Every finding on record at New Glen Oaks Nursing Home, Inc

Based on observation, record review and staff interviews conducted during the Recertification survey from 06/03/2024 to 06/10/2024, the facility did not ensure that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents were afforded the opportunity to participate in the Comprehensive Care Plan meeting. This was evident for 3 of 3 residents reviewed for Care Planning out of 17 total sampled residents (Resident #41, #23, and #48). The findings are: The facility's policy and procedure titled Comprehensive Care Plan reviewed 2/2024 documented the Interdisciplinary team will update the team care plan after each quarterly assessment or reassessment review or more often if necessary. The policy also documented Resident, family, significant others will be invited to attend for admission, when there is a significant change, and annually. 1. Resident #41 was admitted to the facility with diagnosis of Dementia, Hypertension, and Hyperkalemia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident has moderately impaired cognition. The Quarterly Minimum Data Set also documented the resident and family participated in the assessment. On 6/7/2024 at 9:18 AM, Resident #41's family was interviewed and stated they attended a care plan meeting when resident was admitted to the facility over a year ago and have not attended or been invited to attend any care plan meeting since the initial meeting. The Comprehensive Care Plan meeting sign in sheet for Resident #41 contained no signatures from Resident #41 or their representative for quarterly care plan meetings held on 2/21/2024 and 5/22/2024. The Social Service notes dated 2/12/2024 and 5/10/2024 documented the resident's care plans were reviewed quarterly. There was no documented evidence that Resident #41 and or their family representative were invited to participate in the quarterly care plan meetings. 2. Resident #23 was admitted to the facility with diagnosis of Diabetes Mellitus, Dementia, Hypertension. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident has severely impaired cognition. The Quarterly Minimum Data Set also documented that the resident and family participated in the assessment. The Comprehensive Care Plan meeting sign in sheet for Resident #23 contained no signatures from Resident #23 or their representative for quarterly care plan meetings held on 2/13/2024 and 5/8/2024. Social Service notes dated 1/1/2024 to 5/31/2024 contained no documented evidence that Resident #23 and/or their family representative were invited to the quarterly care plan meetings. 3. Resident #48 was admitted to the facility with diagnosis of Aphasia, Hypertension, and Diabetes Mellitus. The Annual Minimum Data Set, dated dated dated [DATE] documented resident rarely/never understood, unable to conduct interview. The Annual Minimum Data Set documented family participated in the assessment. The Comprehensive Care Plan meeting sign in sheet for Resident #48 revealed Resident #48's representative attended the annual care plan meeting held on 4/26/2023 but did not attend the care plan meetings held on 7/19/2023, 10/10/2023, 1/3/2024 and 3/20/2024. The Social Service notes dated 6/1/2023 to 5/31/2024 revealed resident/family was invited to the annual care plan meeting held on 3/20/2024. However, there was no documented evidence that family/resident were invited to the quarterly care plan meetings held on 7/19/2023, 10/10/2023 and 1/3/2024. On 6/6/2024 at 10:23 AM, Registered Nurse #1 stated that resident's care plan meetings are held annually, quarterly, or when there is a significant change in the resident's status. The interdisciplinary team will invite resident/family to the annual care plan meeting, but residents and family members are not invited to the quarterly meeting unless there is a significant change. Registered Nurse #1 also stated the resident/family are made aware that they can always request a care plan meeting if they wish at any time. On 6/5/2024 at 10:13 AM, Social Worker #1 was interviewed and stated, the care plan meeting is done initially upon admission, quarterly, annually, and when there is a significant change in status. Resident/family are invited to the care plan meetings except for the quarterly meetings. Social Worker #1 also stated that it has never been the practice to invite resident/family to the quarterly; therefore, they had not been inviting them to any quarterly meetings. On 6/10/2024 at 1:24 PM, the Administrator was interviewed and stated Resident #48's representative is very involved, visits the facility very often so they have constant communication with the staff. Administrator further stated resident/representative are invited to the care plan meetings but not always available for the attendance. The Administrator also stated they were not aware that residents and /or their representatives were not being invited to all the care plan meetings including quarterly meetings. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interview conducted during the Recertification Survey from 06/03/2024 to 06/10/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to the residents. Specifically, maintenance services necessary to maintain a sanitary, orderly and comfortable interior were not provided to the residents. Specifically, on Unit 2 mismatched paint, unpainted walls, stained bathroom floors, dusty windowsills, a cracked wall, a sticky tabletop surface, and broken window blinds were observed. This was evident in multiple rooms on 1 of 2 units observed. (Unit 2) The findings are: The facility's policy titled Housekeeping Policy with a reviewed date of 02/2024 documented the purpose of the procedure was to provide guidelines for cleaning and disinfecting resident rooms. The policy documented housekeeping surfaces, including tabletops, will be cleaned on a regular basis, when spill occurs, and when these surfaces are visibly soiled. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. The facility's policy titled Maintenance Department with a reviewed date of 03/2024 documented the Maintenance Department provides a safe and functional environmental by systematic inspection and preventative maintenance of all equipment and construction of the facility. It is the responsibility of the Maintenance Department to provide emergency repairs and proper care of the entire physical structure of the facility. On 06/03/2024 between 10:00 AM and 2:00 PM, the following observations were made on Unit 2: a.) Room B11 had unpainted areas on the wall near the air conditioning unit, and there were areas of mismatched paint on either side of the air conditioning unit. b.) Room B12 had mismatched paint on the walls. c.) Room B9 and B14 had areas with unpainted walls. d.) Resident's common bathroom next to Room B15 had black stains on the floor next to the toilet bowl. During an interview on 06/10/2024 at 12:29 PM, Resident #209 stated their room had mismatched paint and they wished it could be painted with the same color to make their room look lively and bright. During an interview on 06/06/2024 at 11:59 AM, the Interim Environmental Director was interviewed and stated they oversee the Housekeeping and Maintenance Departments. The Interim Environmental Director also stated they started plastering and painting the walls in the hallway, the doors, and side rails on the 1st and 2nd floor and plastered the walls near the air conditioning unit as needed. The Interim Environmental Director further stated they make daily rounds to see if any work needs to be done, but they do not keep logs or keep track of the ongoing work. During an interview on 06/10/2024 at 12:02 PM, the Administrator stated they were stated that some rooms need to be painted and they were doing the best to paint all resident rooms. The Administrator also stated that they are planning to hire an Environmental Director. 45351 On 06/03/2024 at 10:53 AM and on 06/04/2024 at 9:33 AM, room B-8W on Unit 2 the overbed table was observed uncleaned with a sticky surface, the wall above the headboard was observed with dark streaks, brown spots, mismatched paints, the blinds and windowsill were dusty, and there were cracks in the walls above the air conditioner. On 06/04/2024 at 11:27 AM and 06/05/2024 at 10:06 AM, in room B-1D on Unit 2 broken blinds, a dusty windowsill, and cracked walls above the air conditioner and the radiator were observed. In addition, the walls were observed with brown stains and mismatched paint and the tabletop had gray paint marks. During an interview on 06/06/2024 at 11:59 AM, the Interim Environmental Director was interviewed and stated they oversee the Housekeeping and Maintenance Departments. The Interim Environmental Director also stated that they do daily rounds on the units and are made aware of any issues. The facility does not have a logbook for maintenance requests. The Interim Environmental Director further stated that windowsills are cleaned daily and as needed by the housekeeping staff, and all broken blinds were recently changed, and they were not aware of any new issues. The Interim Environmental Director stated they had already plastered and painted the walls in the hallway, the doors, and side rails on the 1st and 2nd floor, and it takes more time to do work in resident's rooms and so they have only plastered a few rooms. During an interview on 06/06/2024 at 12:16 PM, the Administrator stated they had recently replaced the broken blinds in some of the rooms and were not aware there are more broken blinds. The Administrator also stated the dusty areas are cleaned and rooms are maintained by the housekeeping staff daily. 10 NYCRR 415.5(h)(2)

Based on observation, record review and interview conducted during the Recertification Survey from 06/03/2024 to 06/10/2024, the facility did not ensure that the most recent hospice plan of care was provided for a resident. Specifically, the Hospice Assessment, Plan of Care, and Hospice team interdisciplinary notes were not provided to the facility and available for review. In addition, the facility was unaware that the resident had been discharged from Hospice Services on 05/30/2024. This was evident for 1 of 1 resident (Resident #9) reviewed for Hospice out of 17 sampled residents. The findings are: The facility policy and procedure titled Hospice Program with a revision date of 02/2024 documented that the facility contracts for hospice services for resident who wish to participate in such program. The policy also documented that when a resident participates in the hospice program, a coordinated plan of care between the facility, Hospice Agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. The Agreement for Hospice Care to Skilled Nursing Facility residents signed between Hospice Care Network and the facility dated March 15, 2016, documented in Section 12.20 that notwithstanding any other provision in this contract, the Hospice remains responsible for: (a) Ensuring that any service provided pursuant to this contract complies with all pertinent provisions of federal, State and local statues, rules and regulations. (b) Planning, coordinating and ensuring the quality of all services provided and (c) Ensuring adherence to the plan of care established for patients. Article 3 Section 2.4 documented that the Hospice shall develop, review, and revise a Hospice Plan of Care for each Hospice resident which reflect the participation of the Hospice, Skilled Nursing Facility and the Hospice resident and family to the extent possible. Hospice will furnish Skilled Nursing Facility with a copy of the Plan of Care and will identify the services to be furnished by Skilled Nursing Facility, and those services to be provided by Hospice. The agreement also documented that would be communication between Hospice and Skilled Nursing Facility to ensure that the needs of Hospice residents are addressed and met 24 hours a day. Resident #9 had diagnoses that included Coronary Artery Disease, Hypertensive Heart Disease with Heart Failure, and Respiratory Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented that the resident was moderately cognitively impaired, dependent on staff for all Activities of Daily Living and was receiving Hospice Care while a resident. On 06/07/24 at 01:29 PM, Resident #9 was observed in their room seated in a wheelchair alert, soft spoken and well-groomed watching a television program. On 06/10/2024 at 12:30 PM, Resident #9 was observed in their room seated in a wheelchair being fed by a Certified Nursing Assistant. Resident #9 was admitted to Hospice on 10/11/2023. The Physician's order dated 05/11/2024 documented resident with Advance Directive, no blood work, Hospice Services, Do Not Resuscitate, Do Not Intubate. Review of the medical record revealed that there was no Comprehensive Care Plan from the Hospice Agency on file. In addition, there were no interdisciplinary team documentation from the different disciplines which included Social Worker, Hospice Physician and Nurse visits. On 06/10/2024 at 1:30PM, Licensed Practical Nurse #2 was interviewed and stated the Hospice Nurse comes once a week. During the visit, the Hospice Nurse sometimes asked about the resident vital signs and at times, the Hospice Nurse will check the vital signs themselves. Licensed Practical Nurse #2 also stated that they did not recall being given any records from the Hospice agency. On 06/10/2024 at 12:05 PM, the Director of Nursing was interviewed and stated that the Hospice Nurse comes to the facility twice a week. The Director of Nursing also stated that after review of the chart they were not able to locate any documentation from the Hospice agency. On 06/10/2024 at 1:24 PM, a telephone interview was conducted with the Hospice Registered Nurse who stated that once a resident is admitted to hospice, they evaluate the resident once or twice a week. A Home Health Aide is assigned five days a week for four hours, but that had been discontinued since Resident #9 was discharged from Hospice on 05/31/2024. The Hospice Registered Nurse also stated that they do not bring reports to the facility but instead submit them to staff in the office who then provide a copy to the facility. The Hospice Registered Nurse stated that they did not inform the facility that Resident #9 had been discharged , however their office staff was aware of Resident #9's status. During a follow up interview conducted on 06/10/2024 at 2:15 PM, the Director of Nursing stated that they were not aware that Resident #9 had been discharged from Hospice Care on 05/31/2024. 10 NYCRR 415.12

Based on observation, record review and staff interviews conducted during the Recertification survey from 06/03/2024 to 06/10/2024, the facility did not ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to therapeutic activities was not revised quarterly. This was evident for 1 of 1 residents (Resident #41) reviewed for Activities out of 17 total sampled residents. The findings are: The facility's policy and procedure titled Comprehensive Care Plan reviewed 2/24 documented the team will update team care plan after each quarterly assessment or reassessment review or more often if necessary. Resident #41 was admitted to the facility with diagnosis of Dementia, Hypertension and Hyperkalemia. The Quarterly Minimum Data Set was completed on 2/15/2024 and 5/16/2024. The Care Plan for Activity titled Customary Routines for Resident #41 was dated 4/6/2023 and last reviewed/revised on 10/27/2023 documented that resident likes keeping up with news via television and loves to color, group activities. The goal was to participate 2-3x a week and will participate independently daily and 1:1 1-2x/week. Interventions included group activity preferences of social entertainment programs and coloring/art. There was no documented evidence that the comprehensive care plan had been reviewed and revised after quarterly assessment on 2/15/2024 and 5/16/2024. On 6/6/2024 10:23 AM, Registered Nurse #1 stated resident's care plans are reviewed/revised after every assessment and during the meetings held annually, quarterly, or when there is a significant change in resident's status. All departments including activity are responsible to review and revise the related care plans. On 6/10/2024 at 10:43 AM, the Interim Recreation Director stated they have been in this role for few months and had not yet attended the care plan meetings for Resident #41. The Interim Recreation Director could not explain why the care plans were not reviewed or revised after the Quarterly assessments were completed on 2/15/2024 and 5/16/2024. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and staff interviews conducted during the Recertification survey from 06/03/2024 to 06/10/2024, the facility did not ensure that the resident's wishes regarding Cardiopulmonary Resuscitation were accurately documented. Specifically, the medical order and labelling of the medical record did not match. This was evident in 1 of 1 resident reviewed for Advanced Directives (Resident #23) out of 17 total sampled residents. The findings are: The facility policy and procedure titled Residents' Rights Regarding Treatment and Advance Directives revised/reviewed 3/24 documented that it is the resident's right to formulate an Advance Directive, and copies will be made and placed on the chart as well as communicated to the staff. Resident #23 was admitted to the facility with diagnosis of Diabetes Mellitus, Dementia, and Hypertension. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident has severely impaired cognition. During observations on 6/6/2024 at 11:43 AM and 12:17 PM, Resident #23's identification bracelet on their wrist was white in color indicating Cardiopulmonary Resuscitation status and was not yellow in color reflecting Do Not Resuscitate. Resident #23's medical paper chart had white label on the chart that documented Cardiopulmonary Resuscitation, Do Not Intubate. The Medical Orders for Life-Sustaining Treatment (MOLST) form dated 8/23/2022 documented resident's health care proxy formulated for Resident #23 to attempt Cardiopulmonary Resuscitation and Do Not Intubate for life-sustaining treatment. The Physician's Order renewed 1/18/2024 documented Cardiopulmonary Resuscitation and Do Not Intubate. The Hospital Discharge Summary documented Resident #23 was hospitalized from 2/13/2024 to 2/21/2024 for hypoxia. The Physician's Orders dated renewed on 5/16/2024 documented to Do Not Resuscitate and did not document Do Not Intubate and Cardiopulmonary Resuscitation orders. The Comprehensive Care Plan for Advance Directive reviewed 5/6/2024 documented Cardiopulmonary Resuscitation, Do Not Intubate remains in place. Interventions included offer explanation on Health Care Proxy, Do Not Resuscitate to resident or representative if resident does not understand, review and regard Advanced Directives quarterly and as needed, assess capacity quarterly, involve Health Care Proxy if resident should lack capacity. The Social Service note dated 5/6/2024 documented resident has Health Care Proxy, and the advance directives remain in place as per MOLST form (Do Not Intubate, Cardiopulmonary Resuscitation). There was no documented evidence Resident #23's Health Care Proxy changed Resident #23's advance directive status during hospitalization or upon readmission from the hospital on 2/21/2024. On 6/6/2024 at 12:18 PM, Registered Nurse #2 stated that Resident #23 has Do Not Resuscitate order as per most recently renewed medical orders. Resident #23 had a full code status prior to hospitalization in February 2024 and upon readmission, the Do Not Resuscitate order was initiated. Registered Nurse #2 also stated they were not able to locate any documentation reflecting the change to Do Not Resuscitate in Resident #23's medical record. On 6/7/2024 at 10:50 AM, the Medical Doctor stated that upon reviewing Resident #23's medical chart, the Do Not Resuscitate order was initiated after resident returned from the hospital. The Medical Doctor also stated that Resident #23's advance directive preferences were reviewed and acknowledged that it should have not been coded Do Not Resuscitate. The Medical Doctor further stated it was entered in error and was an oversight on their part. On 6/7/2024 at 11:03 AM, Social Worker #1 stated that Resident #23 has a Health Care Proxy and has Cardiopulmonary Resuscitation, Do Not Intubate orders in place. Social Worker #1 also stated that Resident #23's advance directive was reviewed with the resident's representative on 5/6/2024 and there were no changes made. 10 NYCRR 415.3(e)(2)(iii)

Based on observations, record review and staff interviews conducted during the Recertification survey from 06/03/2024 to 06/10/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the residents. Specifically, a resident was observed for extended periods of time without ongoing activity program in accordance with their preferences. This was evident for 1 of 1 resident (Resident #41) reviewed for Activities out of 17 total sampled residents. The findings are: The facility's policy and procedure titled Resident Activities reviewed 11/2023 documented the purpose of activity program is to provide a continued interest in living as opposed to existing and to prevent or defer withdrawal from the activities that make life worthwhile. Resident #41 was admitted to the facility with diagnosis of Dementia, Hypertension and Hyperkalemia. The Annual Minimum Data Set, dated dated dated [DATE] documented Resident #41 had moderately impaired cognition. The Annual Minimum Data Set also documented that it is very important for the resident to keep up with news, do favorite activities and somewhat important to do things with groups of people, listen to music, go outside for fresh air and to participate in religious service/practice. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident had moderately impaired cognition. On 6/3/2024 from 10:08 AM to 11:49 AM, Resident #41 was observed sitting in their wheelchair with other residents in the dining room. No staff interaction with residents was observed and there were no activities occurring on the unit. The activity calendar posted on the bulletin board documented rolling resource cart at 10:30 AM. On 6/4/2024 from 9:55 AM to 12:03 PM, Resident #41 was observed sitting and propelling their wheelchair in the hallway aimlessly. There was no staff interaction with residents or an organized activity occurring on the unit. Resident #41 approached the nursing station and began to engage in conversation with the State Surveyor. The activity calendar posted on the bulletin board documented coffee cart at 10:30 AM. On 6/10/2024 from 10:01 AM to 12:02 PM, Resident #41 was observed wandering around in the hallway without any interaction. No staff interaction with residents was observed and there was not an organized activity occurring on the unit. The activity calendar posted on the bulletin board documented morning coloring at 10:30 AM. The Care Plan for Customary Routines initiated 4/6/2023 and last reviewed 10/27/2023 documented that resident likes keeping up with news via television and loves to color, group activities. The goal was to participate 2-3x a week and will participate independently daily and 1:1 1-2x/week. Interventions included group activity preferences of social entertainment programs and coloring/art. The Therapeutic Recreation assessment completed 2/19/2024 documented resident is alert and oriented to person with some confusion. Resident enjoys relaxing in the dayroom with peers, coloring, and reading magazines. Activity preferences are art/craft, entertainment program, magazine, 1:1 visit from recreation staff, family visits, 1:1 strolling music visit. Resident will participate 2-3 per week, and 1:1 visit 1-2 per week. The Activity Log from 3/1/2024 to 5/31/2024 revealed resident attended 18 days out of 92 days (6 days in March 2024, 6 days in April 2024, 6 days in May 2024). Activities attended included Bingo, Sunday Social, Birthday Party, Movie, and Fresh Air Club. There was no documented evidence Resident #41 was engaged in an ongoing activity to meet their interests and needs. There was no documented evidence that Resident #41 refused to participate in any activities. On 6/10/2024 at 12:22 PM, Certified Nurse Aide #1 stated there are activities happening sometimes in the dining room. Resident #41 likes to have conversations and socialize with their friend. Certified Nurse Aide #1 also stated there was no activity happening on the unit today. On 6/10/2024 at 12:43 PM, Licensed Practical Nurse #1 stated Resident #41 likes to watch television and talk to their friend who also resides on the unit. Licensed Practical Nurse #1 also stated they have seen Resident #41 participate in activities like watching movies, birthday celebration, bingo, and Pictionary games. Licensed Practical Nurse #1 further stated residents will need to be assisted to attend any event happening on the 1st floor, however, they have not seen Resident #41 attend any event on the 1st floor. On 6/10/2024 at 10:21 AM, Recreation Assistant #1 stated the morning activity starts usually around 10:30AM in the dining room of the 1st or 2nd floor. Recreation Assistant #1 also stated that they visit residents on the unit prior to the morning activity to chat and invite them to the activity Recreation Assistant #1 further stated that Resident #41 does not prefer group activities but likes to attend Sunday social, likes to listen to music, and always gets coffee especially when the coffee cart is going around on the unit. Resident #41 is confused most of the time and does not seem to understand when they are asked to participate in the activities. On 6/10/2024 at 10:43 AM, the Interim Recreation Director stated they have been in this role for few months; therefore, they were not able to explain when Resident #41 was assessed for their activity preferences. The Interim Recreation Director also stated that based on their experience, Resident #41 likes to read magazines and have open conversation with others. Resident #41 is confused and does not really understand when they are invited to the activity, so they do not know which activities are preferred by the resident although the goal is for Resident #41 to participate more in activities. The Interim Recreation Director further stated that the care plan was created by the previous Recreation Director, and they had not participated in Resident #41's care plan meeting and was not able to explain why the care plan had not been revised since 10/27/2023. The Interim Recreation Director stated that activities in the facility were mostly happening on the 1st floor so residents on the 2nd floor would need to be assisted to the 1st Floor to attend the activities. 10 NYCRR 415.5(f)(1)

Based on interview and record review conducted during the Recertification Survey from 06/03/2024 to 06/10/2024, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 3 (Resident # 2, # 21, # 23) of 3 residents reviewed for Resident Assessment out of 17 total sampled residents. Specifically, Resident #2, #21, and #23's Minimum Data Set assessments were not transmitted within 14 days of completion. The findings include but are not limited to: The facility's policy titled Electronic Submission of Minimum Data Set with a reviewed date of 04/2024 documented all Minimum Data Set Assessments will be completed and electronically encoded into the facility's Minimum Data Set information system and transmitted to the Centers for Medicare and Medicaid Services Quality Improvement Evaluation System (QIES) in accordance with current Omnibus Budget Reconciliation Act regulations governing transmission of Minimum Data Set data. The facility policy also documented comprehensive assessments must be transmitted electronically within 14 days of care plan completion and all other Minimum Data Set assessments must be submitted within 14 days of Minimum Data Set completion date. The Quarterly Minimum Data Set Assessment for Resident #2 was completed on 01/02/2024 and was not transmitted to the Centers for Medicare and Medicaid Services Data System until 04/10/2024. The Quarterly Minimum Data Set Assessment for Resident #21 was completed on 01/02/2024 and was not transmitted to the Centers for Medicare and Medicaid Services Data System until 03/10/2024. The Significant Change in Status Minimum Data Set Assessment for Resident #23 was completed on 01/09/2024 and was not transmitted to the Centers for Medicare and Medicaid Services Data System until 04/11/2024. In addition, the Quarterly Minimum Data Set Assessment for Resident #23 was completed on 05/06/2024 and was not transmitted to the Centers for Medicare and Medicaid Services Data System until 06/06/2024. On 06/10/24 at 12:02 PM, the Minimum Data Set Coordinator (MDSC) was interviewed and stated they are responsible for scheduling and ensuring each department completed their section in the Minimum Data Set assessment. The Minimum Data Set Coordinator also stated that the owner of the facility is the one who transmits the Minimum Data Set to the Centers for Medicare and Medicaid Services Data System once completed. Th Minimum Data Set Coordinator further stated they did not know the reason why Residents #1, #21, and #23's Minimum Data Set assessments were submitted late. On 06/10/24 at 1:55 PM, the facility's owner was interviewed and stated they had no idea the Minimum Data Set assessments were submitted late. On 06/10/2024 at 12:27 PM, the Administrator was interviewed and stated the Minimum Data Set Coordinator ensures the completion of the Minimum Data Set assessments and the Owner of the facility transmits the assessments to the Centers for Medicare and Medicaid Services Data System. The Administrator also stated they were not aware there were Minimum Data Set assessments that were submitted late. 10 NYCRR 415.11

Based on record review and interviews conducted during the recertification survey, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 44 of 44 Residents reviewed for Resident Assessments. (Resident #s 26, 21, 11, 29, 52, 45, 16,48, 50, 8, 51, 33, 46, 28, 55, 32, 12, 1, 25, 31, 4, 7, 23, 19, 30, 44, 22, 27, 24, 14, 3, 17, 10, 54, 9, 5, 20, 18, 13, 15, 2, 47, 49, 53). Specifically, admission, annual, and quarterly MDS assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. The findings include but are not limited to: The Centers for Medicare Services (CMS) Resident Assessment Instrument Manual (Dated October 2017) documented MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD) 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. 1. Resident #51 Admission MDS with ARD 03/07/2022 was submitted 07/12/2022 = 4 months late. 2. Resident #15 Quarterly MDS with ARD 02/17/2022 was submitted 07/04/2022 = more than 4 months late. 3. Resident #53 Admission MDS with ARD 03/14/2022 was submitted 07/12/2022 = 4 months late. On 08/10/22 at 12:52 PM, MDS Coordinator was interviewed and stated MDS assessments must be submitted 14 days after completion. The Owner of the facility submits the MDS assessments. On 08/10/22 at 01:53 PM, the Administrator was interviewed and stated that the Owner told the Administrator the facility had a waiver and the Owner knows the rules for MDS submission. On 08/10/22 at 02:31 PM, the Owner was interviewed and stated they believe it is 30 days in total for the MDS to initiated and submitted. an interview was conducted with the President/Owner. The President stated that the MDS goes to the Keys system and that the person assigned to the system creates a file when it says that the MDS is ready to be submitted, it is submitted. There was a backlog of MDS submissions from the COVID-19 pandemic and this was part of the waiver. The Administrator does not have control of how fast the books are submitted. MDS lists are created. 415.11

Based on record review and interview conducted during the Recertification and Complaint (NY 296) Survey from 8/3/22 to 8/10/22, the facility did not ensure a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infection. This was evident for 1 (Resident #167) of 1 residents reviewed for Urinary Catheter Care out of a sample of 19 residents. Specifically, Resident #167 had a Foley Catheter (FC), was at high risk for urinary tract infection, and did not have a repeat urine culture following the lab report recommending for repeat collection of urine specimen. The findings are: The facility's policy titled Specimen Collection and Labs dated 11/2019 documented nursing staff will comply with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record will document the date and time the specimen was collected, the name and title of the individual(s) who performed the procedure, and the character, clarity, and color of urine. Resident #167 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented that resident was cognitively intact, totally dependent on staff for most activities of daily living and had an indwelling catheter. On 10/06/2021 at 10:16 AM, the Complainant reported to the Aspen Complaint Tracking System (ACTS) Resident #167 was discharged from the hospital and admitted to the facility with a FC in September 2021 and was examined by the Medical Doctor (MD) on 9/11/21. On 9/27/21, Resident #167 was observed with blood in the catheter tubing, the catheter was removed, and a urine culture was taken. The family informed facility staff that Resident #167 was displaying signs of a urinary tract infection including slurring, being tired, and being forgetful. Facility staff told the family the MD would be consulted re: ordering antibiotic therapy. On 9/30/21, the lab reported Resident #167's urine sample was contaminated. Another urine sample was collected but not sent to the lab. Resident #167 was transferred to the hospital on 10/5/21 and the hospital MD informed the family Resident #167 was in grave condition as result of this infection. The Comprehensive Care Plan (CCP) related to FC, initially discontinued 8/23/21 and resumed on 9/10/21, documented Resident #167 had a foley catheter. Staff were to provide catheter care each shift and report changes in urine features to the Medical Doctor (MD). The Hospital Discharge Summary Instructions dated 9/10/2021 documented Resident #167 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #167 will have a high risk of another urinary tract infection without a chronic indwelling FC. Nursing Note (NN) dated 9/16/21 documented the Urologist recommended for Resident #167 to keep the FC until further notice. NN dated 9/27/21 documented Resident #167's FC was cloudy and pus colored, and Resident #167 complained of pain upon urination. The MD was called and recommended a urine culture be done and FC be removed. PO order dated 9/27/21 documented a urine culture and FC removal for Resident #167. NN dated 9/27/21 documented Resident #167 was voiding, had 2 wet diapers, and voided approximately 100 ccs into a bed pan. Lab Report dated 09/29/2021 documented the urine culture for Resident #167 collected on 9/27/2021 was probably contaminated. Please resubmit. There was no documented evidence the Lab Report was reviewed, or MD was made aware another urine culture was recommended for Resident #167. NN dated 10/5/21 documented Resident #167 had increased weakness, poor appetite, and poor intake. Resident #167 was transferred and admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Lab Report dated 10/07/2021 documented the urine culture for Resident #167 collected on 10/05/2021 was probably contaminated. Please resubmit. NN dated 10/21/21 documented Resident #167 was readmitted from the hospital with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD Admission history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/08/22 at 02:20 PM, Registered Nurse (RN) #1 was interviewed and stated if the lab reported a specimen is contaminated, the MD is informed, the RN obtains an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/08/22 at 03:57 PM, RN #2 was interviewed and stated if they are unable to collect the specimen during their tour, it is handed over for the next shift to collect and document as needed. RN #2 stated that they could not provide a reason Resident #167's medical record did document time of collection and pick up by the lab. On 08/08/22 at 04:27 PM, the MD was interviewed and stated treatment is ordered based on the results of lab reports. A repeat lab culture was ordered for Resident #167 when the lab reported the initial specimen might have been contaminated. The MD believed the contamination of the urine specimen was due to incompetency of the staff that collected the specimen. On 9/27/21, the RN was given an order to temporarily discontinue the Resident #167's catheter, flush, observe, and then reinsert the FC. The MD could not recall giving an order to permanently remove the resident's FC and could not understand the reason the nurse failed to follow instructions. The MD was not aware if a repeat urine specimen was collected from Resident #167. The MD stated they were surprised there was no documentation in Resident #167's medical record re: the lab report or urine specimen collection. On 08/10/22 at 12:00 PM, an interview was conducted with the Director of Nursing (DON) who stated time of urine collection and pick up is documented in the resident's chart, the supervisor notes, and endorsed to the incoming shift to follow up. The DON was not employed by the facility at the time of the complaint. 415.12

Based on record review and interviews conducted during the Recertification and Complaint Survey (NY 614) from 8/3/22 to 8/10/22, the facility did not ensure a resident received adequate supervision and devices to prevent accidents. This was evident for 1 (Resident #7) of 2 residents reviewed for Accidents. Specifically, CNA #1 did not properly apply a Dycem cushion to Resident #7's causing Resident #7 to slide from their wheelchair to the floor. The findings are: The facility's policy titled Accidents, last revised 08/2018, documented the facility will ensure residents receive adequate supervision. An accident refers to any unexpected or unintentional incident or chain of events, which may or may not result in injury to the resident. Failure to implement interventions, including adequate supervision to reduce the risk of an accident, is an avoidable accident. Resident # 7 had diagnoses of [CONDITION(S)] with essential tremors and [CONDITION(S)]. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #7 was severely cognitively impaired, required extensive assistance of one person for bed mobility, transfers, and locomotion on unit, used a wheelchair for locomotion, and had a fall with major injury. A Facility Reported Incident made to the Aspen Complaint Tracking System dated 7/6/22 documented Resident #7 was wheeled by CNA #1 towards the dining room on 7/5/22. CNA #1 paused, and Resident #7 continued to propel themselves and slid from the wheelchair before CNA #1 could prevent a fall. Resident #7 fell on to their knees and hit their head. An addendum to the report dated 7/8/22 documented CNA #1 placed a sheet over the top of a Dycem cushion on the resident's wheelchair, causing Resident #7 to slide out of the wheelchair. CNA #1 was not aware a sheet should not be placed on top of the Dycem cushion. An Occupational Therapy (OT) note dated 12/22/21 documented a recommendation for Resident #7 to have a Dycem cushion applied to their wheelchair to keep Resident #7 in an upright posture when out of bed. Comprehensive Care Plan (CCP) related to risk for falls initiated 5/9/22 documented Resident #7 had a Dycem cushion applied to the wheelchair to prevent sliding and decrease risk for falls. Resident Care Profile for July 2022 documented Resident #7 was at risk for falls. Ensure Dycem is on top of the wheelchair cushion to prevent Resident #7 from sliding. Resident #7 is encouraged to wheel self with feet and anti-thrust cushions. The Accident Report dated 07/05/22 documented Resident #7 was observed on the floor at 5:20AM in a kneeling position. CNA #1 reported they were wheeling Resident #7 in the hallway and Resident #7 slid from the wheelchair. There was no documented evidence the facility provided education or inservice to the 11PM - 7AM shift, including CNA #1, on the proper use of a Dycem cushion. As a result, Resident #7 had an avoidable accident where they slid from their wheelchair. On 08/09/22 at 8:22 AM, CNA #1 was interviewed via telephone and stated they work on the 11PM - 7AM shift. CNA #1 transferred Resident #7 out of bed on 7/5/22 at approximately 5AM and placed a sheet under the cushion on their wheelchair to relieve pressure. CNA #1 was assisting Resident #7 with wheeling down the hallway when Resident #7 slid off the wheelchair with the sheet that was underneath them. The facility did not provide CNA #1 with inservice or training on proper use of the Dycem cushion and CNA #1 did not know using a sheet was contraindicated. On 08/09/22 at 10:38 AM, the OT Director was interviewed and stated OT recommended for Resident #7 to have a Dycem cushion. The OT Director provides inservices on proper usage of assistive devices on the day (7AM - 3PM) and evening (3PM - 11PM) shifts. The Registered Nurse (RN) supervisors inservice the night shift (11PM - 7AM). On 08/09/22 at 11:06 AM, the Director of Nursing (DNS) was interviewed and stated there was no documented evidence CNA #1 was inserviced on use of a Dycem cushion and the contraindication of using a sheet with the Dycem cushion when positioning the resident in the wheelchair. On 08/10/22 at 01:30 PM, the Administrator was interviewed and stated the Rehab Department and Nursing staff work together to inservice staff on proper usage of devices. The content of the in-service involving positioning devices may not include that a sheet is not supposed to be placed with a Dycem cushion. 415.12(h)(1)

Based on staff interviews and record review conducted during the Recertification and Complaint Survey (NY 614) from 8/3/22 to 8/10/22, the facility did not ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for a residents' needs as described in the plan of care. This was evident for 1 (Resident #7) of 2 residents reviewed for Accidents. Specifically, Certified Nursing Aide (CNA) #1 was not competent in placing a antithrust Dycem cushion to Resident #7's wheelchair, resulting in Resident #7 sliding from the wheelchair and falling on the floor. The findings are: Resident # 7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #7 was severely cognitively impaired, required extensive assistance of one person for bed mobility, transfers, and locomotion on unit, used a wheelchair for locomotion, and had a fall with major injury. A Facility Reported Incident made to the Aspen Complaint Tracking System dated 7/6/22 documented Resident #7 was wheeled by CNA #1 towards the dining room on 7/5/22. CNA #1 paused, and Resident #7 continued to propel themselves and slid from the wheelchair before CNA #1 could prevent a fall. Resident #7 fell on to their knees and hit their head. An addendum to the report dated 7/8/22 documented CNA #1 placed a sheet over the top of a Dycem cushion on the resident's wheelchair, causing Resident #7 to slide out of the wheelchair. CNA #1 was not aware a sheet should not be placed on top of the Dycem cushion. An Occupational Therapy (OT) note dated 12/22/21 documented a recommendation for Resident #7 to have a Dycem cushion applied to their wheelchair to keep Resident #7 in an upright posture when out of bed. Comprehensive Care Plan (CCP) related to risk for falls initiated 5/9/22 documented Resident #7 had a Dycem cushion applied to the wheelchair to prevent sliding and decrease risk for falls. Resident Care Profile for July 2022 documented Resident #7 was at risk for falls. Ensure Dycem is on top of the wheelchair cushion to prevent Resident #7 from sliding. Resident #7 is encouraged to wheel self with feet and anti-thrust cushions. The Accident Report dated 07/05/22 documented Resident #7 was observed on the floor at 5:20AM in a kneeling position. CNA #1 reported they were wheeling Resident #7 in the hallway and Resident #7 slid from the wheelchair. There was no documented evidence the facility provided education or inservice to the 11PM - 7AM shift, including CNA #1, on the proper use of a Dycem cushion. As a result, Resident #7 had an avoidable accident where they slid from their wheelchair. On 08/09/22 at 8:22 AM, CNA #1 was interviewed via telephone and stated they work on the 11PM - 7AM shift. CNA #1 transferred Resident #7 out of bed on 7/5/22 at approximately 5AM and placed a sheet under the cushion on their wheelchair to relieve pressure. CNA #1 was assisting Resident #7 with wheeling down the hallway when Resident #7 slid off the wheelchair with the sheet that was underneath them. The facility did not provide CNA #1 with inservice or training on proper use of the Dycem cushion and CNA #1 did not know using a sheet was contraindicated. On 08/09/22 at 10:38 AM, the OT Director was interviewed and stated OT recommended for Resident #7 to have a Dycem cushion. The OT Director provides inservices on proper usage of assistive devices on the day (7AM - 3PM) and evening (3PM - 11PM) shifts. The Registered Nurse (RN) supervisors inservice the night shift (11PM - 7AM). On 08/09/22 at 11:06 AM, the Director of Nursing (DNS) was interviewed and stated there was no documented evidence CNA #1 was inserviced on use of a Dycem cushion and the contraindication of using a sheet with the Dycem cushion when positioning the resident in the wheelchair. On 08/10/22 at 01:30 PM, the Administrator was interviewed and stated the Rehab Department and Nursing staff work together to inservice staff on proper usage of devices. The content of the in-service involving positioning devices may not include that a sheet is not supposed to be placed with a Dycem cushion. 415.3

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that standard precautions were maintained to prevent potential spread of infection. Specifically, staff were observed providing assistance between residents (res) without washing or sanitizing their hands in the dining room. This was evident for 2 of 2 dining rooms observed during the Dining Observation (Dining room [ROOM NUMBER]A and 2B). The Findings are: The facility policy and procedure titled Infection Control Hand Washing documented: Purpose: To provide guideline to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infection. Objective: to prevent the spread of infectious diseases. When to Wash Hands: Appropriate twenty (20)- second handwashing must be performed under the following conditions: before and after caring for residents; after handling used dressings; contaminated tissues, lines, etc.; after contact with blood; broken skin or items or work surfaces potentially contaminated with a resident's secretions or blood secretion, after removing gloves; and upon completion of duty. 1) On 07/26/2018, the following was observed in the dining room located on 1A : At 12:20 PM, Certified Nursing Assistant (CNA) #1 was feeding Resident #104 and #36. She stood up and walked over to Resident #24. She proceeded to move Resident #24's wheelchair closer to the meal table. She then returned to the table where Residents #104 and #36 were seated and resumed feeding both residents without sanitizing or washing her hands. At 12:25 PM, the Licensed Practical nurse (LPN) was observed placing residents' completed trays on the tray rack. She walked over to Residents #104 and #24, and began assisting them with their meals. She left Resident #104 and went to the water dispenser and obtained a cup of water and gave it to Resident #104. She returned to resident #24 and resumed feeding the resident without washing or sanitizing her hands. On 07/26/2018 at 12:30 PM, CNA #1 was interviewed. She stated that she was feeding the residents and is aware that the policy is to sanitize or wash her hands before and after resident contact or contact with resident equipment. She further stated that in-services were provided recently on hand hygiene, and she should have sanitized or washed her hands between assisting the residents. On 07/26/2018 at 12:35 PM, the LPN who worked on the 1st floor was interviewed. She stated that she should have washed or sanitized her hands after placing the dirty trays on the rack. She also stated that hand hygiene should have been performed prior to obtaining the cup of water for Resident #104. The nurse further stated that a hand hygiene in-service was provided recently. 2) On 07/26/2018, the following was observed in the dining room located on 2B: At 12:38 PM, CNA #2 was observed placing dirty trays on the tray rack. She proceeded to Resident #351 and began cutting up the resident's food on the tray. She left the resident's tray and went to the water dispenser and poured water into a cup and gave it to the resident. The CNA did not wash or sanitize her hands after placing dirty trays on rack or before and after assisting the resident with the meal. On 07/26/2018 at 1:00 PM, CNA #2 was interviewed. She stated she should have washed or sanitized her hands after placing dirty trays on the rack and before assisting Resident #35 with cutting their food. On 07/27/18 at 11:48 AM, the Director of Nursing (DON) was interviewed. She stated that Staff are required to wash their hands or use the hand sanitizer gel or wipes between residents. She stated that staff receive in-services upon employment, annually, and if there are any problems identified or any outbreaks within the facility or in the community. The DON stated that they have been in-serviced on proper hand hygiene. 415.19 (b) (4)

Based on observation, record review, and staff interviews during the Recertification Survey, the facility did not ensure that care was provided in accordance with each resident's written plan of care. This was identified for one (Resident #14) of six residents reviewed during the medication administration pass observations. Specifically, during observation of the medication administration pass on 8/21/2017 at 9:35 AM, the Licensed Practical Nurse (LPN) administered the medication [MEDICATION NAME] (a diabetic medication) to Resident #14; however, the LPN did not follow the administration instructions to give the medication once daily before meals as directed in the physician orders. The finding is: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #14 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. The MDS documented the resident had Diabetes Mellitus. A physician's orders [REDACTED]. During the initial tour of the facility on 8/21/2017 at 9:10 AM the Registered Nurse (RN) supervisor stated that the residents on the second floor are served breakfast at approximately 8:00 AM. On 8/21/2017 at 9:35 AM the LPN was observed to administer [MEDICATION NAME] 1 mg tablet to Resident #14. On 8/21/2017 at 9:45 AM the LPN medication nurse was interviewed. The LPN acknowledged that the order read for the medication to be given before meals and she had given the medication to the resident after the resident had finished breakfast. The LPN stated that she would contact the Physician to clarify the order. The Medical Director was interviewed on 8/24/2017 at 1:25 PM. The Medical Director stated the staff must not have read the order correctly and that she was going to review the resident's medical record and medications. 415.11(c)(3)(ii)

Based on observation, record review and staff interviews during the Recertification Survey the facility did not ensure that each resident's environment remained as free from accident hazards as is possible on 1 of 2 nursing units. Specifically, during observation of Resident #25's room on 8/22/2017 at 10:15 AM, an uncapped soiled razor was observed in an open box on top of the resident's bedside table. The finding is: Resident #25 had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. During the room tour of Resident #25's room on 8/22/2017 at 10:15 AM a disposable razor was observed in an open cardboard box on top of the resident's bedside table. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #25 could understand and be understood. The resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition. The resident required extensive assist of one staff member for bed mobility, transfer, and ambulation in the corridor. The resident was dependent on one staff member for personal hygiene and bathing. Resident #25 was observed on 8/21/2017 at 11:30 AM. The resident was observed to self propel the wheelchair in the dining room. A Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) Functional Deficit dated 7/26/2017 documented Resident #25 required extensive assist of one staff member with personal hygiene. Interventions included but were not limited to: assist with mouth, hair, and nail care; and provide all aspects of personal hygiene. The Certified Nursing Assistant (CNA) Accountability Record (CNAAR) Assignment/Instruction sheet documented Resident #25 required assistance with personal hygiene, including shaving. The August 2017 CNAAR documented the resident required extensive assist of one staff member for personal hygiene care, which included combing hair, brushing teeth, and shaving. An interview was conducted on 8/22/2017 at 10:20 AM with the Certified Nursing Assistant (CNA) who was assigned to Resident #25. The CNA stated the razor should not be at the resident's bedside and should be disposed after use in the sharps container. The CNA stated she did not shower or shave the resident that morning and that the resident is usually shaved in the evening. The Director of Nursing Services (DNS) was interviewed on 8/22/2017 at 11:25 AM and acknowledged that the razor should not be kept at the resident's bedside. The 3:00 PM -11:00 PM RN Nursing Supervisor was interviewed on 8/24/2017 at 3:30 PM and stated that the CNAs receive training regarding sharps and are aware that razors are not to be left at residents' bedside and should be disposed of in the sharps containers. The 3:00 PM -11:00 PM CNA who worked on the the weekend of 8/19/2017 and 8/20/2017 and was assigned to Resident #25 was interviewed on 8/24/17 at 4:30 PM. The CNA stated that she did not shave Resident #25 and that if she had she would have placed the razor in the sharps container. 415.12(h)(1)

Based on observation, record review and staff interviews during the recertification survey the facility did not develop a Comprehensive Care Plan (CCP) with goals and interventions specific to the medical needs of the resident. This was evident for one (Resident #19) of five Stage 2 sampled residents reviewed for Unnecessary Medications. Specifically, Resident #19 did not have a CCP developed for a [DIAGNOSES REDACTED]. The finding is: Resident #19 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 0, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff member for bed mobility, transfer, ambulation, eating and toileting. The resident was dependent on staff for dressing and personal hygiene needs. The nursing progress note dated 6/27/2017 documented the resident's right abdominal area was noted with redness and was warm to touch. A telephone order was received for [MEDICATION NAME] (an antibiotic medication) 875 milligrams (mg) by mouth (PO) twice a day (BID) for 7 days for [MEDICAL CONDITION] of the right lower abdomen. A physician progress notes [REDACTED]. There was no Comprehensive Care Plan (CCP) developed for the [DIAGNOSES REDACTED]. The Director of Nursing Services (DNS) and the wound care nurse were interviewed concurrently on 8/23/2017 at 2:55 PM. The DNS and the wound care nurse stated they did not recall the resident being treated for [REDACTED]. The DNS stated that either herself, the MDS nurse, or the nursing supervisor would develop a CCP. The DNS stated a CCP was not developed for Celluitis for Resident #19 and should have been. The Registered Nurse (RN) nursing supervisor who covers the evening shift was interviewed on on 08/24/2017 at 4:13 PM. The RN stated that she recalled Resident #19 was treated for [REDACTED]. The RN stated that staff observed the redness on the resident's abdomen and notified her and that she assessed the resident. The RN stated the area on the abdomen was red and warm to touch, and that she contacted the physician who gave her an order for [REDACTED]. 415.11(c)(1)

Based on record review and staff interviews during the recertification survey the facility did not ensure that the Minimum Data Set (MDS) Assessments were completed in their entirety, despite being signed by the Registered Nurse (RN) MDS Coordinator as completed. This was evident for two of 26 Stage two sampled residents. Specifically, 1) Resident # 43 had three MDSs that were signed as completed, however Section G: Functional Status was not addressed, and 2) Resident # 28 had two MDSs that were signed as completed, however Sections A: Identification Information, C: Cognitive Pattern, and D: Mood were not addressed. This is a repeat deficiency. The findings are: 1) Resident # 43 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition. On 5/31/16 at 2:10 PM the RN MDS Coordinator was interviewed. The RN stated that she is responsible to review the MDS for completion. The RN stated that she was aware that she should not be signing that the MDS are completed until the MDS is completed. The RN further stated that she is also responsible to ensure that all responsible staff completed their sections. On 6/1/16 at 10:00 AM the Physical Therapist (PT) was interviewed. The PT stated that he is responsible to complete Section G of the MDS. The PT also stated that he receives a list of MDSs that need to be completed. Additionally, he stated that Resident #43 was an oversight. 2) Resident #28 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A 30-Day Minimum Data Set (MDS) assessment dated [DATE] was reviewed. Sections (A) Identification Information was incomplete, section (B) Cognitive Patterns and section (D) Mood was not completed yet the MDS Assessment was signed by the Registered Nurse as being completed. A 60-Day MDS assessment dated [DATE] was reviewed. Sections (A) Identification Information, section (C) Cognitive Patterns and section (D) Mood was not completed yet the MDS Assessment was signed by the RN as being completed. On 5/31/16 at 2:10 PM the RN MDS Coordinator was interviewed. The RN stated that she is responsible to review the MDS for completion. The RN stated that she was aware that the MDS Assessments should not be signed as being completed until they are completed. The RN further stated that she is also responsible to ensure that all responsible staff completed their sections. On 6/1/16 at 11:16 AM the Director of Social Work (DSW) was interviewed. The DSW stated that she was responsible for completing sections A, C, and D. The DSW stated that she was given a schedule of all the MDSs that should have been completed but that she must have missed these booklets. 415.11(b)

Based on record review, staff and resident interview during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed for each resident that included measurable objectives and timetables to meet residents' medical and nursing needs that were identified in the comprehensive assessment. Specifically, for Resident # 39, a CCP was not developed for one of two residents reviewed for dental services, in a total sample of twenty-six Stage 2 residents. The finding is: Resident # 39 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Physician order [REDACTED].>The Dental Consult dated 12/23/2015 documented that Resident #39 had most of her own teeth with some loose natural teeth. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had clear speech, could understand and be understood. The resident's Brief Interview for Mental Status (BIMS) was scored as 13, indicating that the resident was cognitively intact. The Oral/Dental Status section of the MDS documented that None of the above were present. review of the resident's medical record revealed [REDACTED].#39 to address dental needs. On 05/31/2016 at 1:35 PM an interview was conducted with Resident # 39. The resident stated she had been seen by the dentist when she first came to the facility in December. Resident # 39 stated that at the time of the dental exam the dentist told her she had a few loose teeth on the upper right side of her mouth. The resident further stated that she was missing some teeth on both the right and left lower portion of her mouth and that she wanted to get a partial (bridge) made. The resident stated that she had not spoken to staff about the partial bridge because she did not think she was going to be in the facility this long. The resident stated she would like to get the work started. An interview was conducted with the Licensed Practical Nurse (LPN), charge nurse for Unit 1, on 05/31/2016 at 1:50 PM. The LPN stated that when a consult is completed by the consulting physician it is reviewed by the nurse (LPN charge nurse or Registered Nurse, (RN) nursing supervisor) and if recommendations are made that require a follow up, the supervisor would contact the resident's physician for telephone orders. The LPN stated that the consult is then placed in the physician's folder for review and signature. The LPN charge nurse stated that there is a facility Minimum Data Set (MDS) nurse who completes all the MDSs and the Comprehensive Care Plans (CCP). The RN Supervisor/ MDS nurse was interviewed on 05/31/2016 at 2:15 PM and stated that she had completed Resident #39's CCP. The RN MDS nurse stated that she thought that maybe the dental evaluation was completed after the MDS completion date. The MDS nurse reviewed the Dental Consult and stated that the MDS should have documented that Resident # 39 had missing and loose teeth. The MDS nurse also stated that there should have been a CCP initiated to address the resident's dental needs. 415.11(c)(1)

Based on record review and staff interview during the recertification survey, the facility did not transmit the required Minimum Data Set (MDS) sub-set data according to the CMS (Center for Medicare and Medicaid Services) requirements for transmittal of Entry MDS, Discharge MDS and Death in facility MDS. This was evident for 8 records reviewed for the 8 Stage 1 Admission Sample residents reviewed. Specifically, Residents # 39, # 6, # 35, # 40, # 27, # 14 and # 41 were admitted to the facility and discharged from the facility without an MDS Entry Assessment completed or an MDS Discharge completed for transmission. Resident # 19 expired in the facility without a Death in facility MDS being completed. The findings are: Resident # 39 was admitted to the facility on [DATE]. There was no Entry MDS completed. The resident is currently still a resident in the facility. Resident # 6 was admitted to the facility on [DATE] and discharged to home on [DATE]. There were no Entry or Discharge MDSs documented or transmitted. Resident # 35 was admitted to the facility on [DATE] and discharged to the resident's home on [DATE] without the Entry MDS completed or Discharge MDS transmitted. Resident # 40 was admitted on [DATE] to the facility for short term rehabilitation and was discharged on [DATE] without the Entry MDS completed or the Discharge MDS transmitted. Resident # 27 was admitted on [DATE] for short term rehabilitation and discharged to home on [DATE] without an Entry MDS every being completed or the Discharge MDS being transmitted. Resident # 14 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] without an Entry MDS being completed or a discharge MDS being transmitted. Resident # 41 was admitted on [DATE] and discharged on [DATE] without an Entry MDS being completed or a Discharge MDS being transmitted. Resident # 19 was admitted to the facility on [DATE] with no MDS Entry completed. The facility Discharge Summary dated [DATE] documented that the resident expired in the facility. The Death in facility MDS was not transmitted. The Registered Nurse (RN)/MDS Nurse was interviewed on [DATE] at 1:20 PM. The RN stated that it was not part of her responsibilities to complete those MDS forms and that she was unaware that they were a requirement. The Director of Nursing Services (DNS)/RN was interviewed on [DATE] at 11:06 AM. The RN stated that the Entry MDS are combined with the Admission MDS Section A. The Discharge MDS are completed by the DNS and entered into the computer by the Nursing Secretary. The facility owner then transmits them. The Discharge MDS for the residents have not been transmitted to date. The facility owner was interviewed on [DATE] at 11:48 AM. The facility owner stated that the Entry MDS is combined with the Admission MDS and the Discharge MDS are completed by the DNS and then put into his computer and he transmits them. He stated that there has been a lot of discharges lately but usually there is not many that need to be transmitted. The facility owner stated that he was not aware that the Entry could not be combined with another MDS. The CMS (Center for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, Ch. 2, page ,[DATE] documents Entry and discharge reporting are required on all residents in the SNF (Skilled Nursing Facility). 415.11

Based on record review, observation and staff interviews during the recertification survey, the facility did not ensure that a determination was made that there had been a significant change in the resident's physical or mental condition. This was evident in 2 of 19 Stage two sampled residents. Specifically, 1) Resident #25 had a decline in Activities of Daily Living (ADLs), Cognition and Urinary Continence as documented on the Minimum Data Set (MDS) Assessment. There was no documented evidence as to why a Significant Change Assessment had not been initiated. 2) Resident # 4 had a decline in functional status in multiple ADLs, a new [DIAGNOSES REDACTED]. This resulted in no actual harm with the potential for minimal harm that is not immediate jeopardy. The finding is: 1) Resident # 25 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. The Functional Status documented on the MDS that the resident required extensive assistance of one person for bed mobility, dressing and personal hygiene. The MDS also documented that the resident was occasionally incontinent of bowel and bladder. In addition, the MDS documented that the resident was not receiving Antipsychotic medications. The quarterly MDS assessment dated [DATE] documented that the resident had a BIMS score of 4 indicating a further decline in cognition. The Functional Status documented on the MDS that the resident was now totally dependent on two person assistance for bed mobility, transfer, dressing and personal hygiene. The MDS also documented that the resident was always incontinent of bowel and bladder. In addition, the resident was receiving Antipsychotic medications 7 days during the assessment period. The resident was observed sleeping in bed on 6/2/15 at 10:30 AM. The resident was again observed at 12:30 PM in the day room. The resident was observed calling Mamma. 2) Resident # 4 has [DIAGNOSES REDACTED]. The 30 day MDS assessment dated [DATE] documented that the resident had a BIMS score of 2, indicating severely impaired cognition. The MDS documented that the resident had a Mood Score of 5, indicating Mild Depression. The Functional Status documented on the MDS that the resident participated in Bed Mobility, Transfer, Toilet Use, Dressing, Personal Hygiene and Bathing with an extensive assist (some weight bearing support by staff) of 1 staff member. The MDS documented that the resident could ambulate with total assistance of 1 staff member and was totally dependent on staff for locomotion. In addition, the MDS documented that the resident was receiving Antipsychotic and Antidepressant medications daily. The 60 day MDS assessment dated [DATE] documented that the resident had a decline in functional status including Bed Mobility, Transfer, Ambulation, Dressing, Personal Hygiene and Bathing to being totally dependent on staff ( 4/2 ) and non ambulatory. In addition, the resident was receiving Antianxiety medications 5 days during the assessment period with a new [DIAGNOSES REDACTED]. The resident's day shift Certified Nurse Aide (CNA) was interviewed on 6/02/15 at 9:30 AM. The CNA stated that the resident transfers with two assist and a walker, he needs assistance with eating, will not participate in his own care and does not participate in bed mobility. The resident was observed in bed on 6/02/15 at 9:30 AM. The resident was eating breakfast without assistance. The resident was alert and responded to the surveyors greeting without difficulty. The MDS Coordinator/Registered Nurse (RN) was interviewed on 6/02/15 at 11:00 AM regarding Resident # 25 and # 4. The RN stated that the Interdisciplinary Team (IDT), at the resident's care plan meeting, would have determined if the resident required a Significant Change Assessment and would notify the MDS Coordinator. The RN also stated that comparisons are made between MDS while completing the assessments. The RN stated that the changes in the resident's functional level required a Significant Change Assessment. 415.11 (a)(3)(ii)

Based on observation, record review and staff interview during the recertification survey, the facility did not provide an accurate and complete assessment for a resident with bilateral contractures of both upper and lower extremities. This was evident for one of three resident's reviewed for Rehabilitation in a total Stage 2 sample of 19 residents. Specifically, Resident # 28 has upper and lower extremity contractures which were not identified on the Minimum Data Set (MDS) Assessment as Functional Limitations in Range of Motion ( Section G0400). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 28 has [DIAGNOSES REDACTED]. The resident's Comprehensive Care Plan (CCP) titled Self Care Deficit dated 7/10/14 included documentation that the resident had contractures of both knees, was a total assist for all activities of daily living (ADL). The MDS assessment dated [DATE] documented that the Brief Interview for Mental Status (BIMS) Score was 15, indicating that the resident was cognitively intact. The MDS documented that the resident was totally dependent on staff for all ADLs, and required two staff for bed mobility and transfer. The MDS documented that there were no functional limitations and no impairments of the resident's upper and/or lower extremities. An Occupational Therapy (OT) Quarterly Review dated 3/27/15 documented that the resident had contractures of both shoulders and both hands with severe arthritic deformities. Additionally, the OT Quarterly Review documented that the resident had right and left lower extremity contractures. Resident was observed on 5/29/15 at 9:00 AM. The resident had contractures to both hands and both legs. The resident was positioned in a geri recliner. The MDS Coordinator/Registered Nurse (RN) was interviewed on 6/02/15 at 11:00 AM. The RN stated that the resident's contractures should have been captured as functional limitations on the MDS and that the care plan is developed from the MDS. There was no CCP specific for the Contractures. 415.11(b)