Every finding on record at Methodist Home for Nursing and Rehabilitation

Based on record review and interviews, the facility failed to ensure each resident was offered the COVID-19 immunization. This was evident for two (2) of five (5) residents (Residents #38 and #135) sampled for immunization out of 24 total sampled residents. Specifically, there was no documented evidence of screening, administration or declination, and education on the COVID-19 immunizations for Residents #38 and #135.The findings include:The facility policy titled COVID-19 Vaccine for Residents with a last reviewed date of 05/2025 documented that the facility shall offer all consenting, unvaccinated existing residents an opportunity to receive the first of any required next does of the COVID-19 vaccine. The Infection Control Preventionist will re-offer COVID-19 vaccine on a regular basis to those residents who have declined and will document accordingly.1.) Resident #38 had diagnoses that included Multiple Sclerosis (a chronic autoimmune disease of the central nervous system), Non-Alzheimer's Dementia (loss of memory), and Chronic Obstructive Pulmonary Disease (a lung condition that makes it hard to breath). The Quarterly Minimum Data Set (a resident assessment tool) dated 12/18/2025 documented that Resident #38 had severely impaired cognition and that Resident #38's COVID-19 immunization status was not up to date. The facility was able to provide documented evidence that Resident #38 was administered the Spikevax 2023-2024 vaccine on 11/21/2023.A nursing note dated 10/29/2025 documented that Resident #38's representative gave consent for the COVID-19 booster when offered by the facility. However, the facility was unable to provide documented evidence that Resident #38 received any further COVID-19 vaccines in order to be up to date with COVID-19 vaccination.2.) Resident #135 had diagnoses of Type 2 Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar), Non-Alzheimer's Dementia (loss of memory), and Hypertension (high blood pressure). The Quarterly Minimum Data Set, dated [DATE] documented that Resident #135 had moderately impaired cognition and that Resident #135's COVID-19 immunization status was not up to date.The facility was able to provide documented evidence that Resident #135 was administered the Spikevax 2024-2025 vaccine on 10/28/2024 but was unable to provide documented evidence that Resident #135 was reoffered and reeducated on the COVID-19 immunization.During an interview on 01/09/2026 at 1:24 PM, the Infection Preventionist who was also the Assistant Director of Nursing stated they will start administering COVID-19 vaccines on 01/12/2026 for those residents or resident representatives who consented to the immunization.During an interview on 01/12/2026 at 1:00 PM, the Director of Nursing stated the COVID-19 vaccination was put on hold because they were administering the Influenza immunizations in October 2025 and in December 2025. They stated there was a Flu outbreak and all the residents in the building were given Tamiflu. The Director of Nursing also stated the last bulk delivery for the COVID-19 vaccine was in the last week of October 2025. Those vaccines were administered to some of the residents.10 NYCRR 415.19

Based on record review and interviews conducted during the Recertification Survey, the facility failed to ensure that each resident was offered the pneumococcal and influenza immunizations. This was observed in one (1) of five (5) residents (Resident #38) sampled for immunizations out of a total of 24 sampled residents. Specifically, there was no documented evidence that Resident #38 were offered, educated, received or declined the pneumococcal immunization.The findings include:The facility policy titled Pneumococcal Vaccine with a revised date of 01/2026 documented that unless previously immunized or contraindicated, all residents and staff will be offered Pneumococcal vaccine.Resident #38 had diagnoses that included Multiple Sclerosis (a chronic autoimmune disease of the central nervous system), Non-Alzheimer's Dementia (loss of memory), and Chronic Obstructive Pulmonary Disease (a lung condition that makes it hard to breath). The Quarterly Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #38 had severely impaired cognition and that Resident #38's pneumococcal immunization status was up to date. The facility provided documented evidence that Resident #38 was administered Pneumovax 23 vaccine on 03/01/2018. However, there was no documented evidence that Resident #38 received any further Pneumococcal vaccines in order to be up to date with pneumococcal vaccination.During an interview on 01/09/2026 at 1:24 PM, the Infection Preventionist who was also the Assistant Director of Nursing stated, they offered the Pneumococcal, Influenza, and COVID-19 vaccines to Resident #38's representative and they have refused all of them. The Infection Preventionist was unable to provide a Pneumococcal vaccine declination form for Resident #38.During an interview on 01/12/2026 at 10:36 AM, Attending Physician #1 stated it is recommended that if a resident previously received Pneumovax 23, they should also be revaccinated against pneumococcal disease. Attending Physician #1 stated they were unaware if Resident #38 was offered or refused a Pneumococcal vaccine.During an interview on 01/12/2026 at 1:00 PM, the Director of Nursing stated that residents are offered and revaccinated for pneumococcal disease depending on which vaccine was previously received. The Director of Nursing was unable to explain why Resident #38 wasn't offered a revaccination for pneumococcal disease.10 NYCRR 415.19

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards. This was evident for one (1) (3rd Floor) of six (6) medication carts observed, and one (1) of three (3) (3rd Floor) medication rooms observed. Specifically, expired medications were stored in the 3rd floor medication cart and medication room. The findings include: The facility policy titled, Storage of Medications dated May 2003, with a last revised date of July 2024 documented Medications are stored according to procedures established and in compliance with state and federal regulations, as well as manufacturer's recommendations.checks expiration dates of all stock medications on a weekly basis. On 01/07/2026 at 10:12 AM, the facility medication storage task was performed on the 3rd Floor. A bottle of 237 milliliter Gerilanta (Mylanta) with an expiration date of 09/2025 was observed in medication storage room. Abottle of 473 milliliter Acetaminophen liquid 160 milligram/5 milliliter with expiration date of 11/2024 was observed in the medication cart. On 01/07/2026 at 10:23 AM, Licensed Practical Nurse #2 was interviewed and stated that the nurses and pharmacist are expected to check for expired medication in the medication cart and medication room. Licensed Practical Nurse #2 also stated that they usually check the cart daily for expired medication, and that they must have missed the expired Tylenol bottle that was still in the cart. On 01/07/2026 at 10:25 AM, Registered Nurse #4 was interviewed and stated that every nurse is expected to check for the expiration date on the medication bottle and blister pack daily. Registered Nurse #4 stated that the medication carts and rooms are checked and that the expired medications that were observed in the cart and the storage room was an oversight. On 01/09/2026 at 11:04 AM, Pharmacy Consultant was interviewed and stated that they come to the facility every month to do unit evaluation, to check the cart, and unit medication storage to ensure that there are no expired medications. they stated that the last time they checked the medication carts and storage was on 12/22/2025. The Pharmacy Consultant stated that it was extremely surprising that there are expired medications in the cart and storage room and that it might have originated from Central Supply. They stated they have been reminding the staff to replenish their stock using first in, first out to ensure that they do not stock expired medications. On 01/09/2026 at 11:31 AM, the Director of Nursing was interviewed and stated they cannot explain why there were expired medications on the unit. They stated the night supervisor is responsible for ensuring there are no expired medications on the units. they stated that instructions were given to the staff to ensure that the old medications are taken out when stocking with the new ones. The Director of Nursing also stated that the medication nurses were instructed to check their medication carts daily to ensure there are no expired medications. On 01/09/2026 at 12:17 PM, the Administrator was interviewed and stated it is unimaginable that the staff are not taking out expired medications off the unit. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews, the facility failed to ensure that a resident who is administered enteral tube feedings received the appropriate treatment and services to prevent complications. This was evident in one (1) (Resident #38) of one (1) resident reviewed for tube feeding out of 22 total sampled residents. Specifically, Resident #38's enteral tube feeding formula and water bag being administered were not labeled with the resident's name, date, and start time of administration. The findings are:The facility's policy and procedure titled Enteral Feedings dated May 2003 with a last revised date of July 2024 documented, Change feeding bag/tubing every time an enteral formula is started. Label the enteral formula with the resident's name, room number, date and time the feeding is initiated.Resident #38 was admitted with diagnoses that included Coronary Artery Disease, Non-Alzheimer's Dementia, Asthma, Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #38 had severe impairment in cognition, required substantial/maximal assistance for most activities of daily living, and total dependent of staff for eating. Minimum Data Set also documented that Resident #38 received an average of 51 percent or more of feedings and 501 milliliters per day or more of fluids through parenteral or tube feeding.The Comprehensive Care Plan for Feeding Tube dated 09/24/2020, and last reviewed on 12/23/2025 documented that resident is on tube feeding related to Swallowing problems and diagnosis of dysphagia. The facility interventions include to check feeding tube for placement and patency before each fluid, feeding, and medication administration; and to assess resident for complication related to feeding tube.On 01/05/2026 at 10:45 AM, Resident #38 was observed in bed with tube feeding, Jevity 1.5 calories 1000 milliliter bottle running at 50 milliliters per hour. There was no start date/time, no name and initial documented on the feeding bottle, water bag and on irrigation cup.On 01/08/2026 at 9:51 AM, during medication observation, Resident #38 tube feeding, Jevity 1.5 call 1,500 milliliter bottle was observed running at 50 milliliters per hour. The tube feeding bottle had no documented date and start time. A physician's order dated 12/29/2025 documented: Formula: Jevity 1.5 Strength, to start at 4:00 PM and to complete at 2:00 PM or until done; with 22 total hours at a 50 milliliter per hour flow rate.On 01/08/2026 at 9:55 AM, Registered Nurse #1 was interviewed and stated that the evening nurse hung and started the feeding and that they are supposed to label the bottle to indicate the start date and time. Registered Nurse #1 stated they cannot say why the bottle and the water bag were not labeled, but if they hang and start any new bottle, they always make sure that they are properly labeled.On 01/08/2026 9:58 AM, Registered Nurse #2 was interviewed and stated that Resident #38's tube feeding starts at 4:00 PM and hung by the evening shift nurse. They stated that the tube feeding bottle and water bag should have been labeled by the evening nurse when starting the feeding. Registered Nurse #2 stated that they have not made round yet to have noticed that the bottle and water bag were not labeled.On 01/09/2026 at 10:40 AM, an interview was conducted with Licensed Practical Nurse #1 that worked on evening tour of 01/04/2026. Licensed Practical Nurse #1stated that they worked evening tour on 01/04/2026, started the tube feeding for Resident #38 and must have mistakenly missed to document the start date and time on the tube feeding bottle and water bag.On 01/09/2026 at 10:57 AM, an interview was conducted with Registered Nurse #3 that was scheduled for evening tour on 01/07/2026. Registered Nurse #3 stated that on the 5th floor, the feed is usually hung by the day shift nurse and that when they came to work on the evening of 01/07/2026, they just checked that the correct feed was hanged. They stated they primed the feeding and water and started the feeding at 4:00 PM. Registered Nurse #3 stated they forgot to check if the tube feeding bottle and water bag were labeled and dated.On 01/09/2026 at 11:37 AM, Director of Nursing was interviewed and stated that the nurse who hangs the feeding must put the name of the resident, start date, and the time the feeding is started to ensure that the correct feeding is administered and started on time. 10 NYCRR 415.12(g)(2).

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for one (1) (Resident #92) of one (1) resident reviewed for anticoagulant use out of 22 total sampled residents. Specifically, Resident #92 who was on Eliquis (a medicine used in adults to reduce the risk of stroke and blood clots) had no comprehensive care plan developed to address anticoagulant use. The findings are:The facility policy titled Comprehensive Care Plan with a revised date of 10/20/2024 documented it is the policy of the facility to develop a comprehensive, individualized, person-centered care plan for all residents that meets the medical, nursing, rehabilitation, and psychosocial needs that have been identified in the assessment performed by the interdisciplinary care team. The individualized care plans will incorporate measurable objectives and timelines.Resident #92 had diagnoses that included End-Stage Renal Disease (kidney failure), Diabetes Mellitus (a disease of inadequate control of blood levels of glucose), and Obesity (the state or condition of being overweight).The admission Minimum Data Set assessment (a resident assessment tool) dated 12/09/2025 documented Resident #2 had intact cognition and was admitted with a diagnosis of End-Stage Renal Disease.The Physician's Order dated 12/03/2025 and renewed on 01/02/2026 documented Eliquis 5 milligram, give 1 tablet by oral route two (2) times per day at 10:00 AM and 6:00 PM for End Stage Renal Disease.A Nurse Practitioner progress note dated 01/08/2026 documented an elevated ProBNP (B-type Natriuretic Peptide blood test marker for heart and kidney failure), to continue Eliquis 5 milligrams extended release; and to monitor vital signs, weight, and Basic Metabolic Panel (blood test checks electrolytes, kidney function, and blood sugar).There was no documented evidence that a comprehensive care plan was created to address anticoagulant use.During an interview on 01/12/2026 at 11:37 AM, Registered Nurse #5 who was also the Unit Manager stated they reviewed the electronic medical record and did not find a care plan to address Resident #92's use of Eliquis. Registered Nurse #5 also stated it is their responsibility to initiate care plans and that they were unable to explain how the care plan to address the use of Eliquis was missed.During an interview on 01/12/2026 at 12:56 PM, the Director of Nursing stated that Registered Nurse #5 is responsible to ensure all care plans are completed to reflect every single identified problem and medication. The Director of Nursing also stated there were three (3) different nurses who developed care plans for Resident #92 and Registered Nurse #5 missed the care plan to address the use of Eliquis.10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews, the facility failed to ensure that Minimum Data Set assessments accurately reflected a resident's status. This was evident for two (2) (Resident #127 and #8) of 25 sampled residents. Specifically, 1.) Resident #127's use of wheelchair seatbelt with alarm and bed alarm were not documented in the Minimum Data Set assessment, and 2.) Resident #8's use of chair alarm and bed alarm were not documented in the Minimum Data Set assessment. The findings include: The facility policy titled Minimum Data Set Submission and Completion last revised 10/2025 documented that it is the policy of the facility to ensure accurate and timely completion and submission of Minimum Data Set assessments for all residents. The policy's procedure documented that the Minimum Data Set Coordinators/designees should sign and date sections Z0500A and B when all appropriate sections of the Minimum Data Set are completed within the assigned time frame, and that by signing this section, the Minimum Data Set Coordinator/designee validates accuracy of data entry coding and attests for completion. 1.) Resident #127 had diagnoses of Non-Alzheimer's Dementia and Osteoporosis. On 01/05/2026 at 11:47 AM, Resident #127 was observed sitting in their wheelchair in the unit hallway. A self-releasing seatbelt with alarm was observed in use. The Comprehensive Care Plan on Falls/Injuries which was last reviewed on 10/29/2025 documented that bed alarm was in use for Resident #127 effective on 08/21/2023. The Comprehensive Care Plan titled Use of Self-Releasing Seatbelt with Alarm effective 04/12/2024 and last reviewed on 10/29/2025 documented that Resident #127 used a self-releasing seatbelt with alarm due to a history of multiple falls and cognitive impairment. The Annual Comprehensive Minimum Data Set assessment dated [DATE] documented that Resident #127 had severe cognitive impairments. It also documented that Resident #127 did not utilize any physical restraints or alarms. The Physician's Order dated 08/11/2023 and last renewed on 01/05/2026 documented that Resident #127 used a bed alarm. The Physician's Order dated 08/11/2023 and lasted renewed 01/05/2026 documented that Resident #127 used a self-releasing Velcro seatbelt with alarm in wheelchair due to frequent falls. On 01/08/2026 at 10:28 AM, Registered Nurse #3 stated that Resident #127 utilized a self-releasing seatbelt with alarm and that their ability to self-release the lap belt was tested daily by the nurse. They also stated that Resident #127 had been utilizing a bed alarm since 2023 but that it was discontinued on 01/08/2026 during the Recertification Survey. 2.) Resident #8 had diagnoses that included Urinary Tract Infection, Diabetes Mellitus (a disease of inadequate control of blood levels of glucose), and Polyosteoarthritis (arthritis affecting multiple joints). The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 12/10/2025 documented that Resident #8 had moderately impaired cognition. It also documented that Resident #8 did not use a chair and bed alarm. A comprehensive care plan for falls effective 01/08/2025 with interventions dated 07/09/2025 documented sensor pad bed alarm and sensor pad wheelchair alarm. The Physician's Orders dated 07/09/2025 and renewed on 12/19/2025 documented chair and bed alarm every day at 12:00 AM-8:00 AM; 8:00 AM-4:00 PM; and 4:00 PM-12:00 AM. Check for proper functioning every shift. A nursing progress note dated 01/09/2026 documented observed Resident #8 asleep in bed and bed alarm in place. On 01/07/2026 at 10:48 AM and 01/08/2026 at 12:08 PM, observed Resident #8 on their bed with bed alarm in place. During an interview on 01/08/2026 at 12:08 PM, Certified Nursing Assistant #2 stated Resident #8 has a bed and chair alarm in use due to their history of falls. They check on resident when they are alerted by the alarm. During an interview on 01/09/2025 at 12:29 PM, the Director of Minimum Data Set stated the Minimum Data Set Assessor, who was overseas is unavailable for an interview, completed this assessment and did not accurately code it to reflect that a chair and bed alarm were used by Resident #8. The Director of Minimum Data Set also stated that they just modified the Minimum Data Set Assessment to correct the issue. During an interview on 01/12/2026 at 12:51 PM, the Director of Nursing stated the Minimum Data Set Assessor who inaccurately completed the Assessment is out of the country. The Director of Minimum Data Set is responsible to review all of the Minimum Data Set Assessments to ensure accuracy of data entry. The Director of Nursing also stated that on 01/05/2026 they instructed the Director of Minimum Data Set to ensure that all alarms are coded on the assessments. 10 NYCRR 415.11 (b)

Based on observation, record review, and interviews conducted during a Recertification Survey from 5/9/2024 to 5/16/2024, the facility did not ensure that services provided meet professional standards of quality. This was evident for 1 (Resident #34) of 22 total sampled residents. Specifically, Resident #34, who was cognitively impaired, was observed in their room holding a medication cup containing 4 tablets without a licensed nurse present. Resident #34 stated the Licensed Practical Nurse gave them the pills and they do not know what the small pill was for. The findings are: The facility policy titled Administration of Medications-General Guide which was revised in November 2020 documented all medications are prescribed by a physician and administered by a licensed nurse. The policy documented that it is the responsibility of the nurse to observe resident to ensure medication consumption. Resident #34 was admitted with diagnoses of Dysphagia, Cerebral infarction, and Type 2 Diabetes. The Minimum Data Set assessment dated [DATE] documented Resident #34 was moderately impaired in cognition. A review of the physician's order dated 4/16/2024 documented active orders for acetaminophen 325 mg tablet, give 2 tablets (650 mg) by oral route every 6 hours as needed; ascorbic acid (vitamin C) 500 milligram tablet, give 1 tablet by oral route once daily at 10:00 AM; amlodipine 10 milligram tablet, give 1 tablet by oral route once daily at 10:00 AM; and Eliquis 2.5 milligram tablet, give 1 tablet by oral route 2 times per day at 10:00 AM and 6:00 PM. On 5/9/2024 at 12:07 PM, Resident #34 was observed in their room holding a medication cup containing 4 tablets without a licensed nurse present. Resident #34 stated Licensed Practical Nurse #2 gave them the pills and they do not know what the small pill was for. On 5/9/2024 at 12:09 PM, Licensed Practical Nurse #2 was interviewed and stated they thought Resident #34 already took the pills when they left the room. They stated the medications in Resident #34's medication cup were Eliquis, Vitamin C, Amlodipine, and Tylenol. After the Surveyor interviewed Licensed Practical Nurse #2, the Licensed Practical Nurse went back to Resident #34's room to watch Resident #34 swallow the tablets and told the Resident that the small pill was Eliquis. On 5/9/2024 at 12:45 PM, Registered Nurse #4 who was also the Nurse Manager was interviewed and stated licensed nurses must observe the resident swallow their medications during medication administration before leaving. Registered Nurse #4 further stated Resident #34 was forgetful and had periods of confusion and must be supervised when taking their medication. On 5/15/2024 at 3:36 PM, the Director of Nursing was interviewed and stated as per facility's policy on medication administration, the licensed nurse must ensure that the resident swallow their medications before leaving. 10 NYCRR 415.11(c)(3)(i)

Based on record review and interviews conducted during an abbreviated survey (NY00273131), the facility failed to ensure that each resident receives adequate supervision to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 03/17/2021, Registered Nurse (RN) #1 instructed Certified Nursing Assistant (CNA) #1 to toilet Resident #1. CNA #1 was not familiar with Resident #1 and was not aware that Resident #1 needed 2 people for transfer and toileting. RN #1 stated that they were not aware of Resident #1's required level of assistance for transfer and toileting. RN #1 did not provide or instruct CNA #1 to review the Resident Nursing Instructions record before toileting the resident. CNA #1 did not review the Resident Nursing Instruction record before performing the task. Consequently Resident #1 received inadequate level of assistance with transfer and toileting. As a result, Resident #1 fell during the transfer and sustained bleeding from the nasal bridge. Resident #1 was transferred to the hospital and did not return to the facility. This resulted in minimal harm that is not Immediate Jeopardy. The findings include: Review of the facility's Policy and Procedure titled Fall Prevention Program dated 03/2021, documented that it is the policy of the Home that all residents will be assessed on admission, readmission, quarterly or whenever a significant change of conditions occurs for factors that would place a resident at a higher risk for falls. Subsequently, all residents at the home will be considered at high risk for falls and individualized interventions/plan of action will be documented in the plan of care. Under procedure the policy documented that each Resident's Comprehensive Care Plan and CNA Accountability record will include documentation to address high risk status and safety interventions at the time of admission/readmission. Review of the facility's Policy and Procedure entitled Provision of Activities of Daily Living dated 03/2021, documented that staff will provide resident the necessary level of assistance that meets the resident's current needs. Resident #1 with diagnoses including Fall, Type 2 Diabetes Mellitus, Cancer, and Hypertension. Resident #1 was no longer a resident in the facility. The Minimum Data Set assessment dated [DATE], identified that Resident #1 had a Brief Interview of Mental Status (BIMS used to determine attention, orientation, and ability to recall information) and a score 15/15 indicating intact cognitive status. Resident # 1 required extensive assistance with two persons assist for bed mobility, transfer, and toileting; extensive assistance of one person assist for dressing and personal hygiene. The Accident Report dated 3/17/2021, documented that on 3/17/2021 at approximately 6:28am, Resident #1 was observed lying on the floor next to their bed with their face down. Resident #1 was noted with nose bleeding and a bump on their forehead upon the Registered Nurse (RN) #1 assessment. Resident #1 remained alert and oriented. Resident #1 stated that he/she was trying to transfer to the wheelchair to go to the bathroom. The Medical Doctor (MD) was notified and ordered to transfer Resident #1 to the hospital. The Investigation Summary Report dated 3/19/2021, documented that on 3/17/2021 at approximately 6:28 am, Resident #1 fell on the floor during transfer from bed to a wheelchair while going to the bathroom. Resident #1 claimed that when she/he stood up from bed to transfer to the wheelchair he/she could not grab CNA #1's hand because the CNA pulled his/her arm away. Resident #1 was noted with bleeding from the nasal bridge and a bump to the left forehead. MD was called and ordered to transfer Resident #1 to the hospital. The statement from CNA #1 revealed that while he/she was locking Resident #1's wheelchair, Resident #1 suddenly got up and fell forward on the floor. The investigation concluded that Resident #1 lost their balance during transfer from bed to chair and fell . However, CNA #1 failed to follow Resident #1's plan of care that required two persons assist with transfer. CNA #1 was suspended for 7 days and re-educated on following resident's plan of care upon return to work. All staff was re-educated an Accident/Incidents, and the CNA's role. A Fall Risk assessment dated [DATE], identified Resident #1 with a total score of 60 which designated the Resident #1 as a high risk for falling. A Falls Care Plan dated 02/17/2021, documented interventions that included staff to maintain a safe, hazard free, and well-lit environment; keep items for resident's use within easy reach and level of vision; have call bell within reach and answer promptly. The care plan was updated on 2/24/2021, with interventions that included neuro-check x 24 hours and reinforce safety measures such as calling for assistance by using the call bell. The Care Plan ADL Functional dated 2/17/2021, documented interventions that included have call light within reach and answer promptly; provide ample time to perform task; monitor for changes in level of participation and refer to MD promptly. The care plan also documented that Resident #1 required 2 persons assist with bed mobility, transfer, and toilet use. Nurse's Progress note dated 3/17/2021, and written by the Registered Nurse Supervisor (RNS) #1 documented that at approximately 6:28 AM, Resident #1 was observed lying on floor with her/his face down on the floor close to the bed in front of the wheelchair. Resident was observed with bleeding from the nasal bridge. Pressure was applied and bleeding stopped. On assessment Resident #1 was observed with a bump and swelling to forehead. Discoloration to the nasal bridge was visible. Resident complained of pain to nasal bridge. Upon interview Resident #1 stated that they were trying to get up to go to the bathroom and transfer to the wheelchair. Resident #1 stated that they fell forward on the floor. Resident #1 was last seen in the room lying in bed around 6:00 am prior the incident. The MD made aware and ordered to transfer resident to the hospital for further evaluation. Resident #1's child was notified about the incident. A Nurses' Transfer Note dated 03/17/202, written by RN #1 documented that the physician ordered the transfer of Resident #1 to the hospital for further evaluation and treatment status post fall. Review of Resident #1's Nursing Instructions for the months of February and March 2021 revealed that Resident #1 required two persons assist with bed mobility, toileting, and transfer. Fall precautions included protective measures such as bed in the lowest position and a star sticker placed on resident's identification band and outside of the room to alert staff. During an interview on 7/27/2022 at 1:05 PM, CNA #1 stated that he/she was on duty at the time of the incident and was not assigned to Resident #1. CNA #1 stated that when he/she answered the call bell, RN #1 instructed her/him to assist Resident #1 with toileting. CNA #1 stated that he/she put the wheelchair closer to the bed to assist Resident #1, but while he/she was locking the wheelchair, Resident #1 suddenly stood up from the bed, stumbled, and fell . CNA #1 stated that Resident #1 fell forward on the floor on their face. CNA #1 stated that he/she was not able to prevent Resident #1 from falling. CNA #1 stated that he/she called the nurse immediately. CNA #1 stated that he/she was in-serviced on fall prevention and CNA accountability record check. CNA #1 stated that he/she did not check Resident #1's task for transfer and toileting on the CNA documentation record to see if Resident #1 was a two persons assist. CNA #1 stated that he/she is aware that he/she must check resident's task before providing care. A follow up telephone interview was conducted on 7/28/2022 at 9:37 am, with CNA #1. CNA #1 stated that he/she had never been assigned to Resident #1 before the incident and was not aware that Resident #1 required two persons assist with toileting. During an interview on 7/27/2022 at 2:37 PM, RN #1 stated that he/she worked on the 11:45-8 AM shift on the day of the incident. RN #1 stated that he/she was in Resident #1's room and the resident told him/her that they wanted to use the bathroom. RN #1 stated that he/she called and instructed CNA #1 to toilet Resident #1. RN #1 stated that CNA #1 was the only staff available at the time. RN #1 stated that CNA #1 called him/her and said that Resident #1 fell on the floor. RN #1 stated that he/she saw Resident #1 lying face down on the floor. RN #1 stated that he/she called the supervisor immediately. RN #1 stated that he/she did not recall CNA #1 asking him/her how many persons Resident #1 required for transfer and toileting. During a follow up telephone interview was conducted on 7/28/2022 at 9:40 AM, with RN #1 who stated that he/she was aware that Resident #1 was at risk for falls. RN #1 stated that he/she was not aware that Resident #1 required two persons to assist with toileting. RN #1 stated that he/she did not tell CNA #1 to get another person to assist Resident #1 with toileting. RN #1 stated that he/she makes regular rounds in the unit to ensure resident's care plan is followed. During a telephone interview on 7/28/2022 at 12:50 PM, Registered Nurse Supervisor (RNS) #1 stated that he/she worked the 12-8 am shift on the day of the incident. RNS #1 stated that RN #1 informed him/her around 7:00 am about the incident. RNS #1 stated that he/she observed Resident #1 on the floor bleeding from the bridge of the nose. RNS #1 stated that the resident reported that they were trying to go to the bathroom by themselves. RNS #1 stated that he/she applied pressure on the injured site and the bleeding stopped. RNS #1 stated that he/she called the MD and the MD ordered to transfer resident to the hospital. RNS #1 stated that staff received in-services on fall prevention and CNA instructions. RNS #1 stated that he/she supervises staff by doing rounds and spot checks to ensure staff following residents' plan of care. During an interview on 7/27/2021 at 12:10 PM, the Director of Nursing (DON) stated that Resident #1 was at risk for falls and had previous falls in the community. The DON stated that CNA #1 was interviewed and stated that he/she was locking the wheelchair while Resident #1 tried to get up and fell on the floor. The DON stated CNA #1 was not aware that the resident required two persons assist with transfer and toileting and did not follow the plan of care for the resident. CNA #1 was suspended for 7 days. The DON stated that CNA #1 and all staff were re-educated on following resident plan of care and fall prevention. During a follow-up interview on 09/12/2022 at 11:50 AM, the DON stated that the procedure for CNAs before they are assigned to the residents is to review CNA accountability Instructions for residents assigned to ensure that appropriate assistance is provided. The DON also stated that they were aware that RN #1 instructed the CNA to toilet the Resident #1. The DON further stated that the charge nurse's responsibilities include being familiar with the residents' plan of care and providing adequate supervision and guidance to the CNAs. The DON stated that RN#1 should have informed CNA #1 that Resident #1 required 2 persons assistance for toileting, bed mobility, and transfer. The DON also stated that they were not aware that RN #1 did not inform CNA #1 that Resident #1 required 2 persons assist for toileting, transfer, and bed mobility. 10 NYCRR: 415.12(h)(2)

Based on record review and interviews conducted during the recertification survey from 8/15/22 to 8/22/22, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted in a timely manner. This was evident for 2 (Resident #2 and #3) of 2 residents reviewed for the Resident Assessment task. Specifically, MDS assessments for Resident #2 and Resident #3 were not transmitted within 14 days of their completion date. The findings are: The facility policy titled MDS Submission and Completion last revised 3/18/2020 documented the MDS is electronically submitted /transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days after the completion of a resident's assessment. A submission receipt and validation report are then obtained to verify the completion submission process. 1. Resident # 2 MDS with Assessment Reference Date (ARD) 05/06/2022 was completed 05/12/2022 and did not have a submission date. 2. Resident # 3 MDS with Assessment Reference Date (ARD) 05/02/2022 was completed 05/06/2022 and did not have a submission date. The MDS Director was interviewed on 08/18/2022 at 3:00 PM and stated they are responsible for sending completed MDS assessments to CMS. The MDS Director checked the MDS submission record for Resident #2 and Resident #3 and it was an oversight that the MDS assessments were not submitted yet. The MDS Director stated they submitted the assessments to CMS today. 415.11

Based on observations, record review, and interviews conducted during the recertification survey from 8/15/22 to 8/22/22, the facility did not ensure a resident received necessary services to prevent new ulcers from developing. This was evident for 1 (Resident #9 of 4 residents reviewed for Pressure Ulcer/Injury. Specifically, Resident #9 was observed on multiple occasions without bilateral heel pads in place in accordance with a Physician's Order (PO). The findings are: Resident # 9 had diagnoses of stage 4 pressure ulcer and diabetic nephropathy. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #9 was cognitively intact, required the total assistance of two people to perform Activities of Daily Living (ADL), and had an unhealed stage 4 pressure ulcer. On 08/15/22 at 10:55 AM and 12:00 PM, Resident #9 was observed in bed without bilateral heel pads in place. On 08/16/22 at 11:49 AM, Certified Nursing Assistant (CNA) #1 was observed in Resident #9's room while the resident was in bed. Resident #9 did not have bilateral heel pads in place. On 08/17/22 at 09:48 AM, Registered Nurse (RN) #1 was observed in Resident #9's room while the resident was in bed. Resident #9 did not have bilateral heel pads in place. PO initiated 11/06/18 and last renewed on 08/10/2022 documented Resident #9 was ordered to have bilateral heel pads applied while in bed. The Comprehensive Care Plan (CCP) related to pressure ulcers, initiated 11/07/18 and last revised on 08/12/22, documented staff were to apply pads to Resident #9's bilateral heels. On 08/17/22 at 11:47 AM, CNA #2 was interviewed and stated they have been assigned to Resident #9 for a few months. Physical Therapy informed CNA #2 that Resident #9 is supposed to have bilateral heel pads in place when they are out of bed and in the wheelchair. There are no heel pads applied to Resident #9 while they are in bed. On 08/17/22 at 11:58 AM, RN #1 was interviewed and stated the CNA is supposed to apply bilateral heel pads to Resident #9 while the resident is in bed to prevent skin breakdown. The bilateral heel pads are not applied to Resident #9 when in the wheelchair. The CNA was preparing to take Resident #9 out of bed this morning and removed the bilateral heel pads. 415.12(c)1

Based on observation, record review, and interview conducted during the recertification survey from 8/15/22 to 8/22/22, the facility did not ensure the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #74) of 1 residents reviewed for Dialysis Care out of a total sample of 27 residents. Specifically, the admission MDS assessment for Resident #74 did not accurately reflect the resident's ongoing hemodialyis (HD) treatment. The findings are: Resident # 74 had diagnoses of end stage renal disease (ESRD) and atrial fibrillation. On 08/18/22 at 11:28 AM, Resident #74 was observed with an arteriovenous (AV) shunt in their left arm. The Physician's Order dated 07/17/22 documented orders for Resident #74 to have HD Monday, Wednesday, Friday. The Nursing Admission assessment dated [DATE] documented that Resident #74 was admitted to the facility on HD. The MDS assessment dated [DATE] did not document Resident #74 was receiving HD treatment. On 08/18/22 at 12:02 PM, the MDS Coordinator (MDSC) was interviewed and stated the RN who filled out the MDS assessment for Resident #74 was not available for an interview but must have missed coding Resident #74 as receiving HD treatment. The MDSC is responsible for overseeing the completion of MDS assessments but does not check for accuracy of the assessments. On 08/18/22 at 2:20 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated the MDSC is responsible for ensuring MDS assessments are accurate. 415.11(b)

Based on observation, interviews, and record review during an abbreviated survey (NY00286671), the facility failed to report an alleged violation involving abuse immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no not result in serious bodily injury, to New York State Department of Health (NYS DOH). This was evident for 1 out of 3 residents reviewed (Resident #1). Specifically, on 11/13/2021 at 5:00 AM Resident #1 reported to the Charge Nurse (CN) #1 that two Certified Nursing Assistants (CNA #1 and CNA #2) changed their incontinent brief against their wishes and rough handled them. The facility did not report the alleged abuse within 2-hours to NYS DOH. The facility reported the allegation on 11/18/2021. The Findings include: The facility's Policy and Procedure entitled Patient Abuse, Neglect, Exploitation and Mistreatment; Misappropriation of Property; Reporting Requirements of Suspected Crimes revised 08/2020 documented when there is sufficient credible evidence or reasonable cause to believe abuse, neglect, exploitation, mistreatment, injuries of unknown origin, misappropriation of Residents' property and/or mental abuse has taken place, the facility will report to the New York Department of Health (NYSDOH) immediately or as soon as possible but no later than 24 hours after the discovery of the incident. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including Hypertension, Depression, and Alzheimer's disease. The Minimum Data Set (MDS) dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status (BIMS used to determine attention, orientation, and ability to recall information) and score 10/15 indicating moderately impaired cognition. A Nursing Progress Note dated 11/13/2021 documented that Resident #1 verbalized some concerns that happened last night. The Registered Nurse Supervisor (RNS) #1 and the CN #1 interviewed and assessed Resident #1 for signs of injury and pain. Skin check revealed a small senile purpura to the right hand. The Medical Doctor (MD). A Facility Investigation Summary dated 11/13/2021 revealed that Resident #1 complained that two staff members came into their room around 5:00 AM and forced them to change their incontinent brief. Resident #1 initially reported that the staff members were handling them roughly. On a follow up interview, Resident #1 did not recall their allegation. On exam Resident #1 was found with no signs and symptoms of injuries. Facility contacted Resident #1's child who reported that Resident #1 did not like their morning care to be provided before 8:00 AM. The facility investigation concluded that there was no evidence of physical abuse. Review of NYS DOH Intake Information sheet dated 11/19/2021, revealed that the facility became aware of the alleged abuse violation on 11/13/2021 at 9:30 AM and reported it to NYS DOH on 11/18/2021 at 05:06 PM. During a telephone interview on 07/28/2022 at 1:32 PM, Registered Nurse Supervisor, (RNS) #1 stated that Licensed Practical Nurse (LPN) #1 reported to him/her that Resident #1 alleged that two staff members came to their room and beat them up during incontinent care. RNS #1 stated that he/she examined Resident #1 with no signs of injury and that Resident #1 did not complain of pain. During a telephone interview on 07/28/2022 at 4:00 PM, the Director of Nursing (DON) stated that suspected abuse allegations must be reported to NYS DOH within 24 hours. The DON stated that Resident #1 was promptly assessed and there was no evidence of abuse, neglect, or mistreatment. The DON stated that they should have reported the incident timely. 483.12 (c) (1)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, multiple residents were observed with their oxygen tubing lying on the floor. This was evident for 3 of 24 sampled residents (Resident #s 248, 21, and 31). The findings are: A facility Oxygen Concentrator Policy and Procedure dated 10/2017 documents that If any respiratory supply (masks, cannula, tubing) gets in contact with any dirty surface, wipe or clean with a germicidal solution as per manufacturer's recommendation or if the respiratory supply is visibly soiled, replace with a new respiratory supply. 1) Resident #248 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/25/19 at 09:41 AM, Resident #248 was observed in his room lying in bed. The resident had a nasal cannula in his nose and oxygen tubing connected to a portable oxygen tank next to his bed. The oxygen tubing was lying on the floor in between the bed and the oxygen tank. At 09:44 AM, The Licensed Practical Nurse (LPN #2) came into the room. After interacting with the resident, the LPN observed the oxygen tubing lying on the floor. The LPN picked up the oxygen tubing with her bare hands and placed it on top of the oxygen tank so that it was no longer lying on the floor. The LPN did not sanitize or change the tubing before leaving the room. The physician's orders [REDACTED]. On 09/25/19 at 11:55 AM, LPN #2 was interviewed. LPN #2 stated that it is not standard procedure to pick the oxygen tubing off the floor and place it on to the oxygen tank. LPN #2 stated that she would normally replace the oxygen tubing in order to adhere to infection control practices. The LPN stated that she was preparing to do the resident's wound care and was waiting for the wound care doctor. She was going to change the tubing afterwards. LPN #2 then stated that she is going to change the tubing at this time. 2) Resident #21 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. On 09/27/19 at 10:39 AM, Resident #21 was observed sleeping in bed in his room. The resident had a nasal cannula in his nose and oxygen tubing connected to a oxygen concentrator next to his bed. The oxygen tubing was observed to be lying on the floor in between the resident's bed and the oxygen concentrator. The Hospice Aide (HA) assigned to the resident was sitting in a chair across from the resident's bed, facing the resident. When the SA pointed out to the HA that the resident's tubing was on the floor, the HA stated that she knows that oxygen tubing should not be on the floor. The resident was just placed back on oxygen therapy and this may be why the tubing fell . The HA stated that she does not know what the facility policy is regarding how to address oxygen tubing that has come into contact with the floor. The HA stated that she believes it is acceptable to wipe down the tubing with alcohol. The HA then picked up the oxygen tubing with her bare hands and placed it onto the oxygen concentrator without sanitizing it. The monthly renewal physician's orders [REDACTED]. The Oxygen order has been active since 7/9/19. On 09/27/19 at 11:42 AM, an interview was conducted with the resident's assigned Certified Nursing Assistant (CNA), CNA #2. She has been working in the facility for approximately 4 years. Resident #21 receives Hospice care and has a HA at bedside. CNA #2 stated that the HA will not provide care to the resident without a CNA present. The HA does not touch the resident's oxygen concentrator. There are times that the HA will alert the staff if oxygen tubing has been observed on the resident's floor. If the tubing is on the floor, the Nursing staff are responsible for replacing it. Oxygen tubing should not be touching the floor while attached to the resident. It is an infection control issue. An interview was conducted with LPN #1 on 09/27/19 at 11:54 AM. LPN #1 stated that if oxygen tubing is found to be on the floor, the facility policy is to sanitize the tubing with a germicide wipe and roll it up so it is off the floor. The HA has not brought any concerns to the LPN's attention regarding oxygen tubing being on the floor for Resident #21. On 09/30/19 at 11:04 AM, an interview was conducted with the Assistant Director of Nursing (ADON)/Infection Control Preventionist. The ADON stated that she is responsible for assisting in developing the facility's infection control policies and for providing the staff with inservices related to infection control. The goal of the facility is to not have any tubing touching the floor. If oxygen tubing is observed to be on the floor while attached to a resident, the facility policy is that the tubing should be wiped down with a germicidal wipe and then removed from the floor. The germicidal wipe cannot be used for the nasal cannula because this part gets inserted into the resident's nose. The ADON stated that she provides inservices to all staff members regarding infection control policies. Any outside HAs already received infection control inservices prior to coming into the facility. The facility does not inservice HAs. 3) Resident #31 was admitted to the facilty on 10/3/14. On 09/25/19 at 09:53 AM, resident #31 was observed resting in bed with oxygen running at 2L/min via nose cannula. The oxygen concentrator was located at the foot of the bed, and the oxygen tubing run from the foot to the head of the bed was on the floor. On 09/26/19 at 09:33 AM, resident #31 was observed resting in bed with oxygen tubing on the floor running from foot of bed to the head of the bed. Housekeeper #2 was observed sweeping around the tubing on the floor. The physician's orders [REDACTED]. On 09/27/19 at 11:20 AM, CNA #1 was interviewed. CNA #1 stated the resident is on oxygen therapy. CNA #1 stated when she transfers the resident to her wheelchair she will sometimes switch the resident to an oxygen tank. CNA #1 stated the resident prefers to use the oxygen concentrator because she can move around more freely. CNA #1 stated the resident likes to wheel herself into the bathroom and when she has the tank it is more difficult to get out of the wheelchair, so she prefers the long tubing from the concentrator. CNA #1 stated if the oxygen tubing is on the floor she will put it in the tubing bag on the concentrator or on the resident's bed. CNA #1 stated she would tell the nurse to change the tubing when the resident wheels over it with her wheelchair and there are bubbles in the tubing. CNA #1 did not offer any other instances where she would notify the nurse about the tubing. On 09/27/19 at 12:12 PM, Housekeeper #1 was interviewed. Housekeeper #1 is assigned to clean resident #31's room. Housekeeper #1 stated when a resident is on oxygen she does not remember what she was told regarding infection control. Housekeeper #1 stated she does not remember if she received any training about oxygen tubing being on the floor. Housekeeper #1 stated she was off on 9/26/19 and another housekeeper was assigned to clean the residents room, but was working on 9/25/19. On 09/27/19 at 12:30 PM, Housekeeper #2 was interviewed. Housekeeper #2 stated she is a floater and fill in where she is told. Housekeeper #2 was cleaning Resident #31's room on 9/26/19. Housekeeper # 2 stated when she sees oxygen tubing is on the floor she will tell the nurse. When asked if she told the nurse about the oxygen tubing on the floor on 9/26/19 she stated she was off and then corrected herself and stated she worked on the high room numbers. Housekeeper #2 did not have any recollection of tubing on the floor in the resident's room. 415.19(a)(1-3)

Based on observations and interviews, the facility did not ensure infection control practices were maintained. Specifically, reusable medical equipment- a suction machine, was not maintained in a sanitary manner to prevent the transmission of disease. This was evident in 1 of 4 dining room areas reviewed for Infection Control. (Main Dining Room). The findings are: On 9/6/16 at 9:21 AM and at 12:12 PM, the main dining room, an uncovered suction machine canister was observed with green sediments floating inside a clear liquid. On 9/6/16 at 12:22 PM, the Registered Nurse Manager (RNM) stated that he is responsible for checking the function and cleanliness of the suction machine before lunch service. He stated he had just checked to operation of the machine before lunch service but didn't look inside the canister and that this finding was an oversight. On 9/8/16 at 3:29 PM, the RN In-service Coordinator/ Infection Control Nurse was interviewed. The RN stated that the nurse supervisor who is assigned to the main dining room is responsible for checking the function and cleanliness of the suction machine. She further stated she conducts environmental rounds when she is at the facility one of two times out of the week. There were no concerns identified during 9/1/16 environmental rounds. The Suction Machine Checklist form dated September 2016 was reviewed. There was no check off option for checking the cleanliness of the suction machine. The facility's Suction Machine Inspection policy and procedure dated June 2015 was reviewed. The 8-4 Nursing Supervisor is responsible for checking the suction machine and canister daily for cleanliness in the main dining room. The Infection Control Nurse conducts rounds weekly to ensure compliance of policy and cleanliness of suction machine. 415.19(a)(1-3)

Based on observation, record review and staff interviews, the facility did not ensure that the comprehensive Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically: 1) the Annual MDS assessment did not accurately document the resident's oral/dental status. (Resident # 46); 2) Hospice care was not documented for a resident receiving services. This was evident for 1 of 3 resident's reviewed for Dental Status and Services (Resident #46) and 1 resident reviewed for Hospice and/or Palliative Care (Resident # 109). The findings are: 1) Resident # 46 is a [AGE] year old readmitted to the facility 1/7/14 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] documented that resident had short and long term memory impairment, severe cognitive impairment, required supervision and setup help with eating, and was receiving a mechanically altered diet. Section L for Oral/Dental Status documented none of the above were present indicating that the resident had no dental concerns. On 9/6/16 at 12:00 pm, the resident was observed with multiple missing and broken teeth of the upper and lower jaw. The Comprehensive Care Plan for Dental Care reviewed on 5/19/16 and 8/20/16 documented some/all natural teeth loss-no dentures. The Nutrition Risk assessment dated [DATE] documented oral/dental problems-chewing difficulty. Nursing Instructions for Certified Nursing Assistant documented missing teeth and on thin liquid consistency. The Dental Orders and Progress Notes dated 2/4/16 documented broken natural teeth and multiple retained roots, and chart recorded missing teeth and roots on both upper and lower jaw. On 9/9/16 at 11:45 am, the Certified Nursing Assistant was interviewed and stated that the resident has missing teeth and does not have dentures. On 9/9/16 at 12:35 pm, the Registered Nurse Manager was interviewed and stated that she is responsible for the completion of the MDS and when completing the dental section of the MDS, she speaks to the CNA, checks the dentist recommendations as well as conducting her own assessment She also stated that she knows the resident has missing teeth and was unable to explain why she coded it the way she did. On 9/9/16 at 12:55 pm, the Assistant Director of Nursing was interviewed and stated that she is responsible for signing off on the MDS. She further stated that completion of the dental section of the MDS should be completed based on the medical and nursing dental assessment. 2) Resident # 109 is a [AGE] year old admitted to the facility 8/31/15 with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented short and long-term memory impairment and assistance of 1 staff with activities of daily living. The Quarterly MDS dated [DATE], 5/6/16 and 2/5/16 did not document that the resident was receiving Hospice services. physician's orders [REDACTED]. Review of record revealed that Calvary Home Hospice began providing services 10/16/15 and hospice log sheets documented that resident received services from October 2015 through August 2016. On 9/9/16 at 12:25 pm, the Certified Nursing Assistant was interviewed and stated that she had been providing care for the past year and the resident has been receiving Hospice care for most of that time. On 9/9/16 at 12:35 pm, the Registered Nurse Manager was interviewed and stated the resident had been receiving hospice care services for about a year and that this information should have been documented on the MDS. On 9/9/16 at 12:55 pm, the Assistant Director of Nursing was interviewed and stated that she was aware that the resident is receiving Hospice services and this should be reflected on the MDS. She also stated that she reviews sections of the MDS before signing off on it confirming it is accurate and complete. She further stated that she is sure that this was a section that she reviewed, however, she must have missed these omissions. 415.11 (b)

Based on record review and staff interviews, the facility did not ensure that a resident's clinical record was complete and accurately documented. Specifically, there were multiple omissions Insulin injection sites observed on the resident's Medication Administration Record [REDACTED]. (Resident #136). The findings are: Resident #136 is a [AGE] year old admitted to facility on 6/11/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 14 Day Minimum Data Set 3.0 ((MDS) dated [DATE] documented: moderately impaired cognition and received seven days of insulin injections. Physicians orders dated 6/11/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 94 units by subcutaneous route Physicians orders dated 6/13/16 documented the following: Humalog KwikPen 100 unit/ml subcutaneous inject per prescriber's instructions. Protocol Sliding Scale. If BS <100 0 Units; 100-150 6 Units; 151-200 8 Units; 201-250 10 Units; 251-300 12 Units; 301-350 14 Units; 351-400 16 Units. If greater than 400 or below 60 call MD. Physicians orders dated 6/15/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 50 units by subcutaneous route every 12 hours. Physicians orders dated 7/8/16 and 9/2/16 documented the following: Humalog KwikPen 100 unit/ml subcutaneous inject as per insulin sliding scale. If BS =/<70 0 Units; 71-100 5 Units; 100-150 11 Units; 151-200 13 Units; 201-250 15 Units; 251-300 17 Units; 301-350 19 Units; 351-400 21 Units; If greater than 400 or below 60 call MD. Prescribed 7/8/16. 6. Humalog KwikPen 100 unit/ml subcutaneous inject per prescriber's instructions. Protocol Sliding Scale. If BS <100 0 Units; 100-150 6 Units; 151-200 8 Units; 201-250 10 Units; 251-300 12 Units; 301-350 14 Units; 351-400 16 Units. If greater than 400 or below 60 call MD. Physicians orders dated 7/12/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 60 units by subcutaneous route every 12 hours. Physicians orders dated 7/17/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 54 units by subcutaneous route every 12 hours. Physicians orders dated 9/2/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 50 units by subcutaneous route every 12 hours. Physicians orders dated 9/6/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 55 units by subcutaneous route every 12 hours. The MAR's from June to September 2016 were reviewed. There were multiple omissions of the Insulin injection sites for June and July, August and September. On 9/9/16 at 10:03 AM, the Licensed Practical Nurse (LPN) stated that he is responsible for documenting in the electronic medical record (EMR) the blood sugar level, amount of insulin administered, and the injection site at the time of administration. On 9/9/16 at 10:17 AM, the Registered Nurse Manager (RNM) stated the medication nurses should be documenting blood sugar levels, amount of insulin units administered, and injection sites and was unable to locate the where the omitted information was documented. On 9/9/16 at 12:46 PM, the Director of Nursing (DON) stated that the nurses are expected to document the blood sugar level, amount of insulin administered, and injection site in the MAR. She then stated the EMR system will not allow them to proceed if documentation is not complete. Required fields have a red arrow next to it. The DON stated the RNM is supposed to check for MAR indicated [REDACTED]. The DON further stated that the EMR was not set up correctly to prevent the nurse from proceeding if there was an incomplete entry. The facility Administration and Preparation of Insulin Injection policy and procedure dated May 2003 documents .Nurse .documents administration on the administration record. The facility [MEDICATION NAME] Administration, Storage, and Management policy and procedure dated January 2016 documents .Procedure .Giving the injection .document administration . 415.22(a)(1-4)

Based on record review and staff interviews, the facility did not ensure that services provided met professional standards of quality. Specifically, there were multiple omissions of Insulin injection sites observed on the resident's Medication Administration Record [REDACTED]. (Resident #136). The findings are: Resident #136 is a [AGE] year old admitted to facility on 6/11/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 14 Day Minimum Data Set 3.0 ((MDS) dated [DATE] documented: moderately impaired cognition and received seven days of insulin injections. Physicians orders dated 6/11/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 94 units by subcutaneous route Physicians orders dated 6/13/16 documented the following: Humalog KwikPen 100 unit/ml subcutaneous inject per prescriber's instructions. Protocol Sliding Scale. If BS <100 0 Units; 100-150 6 Units; 151-200 8 Units; 201-250 10 Units; 251-300 12 Units; 301-350 14 Units; 351-400 16 Units. If greater than 400 or below 60 call MD. Physicians orders dated 6/15/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 50 units by subcutaneous route every 12 hours. Physicians orders dated 7/8/16 and 9/2/16 documented the following: Humalog KwikPen 100 unit/ml subcutaneous inject as per insulin sliding scale. If BS =/<70 0 Units; 71-100 5 Units; 100-150 11 Units; 151-200 13 Units; 201-250 15 Units; 251-300 17 Units; 301-350 19 Units; 351-400 21 Units; If greater than 400 or below 60 call MD. Prescribed 7/8/16. 6. Humalog KwikPen 100 unit/ml subcutaneous inject per prescriber's instructions. Protocol Sliding Scale. If BS <100 0 Units; 100-150 6 Units; 151-200 8 Units; 201-250 10 Units; 251-300 12 Units; 301-350 14 Units; 351-400 16 Units. If greater than 400 or below 60 call MD. Physicians orders dated 7/12/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 60 units by subcutaneous route every 12 hours. Physicians orders dated 7/17/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 54 units by subcutaneous route every 12 hours. Physicians orders dated 9/2/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 50 units by subcutaneous route every 12 hours. Physicians orders dated 9/6/16 documented the following: Toujeo [MEDICATION NAME] 300 unit/ml (1.5 ml) subcutaneous insulin pen inject 55 units by subcutaneous route every 12 hours. The MAR's from June to September 2016 were reviewed. There were multiple omissions of the Insulin injection sites for June and July, August and September. On 9/9/16 at 10:03 AM, the Licensed Practical Nurse (LPN) stated that he is responsible for documenting in the electronic medical record (EMR) the blood sugar level, amount of insulin administered, and the injection site at the time of administration. On 9/9/16 at 10:17 AM, the Registered Nurse Manager (RNM) stated the medication nurses should be documenting blood sugar levels, amount of insulin units administered, and injection sites and was unable to locate the where the omitted information was documented. On 9/9/16 at 12:46 PM, the Director of Nursing (DON) stated that the nurses are expected to document the blood sugar level, amount of insulin administered, and injection site in the MAR. She then stated the EMR system will not allow them to proceed if documentation is not complete. Required fields have a red arrow next to it. The DON stated the RNM is supposed to check for MAR indicated [REDACTED]. The DON further stated that the EMR was not set up correctly to prevent the nurse from proceeding if there was an incomplete entry. The facility Administration and Preparation of Insulin Injection policy and procedure dated May 2003 documents .Nurse .documents administration on the administration record. The facility [MEDICATION NAME] Administration, Storage, and Management policy and procedure dated January 2016 documents .Procedure .Giving the injection .document administration . 415.11(c)(3)(i)

Based on record review, interview and observation conducted during a recertification survey, the facility did not review and revise the care plan interventions to reflect a resident's changing medical status for one of three residents reviewed for nutrition (Resident #210). Specifically, a resident who was admitted to the facility following abdominal surgery did not have nutrition care plan interventions to address continued weight loss, a surgical wound that was not healing and reduced absorptive area of the small intestines as a result of a surgical procedure. This resulted in a potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a small bowel resection on 3/19/15 to treat an obstruction. The Admission Weights for this resident are: Weight at Admission (03/27/15): 227 lbs. Weight at 15 days after Admission (04/09/2015): 158 lbs. (which is 69 lbs. less than at admission or a 30.4% loss) Weight at 30 days after Admission (04/28/2015): 153 lbs. (which is 74 lbs. less than at admission or a 32.6% loss) Weight at 60 days after Admission (05/19/2015): 149 lbs. (which is 78 lbs. less than at admission or a 34.4% loss) The admission MDS (Minimum Data Set; resident assessment tool) of 4/3/15, Section K Swallowing/Nutritional Status indicated that the resident was 60 inches tall and weighed 165 lbs. The resident had no/unknown weight loss or gain in the past one to six months and was receiving a mechanically altered, therapeutic diet. The 60-day assessment dated [DATE] indicated that her weight was 149 lbs. at the time of the assessment. The weight loss was not identified on the MDS and represented a 9.6% weight loss in 54 days. The Nutrition Risk Assessment revealed that as of 3/31/15 the resident's weight was 165.4 lbs. and was at risk for unintended weight loss due to diarrhea. The resident had a [DIAGNOSES REDACTED]. The diet was identified as a consistent carbohydrate, mechanical soft diet with thin liquids. The resident was noted with a variable appetite and intake. Interventions included a bedtime snack to deter [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. daily for wound healing first became a standing order on 4/2/15. The current care plan for Nutrition was updated on 5/20/15. The resident's Nutritional Status was documented as follows: "mechanically altered diet, [MEDICAL CONDITION] present 2+, therapeutic diet: consistent carbohydrate, diabetes, small bowel obstruction, colon resection". The goal was for the resident to attain and/or maintain stable and adequate nutrition as evidenced by a stable weight of 149 lbs. +/- 3 lbs. A Dietary Progress Note dated 4/23/15 indicated that the initial weight of 226 lbs. was most likely an error. The resident's current body weight was 155 lbs., weight loss of 10 lbs. likely due to fluid shifts related to 2+ [MEDICAL CONDITION] of both lower legs noted upon admission. The progress notes further documented, "Continues with 1+ [MEDICAL CONDITION] of the lower extremities", therefore continued weight loss would be expected. The resident was then started on [MEDICATION NAME] (a diuretic) 20 mg for 3 days; provided bedtime snack to deter [DIAGNOSES REDACTED] overnight; and resident had diarrhea. The progress note dated 5/20/15 indicated that the resident's weight was 149 lbs, a weight loss of 4.1% in 30 days and 9.9% since admission which was attributed to resolving 2+ [MEDICAL CONDITION]. No new dietary interventions were noted. The 6/9/15 progress note documented the resident's weight as 142.9 (down 6.1 lbs. in 21 days), a weight loss of 4.5% in 30 days. Again the documentation indicated that weight loss likely due to fluid shifts relative to 2+ [MEDICAL CONDITION], continue with bedtime snack. No new interventions noted. The RD (Registered Dietitian) was interviewed on 6/11/15 at 10:00 AM and stated that she believes that the resident's continued weight loss is due to fluid shifts related to [MEDICAL CONDITION]. The RD further stated she would change the plan for the resident if she was made aware that the resident no longer had [MEDICAL CONDITION]. The resident was interviewed on 6/11/15 at 10:30 AM and stated that her usual body weight before her hospitalization was around 160 lbs. The resident stated that she was losing weight. The resident further stated that she eats well even when she doesn't feel like it. When asked how her breakfast was, she stated that she loves her breakfast and eat all of it. The RN #1 was interviewed on 6/11/15 at 11:00 AM she stated that the resident has a lot of things going on and that the resident had an abdominal wound from her surgery that was almost healed which opened up and is now draining a lot of fluid. RN #1 stated that due to that, the resident is depressed and upset. RN #1 further stated that sometimes at meals, when the resident doesn't like what is being served, they will offer her something else but the resident won't take the substitute. RN #1 also stated that the resident's granddaughter comes and brings food from the outside. The resident was observed at 12:30 PM on 6/11/15 and revealed that she had eaten about 50% of her lunch and was still attempting to eat. She stated she drinks the milk in the morning but if she drinks it at lunch she gets "too gassy". She stated she is trying to eat because she knows it will help her heal. Review of the Medical Progress Notes dated 5/27/15 revealed that the resident was having severe nausea. A note dated 5/21/15 described the patient with "nausea and emesis". The medical note dated 5/19/15 indicated that the resident had 1+ [MEDICAL CONDITION] both legs, much less than a month ago. The progress note dated 5/27/15 indicated the following: "opening at the lower end of the surgical wound no bigger than last week, when pressed a large amount of pus came out. Spoke with patient's private surgeon early this afternoon, conditions discussed including worsening wound, pus and metabolic acidosis. He recommended a wound vac. Per surgeon, the patient has very little bowel left." In a second interview with the RD on 6/11/15 at 1:45 PM, she was asked how she was addressing the fact that the resident's wound is not healing, and has reopened, and is continuing to lose weight albeit more slowly than before. The RD stated she will change the plan if the resident continues to lose weight over the next few weeks. The RD stated that since the resident's intake is good she did not feel it was necessary to do anything different. The RD stated that she thinks that the resident's weight loss thus far is entirely due to [MEDICAL CONDITION]. The physician was interviewed on 6/11/15 at 2:30 PM and stated that the surgeon told her that following the surgery, the resident has very little bowel left. The physician stated that she did not want to recommend supplements for the resident due to the fact that she is experiencing malabsorption. When asked about optimizing her nutrition intake based on what she has left of her bowel ([DIAGNOSES REDACTED]), the physician stated it should be a consideration. There were no interventions in the nutrition care plan to address the resident's changing medical status and multiple medical [DIAGNOSES REDACTED]. 415.11(c)(2)(i-iii)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that the residents' environment was free of accident hazards as possible for one of three residents reviewed for accidents (Resident #223). Specifically, the mattress did not fit properly in the bed frame resulting in a gap between the mattress and the siderails, which had the potential for entrapment of the resident's extremities between the rails and the mattress. This resulted in a potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #223 was admitted to the facility on [DATE] following hospitalization for an exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Other [DIAGNOSES REDACTED]. RN #1 was interviewed on 6/8/15 at 1:15 PM and stated that the resident used bilateral quarter siderails to facilitate positioning in the bed. Observation of the resident's room was conducted on 6/9/15 at 9:40 AM. It was noted that there was a gap between the siderail and the mattress on the right side of the bed. This observation was reported to LPN #2 and stated that the gap was caused by bed extensions which had been placed on the bed to facilitate the use of a bariatric mattress for a prior resident. LPN #2 stated that they should be removed and would call engineering to take care of this. LPN #3 was interviewed in the morning of 6/10/15 and that the extensions should have been removed before Resident #223 occupied the bed. 415.12(h)(i)

Based on record review, interview and observation, conducted during a recertification survey, the facility did not ensure that a resident maintained parameters of nutritional status for one of three residents reviewed for nutrition (Resident #210). Specifically, a resident who was admitted to the facility following abdominal surgery did not have nutrition interventions to address continued weight loss, a surgical wound that was not healing and reduced absorptive area of the small intestines as a result of a surgical procedure. This resulted in a potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a small bowel resection on 3/19/15 to treat an obstruction. The Admission Weights for this resident are: Weight at Admission (03/27/15): 227 lbs. Weight at 15 days after Admission (04/09/2015): 158 lbs. (which is 69 lbs. less than at admission or a 30.4% loss) Weight at 30 days after Admission (04/28/2015): 153 lbs. (which is 74 lbs. less than at admission or a 32.6% loss) Weight at 60 days after Admission (05/19/2015): 149 lbs. (which is 78 lbs. less than at admission or a 34.4% loss) The admission MDS (Minimum Data Set; resident assessment tool) of 4/3/15, Section K Swallowing/Nutritional Status indicated that the resident was 60 inches tall and weighed 165 lbs. The resident had no/unknown weight loss or gain in the past one to six months and was receiving a mechanically altered, therapeutic diet. The 60-day assessment dated [DATE] indicated that her weight was 149 lbs. at the time of the assessment. The weight loss was not identified on the MDS and represented a 9.6% weight loss in 54 days. The Nutrition Risk Assessment revealed that as of 3/31/15 the resident's weight was 165.4 lbs. and was at risk for unintended weight loss due to diarrhea. The resident had a [DIAGNOSES REDACTED]. The diet was identified as a consistent carbohydrate, mechanical soft diet with thin liquids. The resident was noted with a variable appetite and intake. Interventions included a bedtime snack to deter [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. daily for wound healing first became a standing order on 4/2/15. The current care plan for Nutrition was updated on 5/20/15. The resident's Nutritional Status was documented as follows: "mechanically altered diet, [MEDICAL CONDITION] present 2+, therapeutic diet: consistent carbohydrate, diabetes, small bowel obstruction, colon resection". The goal was for the resident to attain and/or maintain stable and adequate nutrition as evidenced by a stable weight of 149 lbs. +/- 3 lbs. A Dietary Progress Note dated 4/23/15 indicated that the initial weight of 226 lbs. was most likely an error. The resident's current body weight was 155 lbs., weight loss of 10 lbs. likely due to fluid shifts related to 2+ [MEDICAL CONDITION] of both lower legs noted upon admission. The progress notes further documented, "Continues with 1+ [MEDICAL CONDITION] of the lower extremities", therefore continued weight loss would be expected. The resident was then started on [MEDICATION NAME] (a diuretic) 20 mg for 3 days; provided bedtime snack to deter [DIAGNOSES REDACTED] overnight; and resident had diarrhea. The progress note dated 5/20/15 indicated that the resident's weight was 149 lbs, a weight loss of 4.1% in 30 days and 9.9% since admission which was attributed to resolving 2+ [MEDICAL CONDITION]. No new dietary interventions were noted. The 6/9/15 progress note documented the resident's weight as 142.9 (down 6.1 lbs. in 21 days), a weight loss of 4.5% in 30 days. Again the documentation indicated that weight loss likely due to fluid shifts relative to 2+ [MEDICAL CONDITION], continue with bedtime snack. No new interventions noted. The RD (Registered Dietitian) was interviewed on 6/11/15 at 10:00 AM and stated that she believes that the resident's continued weight loss is due to fluid shifts related to [MEDICAL CONDITION]. The RD further stated she would change the plan for the resident if she was made aware that the resident no longer had [MEDICAL CONDITION]. The resident was interviewed on 6/11/15 at 10:30 AM and stated that her usual body weight before her hospitalization was around 160 lbs. The resident stated that she was losing weight. The resident further stated that she eats well even when she doesn't feel like it. When asked how her breakfast was, she stated that she loves her breakfast and eat all of it. The RN #1 was interviewed on 6/11/15 at 11:00 AM she stated that the resident has a lot of things going on and that the resident had an abdominal wound from her surgery that was almost healed which opened up and is now draining a lot of fluid. RN #1 stated that due to that, the resident is depressed and upset. RN #1 further stated that sometimes at meals, when the resident doesn't like what is being served, they will offer her something else but the resident won't take the substitute. RN #1 also stated that the resident's granddaughter comes and brings food from the outside. The resident was observed at 12:30 PM on 6/11/15 and revealed that she had eaten about 50% of her lunch and was still attempting to eat. She stated she drinks the milk in the morning but if she drinks it at lunch she gets "too gassy". She stated she is trying to eat because she knows it will help her heal. Review of the Medical Progress Notes dated 5/27/15 revealed that the resident was having severe nausea. A note dated 5/21/15 described the patient with "nausea and emesis". The medical note dated 5/19/15 indicated that the resident had 1+ [MEDICAL CONDITION] both legs, much less than a month ago. The progress note dated 5/27/15 indicated the following: "opening at the lower end of the surgical wound no bigger than last week, when pressed a large amount of pus came out. Spoke with patient's private surgeon early this afternoon, conditions discussed including worsening wound, pus and metabolic acidosis. He recommended a wound vac. Per surgeon, the patient has very little bowel left." In a second interview with the RD on 6/11/15 at 1:45 PM, she was asked how she was addressing the fact that the resident's wound is not healing, and has reopened, and is continuing to lose weight albeit more slowly than before. The RD stated she will change the plan if the resident continues to lose weight over the next few weeks. The RD stated that since the resident's intake is good she did not feel it was necessary to do anything different. The RD stated that she thinks that the resident's weight loss thus far is entirely due to [MEDICAL CONDITION]. The physician was interviewed on 6/11/15 at 2:30 PM and stated that the surgeon told her that following the surgery, the resident has very little bowel left. The physician stated that she did not want to recommend supplements for the resident due to the fact that she is experiencing malabsorption. When asked about optimizing her nutrition intake based on what she has left of her bowel ([DIAGNOSES REDACTED]), the physician stated it should be a consideration. Review of the laboratory values for total protein and [MEDICATION NAME] (indicators of protein status) on 4/17/15, 5/11/15 and 6/5/15 revealed the total protein was 5.6, 5.6, and 5.5 (normal range 6.2-8.3) and [MEDICATION NAME] was 2.8, 2.7 and 2.6 (normal range 3.5-5.1) respectively. The laboratory values, although not always accurate indicators of nutritional status, are indicating a downward trend. The "Nutrition Guidelines for Patients with [DIAGNOSES REDACTED]: Symptoms include, gas, cramps, diarrhea, fluid loss and weight loss. Eat 6-8 small meals a day. Only drink 1/2 cup of liquids during each meal..." (Memorial Sloan [MEDICAL CONDITION] Center). There was no evidence of nutrition interventions to address the resident's changing medical status and multiple medical [DIAGNOSES REDACTED]. 415.12(i)(1)