (door opens to parking lot) and walked towards the street. Resident #1 made a right turn and was out of camera view. At 8:03 PM, camera #2 showed RNS #1 walking down a stairwell to the parking lot exit door in the basement. The RNS tugged on the exit door; looked through a small glass window (on the door) then reset the alarm located next to the door. The camera did not show RNS #1 open the door and checked the parking lot. RNS #1 was interviewed on 12/02/2019 at 2:08 PM and stated that on 10/09/2019, a few minutes before 8:00 PM, the alarm on the back door that leads to the parking lot was activated. She affirms that she went to check the alarm and that she looked through the glass window on the door and did not see anyone. RNS #1 stated that she did not open the alarming door and did not search the parking lot. She stated that the facility had no protocol to open the alarming door. She stated that after she is checked the back-door alarm, she went to the units and instructed the nurses to perform a headcount of all the residents. She contends that the nurses reported that all the residents were accounted for. Upon inquiry, RNS #1 stated that Resident #1 was not at risk for elopement and that resident checks are usually conducted at the beginning of the shift. Staff also conducts undocumented hourly rounds. LPN #2 was interviewed on 12/02/2019 at 2:53 PM and stated that she heard the door alarm at approximately 8:00 PM. She checked the stairwells on the unit and did not see anyone. LPN #2 contends that she checked all the rooms to make sure that the residents were accounted for. Resident #1's curtain was drawn, and she assumed that the resident was sleeping in bed. Certified Nursing Assistant #2 (CNA #2) was interviewed on 12/02/2019 at 3:07 PM and stated that she heard the alarm sound on 10/09/2019 at 8:00 PM and the staff went room to room to do a headcount. She stated that Resident #1's curtain was closed and that she assumed the resident was asleep. She affirmed that she should have pulled the curtain to ensure Resident #1 was in his bed. CNA #2 stated that she last saw Resident #1 at about 7:30 PM on 10/09/2019. She also stated that Resident #1 was not an elopement risk and that the resident was not on monitoring. CNA #1 was interviewed on 12/09/2019 at 3:45 PM and stated that she worked on the night shift of 10/09/2019. She made rounds at 11:00 PM and Resident #1 could not be found. CNA #1 stated that she reported the situation to the unit nurse (LPN #1). LPN #1 was interviewed on 02/11/2020 at 10:46 AM and stated that CNA #1 reported that Resident #1 was not in his bed. LPN #1 checked the chart to see if Resident #1 was out on pass. LPN #1 stated that Resident #1 did not go out on pass, so they started searching the entire unit. They were unable to locate Resident #1 and she notified RNS #2. The DNS was interviewed on 02/04/2020 at 11:44 AM and stated that on 10/09/2019, it was established that Resident #1 had eloped. The resident left the facility without telling anyone. The facility investigated the incident and found that the evening shift RNS #1 responded to the basement/parking lot door alarm but did not see anyone. The RNS instructed the nurses on the units to do a headcount and all the staff reported that all the residents were accounted for. The DNS affirmed that the staff did not performed a proper headcount. The staff did not pull Resident #1's curtain to ensure that Resident #1 was actually in bed. Upon inquiry, the DNS stated that Resident #1 was not at risk for elopement and that he was not on supervision. Upon inquiry, the DNS stated that when the alarm is activated, staff must check the stairwells and if they do not see anyone, a headcount must be done. The Administrator was interviewed on 02/04/2020 at 12:05 PM and stated that the DNS informed him on 10/09/2019 at 11:00PM, that Resident #1 was missing. The Administrator stated that after the parking lot door alarm was activated, staff did not conduct a thorough headcount. A follow up interview was conducted with the Administrator on 02/11/2020 at 11:30 AM. He stated that the receptionist leaves at 8:00 PM and they do not have a security personnel that mans the desk. The front door is locked after 8:00 PM and the only way to get in and out of the building is to enter a code on the keypad. The lobby door has an alarm. Visitors ring the bell and a staff member comes down and opens the door. The Administrator stated that a camera is located at the Receptionist desk and one is at the nursing station on the first floor. Only the Administrator and the DNS has access to review the camera footage. 415.12(h)(2)

Based on observation and staff interview conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced his dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 18 sampled residents. (Resident #73) The finding is: The facility policy and procedure titled Foley Care revised (MONTH) 2019, documented ensure bag and tubing remain covered at all times. Resident # 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with severe cognitive impairment, and is sometimes understood/understands. The MDS further documented the resident required extensive to total assist of 1 to 2 persons for personal hygiene, toileting, personal hygiene, and bathing. The MDS also documented the presence of an indwelling catheter. On 06/04/19 at 10:04 AM, 06/05/2019 at 08:24 AM and 10:31 AM, the resident was observed lying in the bed closest to the door of the room. The resident's Foley catheter drainage bag and catheter tubing were on the side of the bed facing the door (right side). Yellow urine was observed draining into the uncovered bag, and the tubing and catheter bag were visible from the hallway. On 06/05/19 at 10:34 AM, Licensed Practical Nurse (LPN) #1 was interviewed. LPN #1 stated that no one should see the resident's Foley bag from the hall way because of resident dignity. The LPN also stated one should not know the resident has a Foley bag and when the resident is out of bed. The leg bag should be under the resident's pants. LPN #1 also stated since working at this facility, she had not seen a bag cover. The Foley bag should be placed on the opposite side of the bed away from the resident door so people cannot see the bag. On 06/07/19 at 11:24 AM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA #1 stated the Foley bag should be covered and not visible from hallway. CNA #1 also stated that there are no bags available so pillow cases are used instead. CNA #1 further stated that the Foley bag was not covered today. On 06/05/19 06:15 PM, the Director of Nursing (DON) was interviewed. The DON stated the Foley bag should be covered at all times. The DON also stated that when the resident is in bed and people are walking in the hallway the Foley bag should not be visible. The DON further stated the Foley bag should be on the opposite side of the bed, away from the hall way in a protective covering bag. 415.3 (c)(1)(i)

Based on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure that residents were provided with a bed of proper size and height for the safety and convenience of the resident. Specifically, the facility did not accommodate residents with an appropriately sized bed. This was evident for 2 of 2 residents reviewed during the Environment facility task. (Residents #7 & #5). The findings are: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact and independent with most activities of daily living. During an interview on 6/4/19 at 12:30 PM, Resident # 7 stated that his bed is too short. Upon observation at that time it was observed that the resident had a foot rest at the end of his bed. Resident stated he had requested the foot rest so that his heel would not rest directly on the footboard. Resident was sitting on the bed at the time of the interview. The medical record documented a weight of 320 lbs and height of 76 inches for Resident #7. The resident had been provided a bed with a regular mattress that measured 78 inches in length and 34 inches in width. Review of the Quarterly Comprehensive Care Plan dated 3/7/19 revealed no reference to resident in need of a larger bed. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 6/4/19 at 11:04 AM, the resident reported that his bed is very uncomfortable and he has not had a good night's sleep since he has been in the facility. The resident stated that he thought the bed was not long enough for him as he is a tall man. During observation of the resident in bed on 6/4/19 at 1:30 PM and 6/5/19 at 1:25 PM the resident was observed lying in bed on his left side, with knees pulled to his chest. Resident stated that this is the position he usually sleeps in as the bed does not fit him. The medical record documented a weight of 252 lbs and a height of 78 inches. The resident had been provided a bed with an air mattress that measured 78 inches in length and 34 inches in width. An interview was conducted with Certified Nursing Assistant (CNA) #2 on 06/06/19 at 02:07 PM. CNA #2 stated when Resident #5 first came in to the facility, he was on an air mattress as he had a wound on his leg, and it was taken away. CNA#2 also stated that the resident was re-hospitalized and was placed on an air mattress again, however the mattress was too short, and an extension was reordered. CNA#2 could not recall when a longer mattress was requested but stated that the resident does need a longer bed. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 06/06/19 at 02:34 PM. LPN #2 stated that she checks the beds and CNA's would also report if the resident is not comfortable. LPN #2 also stated that she did not notice that the bed was too short for the resident. LPN#2 further stated that the resident is usually not in bed on my shift, so I did not really observe. An interview was conducted with the Assistant Director of Nursing (ADON) on 06/06/19 at 02:34 PM. The ADON stated according to height and weight of resident on the PRI, she checks for appropriate bed and the need for an air mattress. If the resident has pressure ulcers, an air mattress would be ordered. A resident who is 6 feet tall will get an appropriate bed from the maintenance department. If a resident is complaining about the bed, we will assess and change bed as appropriate. Unit staff should be assessing for comfort of beds. The ADON also stated that she did not recall ever asking resident about beds and whether bed is comfortable and has not observed resident lying in bed to be able to tell that bed was not long enough. On 6/6/19 at 2:59 PM, an interview was conducted with the Director of Maintenance (DOM). The DOM stated that he would ask the ADON what kind of mattress the resident needs. When a resident is tall or heavy Nursing will let him know the type of bed or mattress the resident will need. If a special mattress is required, he will not know unless informed by nursing. He checks the beds routinely and housekeeping will also inform him if there are any issues with the bed. The DOM also stated he does rounds to check the room to see the quality of the mattress, if the bed is working, and headboards are intact. The DOM further stated that he had not been informed by nursing staff that Residents #5 and #7 needed a larger mattress. 415.29

Based on record review and interviews during the recertification survey, the facility failed to ensure the accuracy of a resident's discharge Minimum Data Set (MDS) assessment. Specifically, the discharge MDS coded the resident as hospitalized when the resident was discharged to the community. This was evident for 1 of 3 closed records reviewed. (Resident #77)) The finding is: Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] documented that resident is cognitively intact. Review of Social Service progress note dated 3/15/19 documented the resident's scheduled discharge was for 3/15/19 to home. The nursing staff contacted the pharmacy and medications were ready for pick up. The resident left the facility via private car, accompanied by son and daughter in law with the resident's belongings. The resident was advised to follow up with her Primary MD within 7 days of discharge. Nursing progress note dated 3/14/19 documented that the patient was seen in the facility by the team and that she is going home on Friday. Review of Care Plan Return to Community Referral initiated 2/22/19 and revised 3/15/19 documented that resident is scheduled for discharge home; discharge teaching regarding medications; resident discharge papers, discharge summary, copy of medications and labs given to resident, and homecare referral was made. A post discharge follow-up is scheduled within 7 days. The Discharge MDS dated [DATE] documented in Section A planned discharge. discharge date A 2000 documented discharge date as 3/15/19, and A 2100 documented discharge status as acute hospital. On 6/7/19 at 1:01 PM, a telephone interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she is at the facility two days a week and the two other MDS Assessors are also employed on a part-time basis. The MDS Coordinator also stated she checks the new admission list and prepares the MDS schedule. She also checks the MDS assessment for completion and does the submission. The MDS Coordinator further stated Resident #77 was not discharged to hospital, was discharged home, and the MDS was coded incorrectly. The MDS Coordinator stated that she does not review the MDS for accuracy as the individual assessor is expected to ensure that each section of the MDS is accurate. The MDS assessor who completed the Discharge MDS was not onsite on 6/7/19 and was not available for interview. 415.11 (b)

Based on observations, records review and staff interviews conducted during the recertification survey it was determined that the facility did not provide Housekeeping and maintenance services necessary to maintain a sanitary, orderly interior. In addition the facility did not provide residents with a clean and homelike environment. Specifically, windows from 1st floor to 3rd floor units were observed with dirt , debris and birds dropping on exterior. This was evident for 3 resident care units Units 1 to 3. The findings are: During the initial tour of the facility on 08/20/2018 at 9:45 AM the following observations were made on the on the third floor: 1) The windows in the dinning room /activity room were observed to be dirty. The exterior window panes, which were visible from the interior windows were thick with film of dust, dirt, debris of fallen leaves and bird droppings. 2) Observations were also made of the dining/activity rooms on the first and second floor. The windows were observed to be in the same condition as those on the 3rd floor. On 08/28/2018 at 12:15 PM the State Agency requested an interview with the Maintenance Director. The facility administrator stated, He was fired yesterday. The Administrator also stated that there are no records to reflect when the last time the windows were cleaned. He was unable to state when the last time he put in a work order for the windows to be cleaned. 415.29(j)(I)

Based on observations, records review and staff interviews conducted the recertification survey it was determined that the facility did not ensure that physicians review the resident's total program of care, including medications and treatments at each visits. Specifically, 1) The attending physician for Resident #28 did not review the total plan of care to ensure that an order for [REDACTED]. This was evidenced on 2 of 33 sampled residents reviewed for care. 2) The attending physician for Resident #61 did not document reasons why there were no adjustments to treatment plan after the nursing staff documented that blood sugars were elevated and lab results revealed hemoglobin A1C levels out of accepted parameters. The findings are: 1) Resident #28 is [AGE] years old with [DIAGNOSES REDACTED]. On 08/23/18 at 12:05 PM, Resident#28 was observed in the dining room, seated on his wheelchair, both wheelchair arms were covered with a white moleskin protector, his head tilted backwards, and eyes closed with mouth wide open. On 08/23/18 at 12:26 PM, Resident # 28 remained sleeping, seated in his wheelchair, in the dining room. Resident was being awaken by Certified Nursing Assistant (CNA) #1. Since Resident was difficult to arouse, LPN#1 and CNA#1 wheeled him out of the dining room. Resident's wheelchair had no foot or leg rest, his feet were touching and dragging on the floor. Licensed Practical Nurse(LPN) #1 pushed the sleeping Resident out of the dining room while CNA#1 lifted his legs, holding his pants by the knees to lift his legs and feet while wheeling him from the dining room through the hallway to his room which is passed the second floor Nursing Station and the elevator. On 08/24/18 at 9:32 AM, Resident was lying on his bed, dressed in regular clothes. His eyes were opened but did not verbally respond to greeting. There was a blue floor mat, one on each side of the bed. His wheelchair without a foot/leg rest was positioned at the foot of the bed. On 08/24/18 at 10:45 AM, Resident remained in bed, lying down. Resident was alert, trying to pull the right leg of his sweatpants up. On 08/27/18 at 09:45 AM Resident # 28 was still in bed, with his legs up and knees bent. His wheelchair was not in the bedroom and was in the dining room. The wheelchair without the leg/foot rest had the Resident's name on it. On 08/27/18 at 02:44 PM Resident # 28 was in bed, sleeping with 2 blue wedges on both sides of the bed. On 08/28/18 at 10:32 AM the PT and PTA (Physical Therapist Assistant) did the FAP with the Resident on the resident's unit. Resident was able to ambulate more than 70 ft using a RW. PT was verbally encouraging Resident to take steps while PTA was behind the Resident using the Resident's Wheelchair. PT also stated that a leg rest will be provided for Resident wheelchair. The General Order Record for FAP 70 feet with RW with extensive assist OD as tolerated was initiated by PT who created the order on the Electronic Medical Record(EMR) dated 6/22/18 at 10:07 AM. The EMR showed that an RN verified the order dated of 6/22/18 at 01:40 PM. The Physician order [REDACTED]. The order has a start date of 6/22/18 with an open-ended end date. A previous physician's orders [REDACTED]. There were no MD signatures on the Physician order [REDACTED]. The Resident Progress Notes dated 6/22/18 at 10:04 AM documented PT/Rehabilitation's recommendations: to discontinue Skilled PT and OT services secondary to reaching maximum benefit; Out-of-bed(OOB) - Regular Chair/toilet; transfers with extensive assist x1; FAP 70 feet with Extensive assist x1 one time/day as tolerated. PT further documented that Nursing was made aware, will follow up as needed, quarterly or PRN; MD order in place. Nursing Notes on 6/22/18 at 10:52 pm titled Behavioral Notes added that PT/OT in progress to strengthen and improve gait. No documentation that FAP was put in place from 6/22/2018 to 8/27/18. The CNA's Accountability Record or the Point of Care ADL Category Report walk in corridor was denoted with a number 8(meaning the activity did not occur) and WH was entered for a wheelchair device for locomotion on and off the unit. There were no documented evidence that FAP 70 feet x1 daily was implemented and re-assessments/re-evaluations, and reviews were done by the MD, Nursing and Rehabilitation/Nursing not until 8/29/18. The Rehabilitation Progress on 8/28/18 reported that Resident was seen for screen on Unit as per Nursing Referral with a MD's order. On 08/27/18 at 09:53 AM, CNA#1 was interviewed and recapitulated the incident the previous week when Resident was sleeping on his wheelchair, wheeled out of the dining with LPN#1 pushing the sleeping Resident in his wheelchair while CNA#1 held the Resident's pants by his knees to lift his legs. CNA#1 stated that Resident doesn't walk, only uses a wheelchair. CNA#1 had to hold and pull the pants by the knees because the feet were dragging on the floor. On 08/27/18 at 10:21 AM, The Rehabilitation Progress Notes dated 6/5/18 and 6/22/18 were reviewed with PT. PT stated that Resident was on FAP once a day which started on 6/22/18. PT stated it doesn't matter what shift this FAP occurs. PT stated that there was no order for a leg/foot rest for the wheelchair as it is not safe for the Resident who constantly gets up from the wheelchair. On 08/27/18 at 02:45 PM, CNA#1 stated that CNA#1 never saw him walking, always in his wheelchair. On 08/27/18 at 03:02 PM LPN#1 stated that FAP is done with PT (Resident will walk with 2 Staff). Resident is not on FAP on the unit. Resident doesn't go to PT anymore. FAP is ambulation from bathroom to the room and to dining when Resident is taken out of bed. Resident is not on FAP. There was not documented evidence that FAP was performed with the resident by PT in accordance with the physician's orders [REDACTED]. On 08/27/18 at 03:15 PM CNA#2 who worked on the 3-11pm shift was interviewed. CNA#2 stated that Resident ambulates via wheelchair and confirmed that the wheelchair does not have any leg/foot rest. Resident never ambulate using a rolling walker. Resident does not have a rolling walker. On 08/27/18 at 03:26 PM, LPN#2 who works in the Resident unit from 3pm-11pm was interviewed. LPN#2 stated that Resident cannot barely walk, Resident ambulates using a wheelchair. Resident has no rolling walker. Resident's wheelchair has no leg/foot rest. LPN #2 further stated that it's the PT people who knows more of the ambulation. LPN#2 stated that Resident has no FAP on the 3pm to 11pm shift. On 08/27/18 at 03:32 PM, RN#2 was interviewed. RN#2 stated that RN#2 is not familiar with Resident's ambulation (all she knows is that Resident has a very unsteady gait and needs to be monitored). RN #2 stated FAP and CNA Accountability cannot be connected since FAP never occurred. On 08/28/18 at 09:11AM, PT was interviewed and stated that CNAs are responsible for the FAP task. PT stated that there was an MD order on the computer. A Resident will be discharged from Rehabilitation with PT recommendations. Referrals for re-evaluation will be made to him by the Nurses. There were no referrals made regarding the Resident. On 08/28/18 at 10:32 AM, PT and PTA (Physical Therapist Assistant) did the FAP with the Resident on the Unit. Resident was able to ambulate using a RW. PT verbally encouraged Resident to take steps while PTA was behind the res with the resident's wheelchair. PT also stated that a leg rest will be provided for Res' wheelchair. PT stated that no recommendation was given by Nursing to re-evaluate the Resident for FAP. On 08/28/18 at 01:10 PM, MD was interviewed over the phone.The MD was unable to respond immediately to the question regarding how the resident was assessed for needing FAP. The MD stated that MD assesses the Resident by trying to stand Resident up while Resident is in bed. Resident has been unsteady and weak. MD further stated that I know Resident needs physical therapy to avoid his joints from freezing and to avoid stiffness. I didn't see Resident physically doing the FAP. I don't recall how the recommendation for FAP was sent to me but it's from Rehabilitation to Nursing. 415.15(b)(2)(iii) The facility policy and protocols on Care of the residents with diabetes mellitus states: Glucose Monitoring: The physician will order the frequency of glucose monitoring. The policy and protocols does not document further protocols for the physician to monitor and review the care and treatment rendered for residents diagnosed with [REDACTED]. 2) Resident #61 is [AGE] years old and admitted to the facility with [DIAGNOSES REDACTED]. On 08/24/2018 at 11:58 AM an LPN #7 (Licensed Practical Nurse) was observed doing a FS ( fingerstick ) 273. Insulin coverage was administered subcutaneous to right forearm. The Minimum Data Set ( MDS ) assessment dated [DATE] identified the resident as cognitively impaired. Resident requires set up only for eating, but eats independently. The CCP (comprehensive care plan) was revised on 07/11 (YEAR). The CCP identified the resident with Diabetes Mellitus. The established goal was that resident will be free from signs and symptoms of hypo /hyperglycemi. The interventions/Approache implemented were: observe for signas and symptoms of hypo / [MEDICAL CONDITION], monitor FS as ordered by physician, labs as per physician, diet as per physician and observe for meal completion. The CCP also identified Nutritional status as a potential problem. The resident's plan was a no concentrated sweets, no added salt, regular consistency diet with thin liquids. The CCP noted that resident was observed consuming 76-100% of meals served. The CCP identified that the resident is at risk for dehydration due to medications and fluid intake. The established goals were: resident will adhere to the diet, be free from signs and symptoms of dehydration will have acceptable labs, free from hypo/[MEDICAL CONDITION] and skin will remain intact . The interventions/approaches implemented were: provide diet as prescribed by the physician, conduct meal rounds, monitor intake and weight and laboratories result. The physician's orders [REDACTED]. Blood Glucose monitoring AC (before meals ) and HS with sliding scale of Humalog as follows: 151-200 -4u 201-250- 8u 251-300-12u 301-350-16u 351-400-20u >(greater ) 400-24u >400 and < (lesser) 70 - call MD(medical doctor) For bedtime : 251-300-2u 301-350-4u 351-400-6u >400 8u and call MD A Review of the blood glucose monitoring documentation from 07/29/2018 to 08/24/2018 revealed that the resident had multiple episodes of blood sugar levels being elevated. This was documented in the EMR (electronic medical record) under the Vital Signs field. The results were: 6:00 AM 11:00 AM 4:30 PM HS 08/24/2018 239 216 08/23/2018 216 245 375 201 milligram per dilution ( mg/dl ) 08/22/2018 146 271 315 169 08/21/2018 109 273 290 155 08/20/2018 93 166 243 180/165 08/19/2018 230 329- 1PM 175 183 08/18/2018 112 287 219 215 08/17/2018 200 240 -1:00 PM 260/395 no record 08/16/2018 102 330 249 /185 no record 08/15/2018 123 195 305 191 08/14/2018 186 303 134 280 08/13/2018 123 321 140 250 08/12/2018 113 159 153 no record 08/11/2018 270 171 396 no record 08/10/2018 140 212 229 180 08/09/2018 78 227 247 187 08/08/2018 239 298 325 229 08/07/2018 89 100 263 212 08/06/2018 118 387 198 86 08/05/2018 101 206 295 105 08/04/2018 192 321 98 300 08/03/2018 111 240 173 no record 08/02/2018 150 225 207 185 08/01/2018 147 247 153 165 07/31/2018 119 200 342 142 07/30/2018 88 123 319 211 07/29/2018 89 250 189 no record The record revealed that in a period of 4 weeks, despite of the resident receiving the Humalog sliding scale coverage, the blood sugar levels remained elevated. This was further substantiated with elevated Glycosylated hemoglobin (HGA1C) levels. The HGA1C measures blood glucose levels over a period of time, usually 3 month intervals. The laboratory reports of the (HGBA1C) documented the following results: 04/28/2017 -8.8 /glucose-292; 03/27/2018-9.3; 08/24.2018-9.9 /glucose 100 /bun-28. The normal acceptable HGBA1C is 4.4 to 5.6 %. Further review of the physician's orders [REDACTED]. There was no mention of a medication adjustment . The Nurses notes from 07/20/2018 to 8/27/18 did not reveal evidence that the physician had been informed of the elevated blood sugar levels or HGBA1C levels. On 08/27/2018 at 3:00 PM the Dietician (Staff #4) was interviewed. The Dietician stated that the resident's diet is appropriate and meeting their caloric needs. The Dietician confirmed that the resident is currently on no concentrated sugar, no added salt and regular consistency with thin liquid diet. She further stated that on 05/24/2018 she wrote a recommendation to consider adjusting insulin for better glucose coverage. The Assistance Director of Nursing (RN#1) was interviewed on 08/28/2018 at 11:35 AM. RN #1 stated that the facility policy on residents with diabetes is to do a hemoglobin A1c at least every 3 months. She did not have an answer as to why given that the HGBA1C on 03/27/2018 was 9.3 % there was not another test ordered until 8/24/18. She also could not provide a reason as to why on 8/24/18 the HGBA1C levels were again 9.9% the nurses did not notify the physician about the results. The resident's attending physician was not available for interview during the recertification survey. The covering physician (Staff #1) was interviewed on 08/28/2018. After reviewing the chart he stated that his review after reviewing the blood sugar levels and the lab results he agreed that there was a pattern of elevated blood sugars. The physician further stated that he reviewed the results of 8/28/18. He stated, This morning it is 88 mg/dl and at lunch time is 257 mg/dl , which worries me the most. I will speak to the attending MD to look and evaluate the FS . 415.15 (B)(20(iii)

Based on observations, records review, and interviews during the re-certification survey, the facility did not ensure that a Resident with a sacral pressure ulcer receive the necessary care and treatment to prevent infection of ulcer. Specifically, there was no dressing observed to the sacral area for a resident with a stage 3 pressure ulcer. This was evident for one (1) of two (2) residents reviewed for Pressure Ulcers out of 33 sampled residents. (Resident # 44). The finding is: Resident # 44 was initially admitted on [DATE], re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment ((MDS) dated [DATE] documented, clear speech, usually understood, understands, who required extensive assistance for Activities of Daily needs, (ADL's), who was always incontinent of both bladder and bowel. The resident has active [DIAGNOSES REDACTED]. The MDS assessment documented that the resident had 1 unhealed Stage 2 pressure ulcer. The MDS assessment documented that this pressure ulcer was not present during admission. The date of the oldest stage 2 pressure ulcer is recorded as 6/25/18 on the MDS assessment. The Physician order [REDACTED]. The Comprehensive Care Plan (CCP) dated 06/25/18 for Pressure Ulcer, documented measurable Goals and Approaches which included, that the resident will be free from sign/symptoms of infection, including providing the treatment, as ordered by the medical doctor. The CCP was updated on 7/12/18 and documented that the resident has a pressure injury r/t (Right) Unstageable DTI ( deep tissue injury) to Sacrum. Interventions put in place on 7/12/18 were air pressure relieving mattress to bed, Oho cushion to wheelchair, Administer pain management prior to dressing change and monitor for effectiveness. Administer supplements as ordered by MD. monitor wound for for infection, redness, swelling, pain, foul odor or drainage. Turning and positioning every 2 hours and as needed. Incontinence care every 2 to 4 hours and as needed. On 7/19/18 the CCP was again updated and documented: Stage 3. New Intervention was new MD order. The Nursing Progress notes dated 7/19/18 documented weekly wound documentation and asserted that despite all interventions and due to impaired mobility, incontinence, and medical [DIAGNOSES REDACTED]. The Physician's Progress noted dated 7/19/18 documented: Sacral Decubitus with some DTI last week now a stage 3. Plan [MEDICATION NAME]. The Weekly Wound progress note dated 08/17/18, documented Stage 3 pressure injury remains same in size and necrosis, 1. 6 cm (centimeter) by 1.0 cm by 0.1 with 95 % granulation and 5 % necrosis, draining small amount serous drainage. On 08/23/18 at 12:58 PM the Certified Nurse Aide (CNA#6) was observed wheeling the resident to her room. The State Agency (SA) asked the resident of permission was given given by her to observe the wound care today. The resident said, Yes. On 08/23/18 at 01:04 PM the SA and the LPN #3 entered the residents' room. The resident was lying on her back, wearing only a diaper from the waist down. The CNA who was present, was about to exit the room, when the LPN told the CNA that she needed him to stay, to help position the resident. The LPN set up her supplies at the bedside, and asked the CNA to re-positioned the resident onto her right side. The resident was re-positioned and the diaper was opened and pulled down to expose the sacral area. The residents wound to the sacral area was exposed. There was no dressing covering the stage 3 pressure ulcer region. CNA #6 was interviewed on 08/23/18 at 1:45 PM. CNA #6 stated that he removed the dressing when he changed the resident. On 8/23/18 the Licensed Professional Nurse (LPN #3) was interviewed. LPN #3 stated that CNA's are not to remove any dressings. She stated that if a dressing becomes soiled or falls off, the nurse should be made aware. The LPN stated that placing a diaper over the wound site is an infection control issue, and that it would have been best to keep the resident on her side. The LPN stated that she was unaware that the dressing was off, otherwise she could have placed a protective barrier in between the wound site and diaper, until she was ready to do the dressing change. On 08/24/18 at 08:08 AM the Registered Nurse Supervisor (RN #4) was interviewed. RNS #4 stated that to ensure the care and treatment of [REDACTED]. 415.12(ac)(1) .

Based on observations, record reviews and interviews conducted during the re-certification survey, the facility did not ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. In addition, the Facility did not reassess the effectiveness of the interventions and review and revise the Plan of Care. Specifically, the intervention of FAP (floor ambualtion plan) to address the resident's decline in range of motion and mobility was not reassessed for effectiveness after nursing staff observed that resident was unable to perform task. This was evident in 1 of 1 resident (Resident #28) reviewed for Positioning/Mobility care and services out of 33 sampled residents. The finding is: Resident is [AGE] years old with [DIAGNOSES REDACTED]. On 08/23/18 at 12:05 PM, Resident#28 was observed in the dining room, seated on his wheelchair, both wheelchair arms were covered with a white moleskin protector, his head tilted backwards, and eyes closed with mouth wide open. On 08/23/18 at 12:26 PM, Resident # 28 remained sleeping, seated in his wheelchair, in the dining room. Resident was being awaken by Certified Nursing Assistant (CNA) #1. Since Resident was difficult to arouse, LPN#1 and CNA#1 wheeled him out of the dining room. Resident's wheelchair had no foot or leg rest, his feet were touching and dragging on the floor. Licensed Practical Nurse(LPN) #1 pushed the sleeping Resident out of the dining room while CNA#1 lifted his legs, holding his pants by the knees to lift his legs and feet while wheeling him from the dining room through the hallway to his room which is passed the second floor Nursing Station and the elevator. On 08/24/18 at 9:32 AM, Resident was lying on his bed, dressed in regular clothes. His eyes were opened but did not verbally respond to greeting. There was a blue floor mat, one on each side of the bed. His wheelchair without a foot/leg rest was positioned at the foot of the bed. On 08/24/18 at 10:45 AM, Resident remained in bed, lying down. Resident was alert, trying to pull the right leg of his sweatpants up. On 08/27/18 at 09:45 AM Resident # 28 was still in bed, with his legs up and knees bent. His wheelchair was not in the bedroom and was in the dining room. The wheelchair without the leg/foot rest had the Resident's name on it. On 08/27/18 at 02:44 PM Resident # 28 was in bed, sleeping with 2 blue wedges on both sides of the bed. On 08/28/18 at 10:32 AM the PT and PTA (Physical Therapist Assistant) did the FAP with the Resident on the resident's unit. Resident was able to ambulate more than 70 ft using a RW. PT was verbally encouraging Resident to take steps while PTA was behind the Resident using the Resident's Wheelchair. PT also stated that a leg rest will be provided for Resident wheelchair. The State Surveyor did not observe CNA or nursing providing floor ambulation for this resident. During the recertification survey the State Surveyor only observed PT perform FAP with the resident on one occasion. The resident's Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that functional status of walk in corridor on unit did not occur as indicated by code number 8. The MDS documented that Resident had 230 minutes of physical therapy to be administered to the Resident individually for 6 days with a start date of 6/4/2018; no Restorative Nursing Program was in place. The Resident's Comprehensive Care Plan(CCP) dated 12/16/16 with a long-term goal target date of 9/11/18 and titled ADL Functional /Rehabilitation Potential documented a goal that the Resident's locomotion function will be at the highest level of capability. Intervention indicated: requires limited assists x1 person in locomotion on/off the unit. The responsible disciplines include the CNA, Nursing and Rehabilitation. The Resident's CCP dated 6/4/18 titled ADL Functional/Rehabilitation Potential documented that the Resident requires individualized adaptive positioning secondary to a [DIAGNOSES REDACTED]. The long-term goal target date is 9/6/18. The long-term goal is: the Resident will ambulate with limited assist with appropriate device, will increase standing balance at least one grade, and Resident will increase LE strength by at least one grade. Preserve ROM/slow progression or contractures. The approach start date was 6/22/18 and approach was FAP 70 feet with RW with extensive assist x1 one time/day as tolerated as part of the ADL flowsheet, once a day: 9:00 AM. Responsible Discipline includes: CNA, Nursing, Rehabilitation. The General Order Record for FAP 70 feet with RW with extensive assist OD as tolerated was initiated by PT who created the order on the Electronic Medical Record(EMR) dated 6/22/18 at 10:07 AM. The EMR showed that an RN verified the order dated of 6/22/18 at 01:40 PM. The Physician order [REDACTED]. The order has a start date of 6/22/18 with an open-ended end date. A previous physician's orders [REDACTED]. There were no MD signatures on the Physician order [REDACTED]. The Resident Progress Notes dated 6/22/18 at 10:04 AM documented PT/Rehabilitation's recommendations: to discontinue Skilled PT and OT services secondary to reaching maximum benefit; Out-of-bed(OOB) - Regular Chair/toilet; transfers with extensive assist x1; FAP 70 feet with Extensive assist x1 one time/day as tolerated. PT further documented that Nursing was made aware, will follow up as needed, quarterly or PRN; MD order in place. Nursing Notes on 6/22/18 at 10:52 pm titled Behavioral Notes added that PT/OT in progress to strengthen and improve gait. No documentation that FAP was put in place from 6/22/2018 to 8/27/18. The CNA's Accountability Record or the Point of Care ADL Category Report walk in corridor was denoted with a number 8(meaning the activity did not occur) and WH was entered for a wheelchair device for locomotion on and off the unit. There were no documented evidence that FAP 70 feet x1 daily was implemented and re-assessments/re-evaluations, and reviews were done by the MD, Nursing and Rehabilitation/Nursing not until 8/29/18. The Rehabilitation Progress on 8/28/18 reported that Resident was seen for screen on Unit as per Nursing Referral with a MD's order. On 08/27/18 at 09:53 AM, CNA#1 was interviewed and recapitulated the incident the previous week when Resident was sleeping on his wheelchair, wheeled out of the dining with LPN#1 pushing the sleeping Resident in his wheelchair while CNA#1 held the Resident's pants by his knees to lift his legs. CNA#1 stated that Resident doesn't walk, only uses a wheelchair. CNA#1 had to hold and pull the pants by the knees because the feet were dragging on the floor. On 08/27/18 at 10:04 AM, LPN#1 was interviewed. LPN stated that Resident is usually out of bed and ambulates via wheelchair. The LPN#1 further stated that the PT recommended the wheelchair and ordered by the MD. The wheelchair has no leg/foot rest because PT recommended that he should use his feet when pushing the wheelchair. LPN#1 said that he cannot walk;. If Resident is sleeping, Staff don't take him out in the dining room until 10:00 AM when Recreation comes on the unit. On 08/27/18 at 10:21 AM, The Rehabilitation Progress Notes dated 6/5/18 and 6/22/18 were reviewed with PT. PT stated that Resident was on FAP once a day which started on 6/22/18. PT stated it doesn't matter what shift this FAP occurs. PT stated that there was no order for a leg/foot rest for the wheelchair as it is not safe for the Resident who constantly gets up from the wheelchair. On 08/27/18 at 02:45 PM, CNA#1 stated that CNA#1 never saw him walking, always in his wheelchair. On 08/27/18 at 03:02 PM LPN#1 stated that FAP is done with PT (Resident will walk with 2 Staff). Resident is not on FAP on the unit. Resident doesn't go to PT anymore. FAP is ambulation from bathroom to the room and to dining when Resident is taken out of bed. Resident is not on FAP. There was not documented evidence that FAP was performed with the resident by PT in accordance with the physician's orders [REDACTED]. On 08/27/18 at 03:15 PM CNA#2 who worked on the 3-11pm shift was interviewed. CNA#2 stated that Resident ambulates via wheelchair and confirmed that the wheelchair does not have any leg/foot rest. Resident never ambulate using a rolling walker. Resident does not have a rolling walker. On 08/27/18 at 03:26 PM, LPN#2 who works in the Resident unit from 3pm-11pm was interviewed. LPN#2 stated that Resident cannot barely walk, Resident ambulates using a wheelchair. Resident has no rolling walker. Resident's wheelchair has no leg/foot rest. LPN #2 further stated that it's the PT people who knows more of the ambulation. LPN#2 stated that Resident has no FAP on the 3pm to 11pm shift. On 08/27/18 at 03:32 PM, RN#2 was interviewed. RN#2 stated that RN#2 is not familiar with Resident's ambulation (all she knows is that Resident has a very unsteady gait and needs to be monitored). RN #2 stated FAP and CNA Accountability cannot be connected since FAP never occurred. On 08/28/18 at 09:11AM, PT was interviewed and stated that CNAs are responsible for the FAP task. PT stated that there was an MD order on the computer. A Resident will be discharged from Rehabilitation with PT recommendations. Referrals for re-evaluation will be made to him by the Nurses. There were no referrals made regarding the Resident. On 08/28/18 at 10:24 AM, CNA#1 was questioned regarding FAP. CNA#1 stated that on 8/27/18, CNA#1 tried to walk Resident who was not cooperating, was fighting. CNA#1 stated LPN#1 was verbally told that Resident was uncooperative when FAP was done. CNA#1 stated that this task was not documented anywhere. The Resident is now in his room with the PT who will help CNA to do FAP with the Resident. CNA#1 will document the FAP after it occurred in the Resident Profile in the computer. On 08/28/18 at 10:32 AM, PT and PTA (Physical Therapist Assistant) did the FAP with the Resident on the Unit. Resident was able to ambulate using a RW. PT verbally encouraged Resident to take steps while PTA was behind the res with the resident's wheelchair. PT also stated that a leg rest will be provided for Res' wheelchair. PT stated that no recommendation was given by Nursing to re-evaluate the Resident for FAP. On 08/28/18 at 10:41 AM, LPN#1 was interviewed regarding the CNAs Point of Care(P[NAME]) Report. LPN#1 stated that this report is generated by the RN and given to each shift. The CNAs along with the LPN will carry out the FAP. Documentation is in the CNA accountability in the floor ambulation. LPNs don't document in the Nursing progress notes. Yesterday, FAP was not documented since the task did not occur. On 08/28/18 at 10:59 AM, RN#1 was interviewed. RN#1 stated that the CNAs have the Point of Care(P[NAME]) ADL Report in the computer. CNAs have to enter a comment including Resident's refusal to complete a task. If a task is not occurring, information is shared with the Nursing Staff through the chain of command process (CNAs inform the Charge Nurse, the Charge Nurse informs the RN Supervisor who will call the Medical Doctor and the MD will order a referral to Rehabilitation. The electronic Nursing Progress notes shared with Rehabiliation and other Disciplines were supposed to be monitored by the RN Supervisor. On 6/22/18, the Rehabilitation note with the FAP recommendation was picked up by Nursing. RN#1 admitted that this task was not transmitted by the RN Supervisors to the P[NAME] Report. RN#1 further stated that Rehabilitation's recommendation is written on paper which Rehabilitation submits to the Nursing Supervisor, then RN calls the MD. The RN Supervisor then electronically transmits the order to the P[NAME] menu for the CNAs. RN#1 stated that FAP was not occurring until today since the task was not electronically transmitted and reflected on the CNA's P[NAME]. RN#1 stated that the MD is evaluating the Resident today for FAP. On 08/28/18 at 12:58 PM LPN#1 stated that there is a list of Resident on FAP generated by Rehabilitation. The LPN#1 is familiar with the list. LPN said the CNAs are aware of the FAP which is on the P[NAME] Report. LPN#1 stated that the CNAs are made aware of the FAP list during morning reports. LPN#1 will ask CNAs if the task is done. On 08/28/18 at 01:10 PM, MD was interviewed over the phone.The MD was unable to respond immediately to the question regarding how the resident was assessed for needing FAP. The MD stated that MD assesses the Resident by trying to stand Resident up while Resident is in bed. Resident has been unsteady and weak. MD further stated that I know Resident needs physical therapy to avoid his joints from freezing and to avoid stiffness. I didn't see Resident physically doing the FAP. I don't recall how the recommendation for FAP was sent to me but it's from Rehabilitation to Nursing. 415.11(c)(2)(i-iii)

Based on record review and staff interview during recertification survey, the facility did not ensure that the resident Minimum Data Set (MDS) comprehensive assessment was submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Procession (ASAP) System in a timely manner. Specifically the Annual Assessment was not submitted/transmitted within the 14 calendar days after the assessment was completed. This was evident for 1 of 1 resident (Resident # 1) reviewed for Resident Assessment out of 33 sampled residents. The CMS RAI (Resident Assessment Instrument) Version Manual (Dated (MONTH) (YEAR)) was referenced. Chapter 2 titled Assessments for the RAI was reviewed. Assessment Completion refers to the date that all information needed has been collected and recorded and staff have signed and dated the assessment is completed. Assessment Transmission refers to the electronic transmission of submission files to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the Medicare Data Communication Network (MDCN) CMS RAI Version 3.0 Manual ( Dated (MONTH) (YEAR)) was referenced. Chapter 5 titled Submission and correction of the MDS was reviewed. The MDS completion date must be no later than 14 days after the ARD for all non admission, OBRA and PPS Aassessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessment must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. The facility and procedure titled Electronic Transmission of the MDS ( Revised date (MONTH) 2010) documented the following: 'All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to Centers for Medicare and Medicaid ( CMS)' QIES Assessment Submission and Processing (ASAP) System in accordance with current OBRA regulations governing the transmission of MDS data.' The finding is: Resident # 1 was initially admitted to the facility on [DATE]. The Annual assessment with ARD 07/13/2018 was completed and signed on 07/23/2018 As of 08/27/2018 the assessment was not submitted or transmitted. On Monday 08/27/2018 at 12:56 PM, the MDS Coordinator (RN#3) was interviewed via telephone. She stated, For an MDS annual assessment with ARD 07/13/18, we have up to 14 days to complete the MDS which is 07/27/18, then up to 7 days to complete the care plan which is 08/03/18, then up to 14 days to submit the book which is 08/17/18. She further stated I am a per diem MDS nurse, I don't go to the building everyday. I come at least once a week. When I come, I look at all completed books and then prepare them for submission. The facility is aware of the MDS requirements. They are looking for a full time MDS coordinator. On Monday 08/27/2018 at 4:42 PM, the Administrator was interviewed. The Administrator stated, We had a full time MDS coordinator who went to part time. Finally, we have one MDS coordinator with the commitment to start on (MONTH) the 10th.

Based on observations, record reviews and interviews during the re-certification survey, the Facility did not ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Specifically, Floor Ambulation Program (FAP) did not occur for Resident #28 from 6/22/18 until 8/27/18 despite being recommended by PT (Physical Therapist) and ordered by the attending Physician. In addition there was no documented evidence that the CCP (Comprehensive Care Plan) was reviewed and revised if necessary to meet the Resident's needs. This was evident in 1 of 1 resident (Resident #28) reviewed for Positioning/Mobility care and services out of 33 sampled residents. The finding is: The facility policy and procedure titled Verbal Orders/Policy Interpretation and Implementation revealed the following: Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to enter orders in the electronic medical record. The policy further documented the practitioner will review and countersign verbal orders during his or her next visit. The responsible parties include the Medical Doctor(MD), Physical Therapist(PT), Registered Nurse(RN). The RN did not transcribe the FAP. Resident is [AGE] years old with [DIAGNOSES REDACTED]. On 08/23/18 at 12:05 PM, Resident#28 was observed in the dining room, seated on his wheelchair, both wheelchair arms were covered with a white moleskin protector, his head tilted backwards, and eyes closed with mouth wide open. On 08/23/18 at 12:26 PM, Resident # 28 remained sleeping, seated in his wheelchair, in the dining room. Resident was being awaken by Certified Nursing Assistant (CNA) #1. Since Resident was difficult to arouse, LPN#1 and CNA#1 wheeled him out of the dining room. Resident's wheelchair had no foot or leg rest, his feet were touching and dragging on the floor. Licensed Practical Nurse(LPN) #1 pushed the sleeping Resident out of the dining room while CNA#1 lifted his legs, holding his pants by the knees to lift his legs and feet while wheeling him from the dining room through the hallway to his room which is passed the second floor Nursing Station and the elevator. On 08/24/18 at 9:32 AM, Resident was lying on his bed, dressed in regular clothes. His eyes were opened but did not verbally respond to greeting. There was a blue floor mat, one on each side of the bed. His wheelchair without a foot/leg rest was positioned at the foot of the bed. On 08/24/18 at 10:45 AM, Resident remained in bed, lying down. Resident was alert, trying to pull the right leg of his sweatpants up. On 08/27/18 at 09:45 AM Resident # 28 was still in bed, with his legs up and knees bent. His wheelchair was not in the bedroom and was in the dining room. The wheelchair without the leg/foot rest had the Resident's name on it. On 08/27/18 at 02:44 PM Resident # 28 was in bed, sleeping with 2 blue wedges on both sides of the bed. On 08/28/18 at 10:32 AM the PT and PTA (Physical Therapist Assistant) did the FAP with the Resident on the resident's unit. Resident was able to ambulate more than 70 ft using a RW. PT was verbally encouraging Resident to take steps while PTA was behind the Resident using the Resident's Wheelchair. PT also stated that a leg rest will be provided for Resident wheelchair. The State Surveyor did not observe CNA or nursing providing floor ambulation for this resident. During the recertification survey the State Surveyor only observed PT perform FAP with the resident on one occasion. The resident's Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that functional status of walk in corridor on unit did not occur as indicated by code number 8. The MDS documented that Resident had 230 minutes of physical therapy to be administered to the Resident individually for 6 days with a start date of 6/4/2018; no Restorative Nursing Program was in place. The Resident's Comprehensive Care Plan(CCP) dated 12/16/16 with a long-term goal target date of 9/11/18 and titled ADL Functional /Rehabilitation Potential documented a goal that the Resident's locomotion function will be at the highest level of capability. Intervention indicated: requires limited assists x1 person in locomotion on/off the unit. The responsible disciplines include the CNA, Nursing and Rehabilitation. The Resident's CCP dated 6/4/18 titled ADL Functional/Rehabilitation Potential documented that the Resident requires individualized adaptive positioning secondary to a [DIAGNOSES REDACTED]. The long-term goal target date is 9/6/18. The long-term goal is: the Resident will ambulate with limited assist with appropriate device, will increase standing balance at least one grade, and Resident will increase LE strength by at least one grade. Preserve ROM/slow progression or contractures. The approach start date was 6/22/18 and approach was FAP 70 feet with RW with extensive assist x1 one time/day as tolerated as part of the ADL flowsheet, once a day: 9:00 AM. Responsible Discipline includes: CNA, Nursing, Rehabilitation. The General Order Record for FAP 70 feet with RW with extensive assist OD as tolerated was initiated by PT who created the order on the Electronic Medical Record(EMR) dated 6/22/18 at 10:07 AM. The EMR showed that an RN verified the order dated of 6/22/18 at 01:40 PM. The Physician order [REDACTED]. The order has a start date of 6/22/18 with an open-ended end date. A previous physician's orders [REDACTED]. There were no MD signatures on the Physician order [REDACTED]. The Resident Progress Notes dated 6/22/18 at 10:04 AM documented PT/Rehabilitation's recommendations: to discontinue Skilled PT and OT services secondary to reaching maximum benefit; Out-of-bed(OOB) - Regular Chair/toilet; transfers with extensive assist x1; FAP 70 feet with Extensive assist x1 one time/day as tolerated. PT further documented that Nursing was made aware, will follow up as needed, quarterly or PRN; MD order in place. Nursing Notes on 6/22/18 at 10:52 pm titled Behavioral Notes added that PT/OT in progress to strengthen and improve gait. No documentation that FAP was put in place from 6/22/2018 to 8/27/18. The CNA's Accountability Record or the Point of Care ADL Category Report walk in corridor was denoted with a number 8(meaning the activity did not occur) and WH was entered for a wheelchair device for locomotion on and off the unit. There were no documented evidence that FAP 70 feet x1 daily was implemented and re-assessments/re-evaluations, and reviews were done by the MD, Nursing and Rehabilitation/Nursing not until 8/29/18. The Rehabilitation Progress on 8/28/18 reported that Resident was seen for screen on Unit as per Nursing Referral with a MD's order. On 08/27/18 at 09:53 AM, CNA#1 was interviewed and recapitulated the incident the previous week when Resident was sleeping on his wheelchair, wheeled out of the dining with LPN#1 pushing the sleeping Resident in his wheelchair while CNA#1 held the Resident's pants by his knees to lift his legs. CNA#1 stated that Resident doesn't walk, only uses a wheelchair. CNA#1 had to hold and pull the pants by the knees because the feet were dragging on the floor. On 08/27/18 at 10:04 AM, LPN#1 was interviewed. LPN stated that Resident is usually out of bed and ambulates via wheelchair. The LPN#1 further stated that the PT recommended the wheelchair and ordered by the MD. The wheelchair has no leg/foot rest because PT recommended that he should use his feet when pushing the wheelchair. LPN#1 said that he cannot walk;. If Resident is sleeping, Staff don't take him out in the dining room until 10:00 AM when Recreation comes on the unit. On 08/27/18 at 10:21 AM, The Rehabilitation Progress Notes dated 6/5/18 and 6/22/18 were reviewed with PT. PT stated that Resident was on FAP once a day which started on 6/22/18. PT stated it doesn't matter what shift this FAP occurs. PT stated that there was no order for a leg/foot rest for the wheelchair as it is not safe for the Resident who constantly gets up from the wheelchair. On 08/27/18 at 02:45 PM, CNA#1 stated that CNA#1 never saw him walking, always in his wheelchair. On 08/27/18 at 03:02 PM LPN#1 stated that FAP is done with PT (Resident will walk with 2 Staff). Resident is not on FAP on the unit. Resident doesn't go to PT anymore. FAP is ambulation from bathroom to the room and to dining when Resident is taken out of bed. Resident is not on FAP. There was not documented evidence that FAP was performed with the resident by PT in accordance with the physician's orders [REDACTED]. On 08/27/18 at 03:15 PM CNA#2 who worked on the 3-11pm shift was interviewed. CNA#2 stated that Resident ambulates via wheelchair and confirmed that the wheelchair does not have any leg/foot rest. Resident never ambulate using a rolling walker. Resident does not have a rolling walker. On 08/27/18 at 03:26 PM, LPN#2 who works in the Resident unit from 3pm-11pm was interviewed. LPN#2 stated that Resident cannot barely walk, Resident ambulates using a wheelchair. Resident has no rolling walker. Resident's wheelchair has no leg/foot rest. LPN #2 further stated that it's the PT people who knows more of the ambulation. LPN#2 stated that Resident has no FAP on the 3pm to 11pm shift. On 08/27/18 at 03:32 PM, RN#2 was interviewed. RN#2 stated that RN#2 is not familiar with Resident's ambulation (all she knows is that Resident has a very unsteady gait and needs to be monitored). RN #2 stated FAP and CNA Accountability cannot be connected since FAP never occurred. On 08/28/18 at 09:11AM, PT was interviewed and stated that CNAs are responsible for the FAP task. PT stated that there was an MD order on the computer. A Resident will be discharged from Rehabilitation with PT recommendations. Referrals for re-evaluation will be made to him by the Nurses. There were no referrals made regarding the Resident. On 08/28/18 at 10:24 AM, CNA#1 was questioned regarding FAP. CNA#1 stated that on 8/27/18, CNA#1 tried to walk Resident who was not cooperating, was fighting. CNA#1 stated LPN#1 was verbally told that Resident was uncooperative when FAP was done. CNA#1 stated that this task was not documented anywhere. The Resident is now in his room with the PT who will help CNA to do FAP with the Resident. CNA#1 will document the FAP after it occurred in the Resident Profile in the computer. On 08/28/18 at 10:32 AM, PT and PTA (Physical Therapist Assistant) did the FAP with the Resident on the Unit. Resident was able to ambulate using a RW. PT verbally encouraged Resident to take steps while PTA was behind the res with the resident's wheelchair. PT also stated that a leg rest will be provided for Res' wheelchair. PT stated that no recommendation was given by Nursing to re-evaluate the Resident for FAP. On 08/28/18 at 10:41 AM, LPN#1 was interviewed regarding the CNAs Point of Care(P[NAME]) Report. LPN#1 stated that this report is generated by the RN and given to each shift. The CNAs along with the LPN will carry out the FAP. Documentation is in the CNA accountability in the floor ambulation. LPNs don't document in the Nursing progress notes. Yesterday, FAP was not documented since the task did not occur. On 08/28/18 at 10:59 AM, RN#1 was interviewed. RN#1 stated that the CNAs have the Point of Care(P[NAME]) ADL Report in the computer. CNAs have to enter a comment including Resident's refusal to complete a task. If a task is not occurring, information is shared with the Nursing Staff through the chain of command process (CNAs inform the Charge Nurse, the Charge Nurse informs the RN Supervisor who will call the Medical Doctor and the MD will order a referral to Rehabilitation. The electronic Nursing Progress notes shared with Rehabiliation and other Disciplines were supposed to be monitored by the RN Supervisor. On 6/22/18, the Rehabilitation note with the FAP recommendation was picked up by Nursing. RN#1 admitted that this task was not transmitted by the RN Supervisors to the P[NAME] Report. RN#1 further stated that Rehabilitation's recommendation is written on paper which Rehabilitation submits to the Nursing Supervisor, then RN calls the MD. The RN Supervisor then electronically transmits the order to the P[NAME] menu for the CNAs. RN#1 stated that FAP was not occurring until today since the task was not electronically transmitted and reflected on the CNA's P[NAME]. RN#1 stated that the MD is evaluating the Resident today for FAP. On 08/28/18 at 12:58 PM LPN#1 stated that there is a list of Resident on FAP generated by Rehabilitation. The LPN#1 is familiar with the list. LPN said the CNAs are aware of the FAP which is on the P[NAME] Report. LPN#1 stated that the CNAs are made aware of the FAP list during morning reports. LPN#1 will ask CNAs if the task is done. On 08/28/18 at 01:10 PM, MD was interviewed over the phone.The MD was unable to respond immediately to the question regarding how the resident was assessed for needing FAP. The MD stated that MD assesses the Resident by trying to stand Resident up while Resident is in bed. Resident has been unsteady and weak. MD further stated that I know Resident needs physical therapy to avoid his joints from freezing and to avoid stiffness. I didn't see Resident physically doing the FAP. I don't recall how the recommendation for FAP was sent to me but it's from Rehabilitation to Nursing. 415.12(e)(2)