Every finding on record at Norwegian Christian Home And Health Center

Based on observations, record review, and interview conducted during the Recertification Survey from 08/12/2024 to 08/16/2024, the facility did not ensure infection prevention and control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 2 (Residents #4 and #123) of 2 residents reviewed for Urinary Catheter. Specifically, Resident #4's and #123's urinary drainage bags were observed on the floor in multiple occasions. The findings are: The facility's policy and procedure titled Urinary Catheter Care with a revised date of 04/02/2024 documented that the purpose of the policy and procedure is to prevent catheter-associated urinary tract infections. The policy documented to use standard precautions when handling or manipulating the drainage system and to be sure that catheter tubing and drainage bag are kept off the floor. 1.) Resident #4 was admitted to the facility with diagnoses that included Renal Insufficiency, Renal Failure, End Stage Renal Disease, Obstructive Uropathy, and Neurogenic Bladder. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #4 had moderate impairment in cognition. Resident was totally dependent on staff, does none of the effort to complete the activity; and required the assistance of 2 or more helpers to complete all activities of daily living. During an observation on 08/12/2024 at 7:25 AM and on 08/14/2024 at 9:51 AM, Resident #4's urinary drainage bag was observed on the left side of the bed touching the floor. A Comprehensive Care Plan for indwelling catheter related to benign prostatic hyperplasia / urinary retention, and for being at risk for urinary tract infection was initiated for Resident #4 on 10/10/2022 and was last reviewed on 07/15/2024. The facility interventions include monitoring for signs of urinary tract infection and discomfort. A comprehensive care plan for at risk for urinary tract infection was initiated on 06/24/2016 and was last reviewed on 07/15/2024. The facility interventions include to monitor for possible sign of infection and maintain infection control techniques. 2.) Resident #123 was admitted to the facility with diagnoses that included Renal Insufficiency, Obstructive Uropathy, and Cerebrovascular Accident. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #123 had moderate impairment in cognition and was totally dependent on staff for toileting and hygiene and required substantial/maximal assistance for other activities of daily living. During an observation on 08/12/2024 at 7:32 AM and on 08/14/2024 at 9:54 AM, Resident #123's urinary drainage bag was observed touching the floor. On 08/12/2024 at 10:01 AM and on 08/13/2024 at 10:07 AM, Resident #123's urinary drainage bag was observed resting on the floor mat. A Comprehensive Care Plan for indwelling catheter due to neurogenic bladder was initiated on 12/28/2023 and was last reviewed on 07/12/2024. The facility interventions include monitoring for signs and symptoms of urinary tract infection. On 08/14/2024 at 11:11 AM, an interview was conducted with Certified Nursing Assistant #1, who was assigned to Residents #4 and #123. The Certified Nursing Assistant stated the urinary drainage bag should hang below the bladder and should not be allowed to touch the floor. Certified Nursing Assistant further stated they had not notice that residents' Foley bags were on the floor. On 08/14/2024 at 11:27 AM, Registered Nurse #1 was interviewed and stated that both Residents #4 and #123 were admitted with the Foley catheter. Registered Nurse #1 stated they instructed the Certified Nursing Assistants not to allow the catheter bags to touch the floor to prevent infection. Registered Nurse #1 stated the blue bags were provided yesterday to keep the resident's urinary drainage bag and could not understand why the urinary drainage bags were still kept resting on the floor. On 08/14/2024 at 11:50 AM, Registered Nurse #2, who was the nurse manager, was interviewed and stated they were surprised that residents' urinary drainage bags were allowed to be on the floor by the staff. On 08/16/2024 at 11:55 AM, an interview was conducted with the Director of Nursing who stated that urinary drainage bags must be covered and not placed on the floor. They stated the Registered Nurses are responsible for ensuring that the Certified Nursing Assistants are following this protocol. The Director of Nursing stated they were surprised that staff are not practicing proper infection control after they had been trained. 10 NYCRR 415.19(a)(1-3) 42101

Based on record review and staff interviews conducted during the Recertification Survey from 08/12/2024 to 08/16/2024, the facility did not ensure that the resident and their representative were provided with a summary of the baseline care plan. This was evident in 1 (Resident #9) of 2 residents reviewed for Comprehensive Care Plan out of 31 total sampled residents. Specifically, Resident #9 was not provided a written summary of their baseline care plan. The findings are: The facility's policy titled Care Planning - Baseline with a revised date of 04/2022 documented that a baseline care plan for each resident is developed within 48 hours of completion of the resident assessment. The resident/family must be provided a signed copy of the baseline care plan. Resident #9 was admitted to the facility with diagnoses that included Cancer, Coronary Artery Disease (CAD), and Non-Alzheimer's Dementia. The Minimum Data Set assessment dated [DATE] documented that Resident #9 had intact cognition and participated in assessment and goal setting. A Baseline Care Plan form was completed for Resident #9 with signatures of interdisciplinary staff dated 02/09/2024, 02/10/2024 and 02/12/2024. There was no documented evidence that Resident #9 was provided with a written copy of the baseline care plan. On 08/12/2024 at 8:19 AM, Resident #9 was interviewed and stated they had been in the facility for about 2 years and had not been invited to a care plan meeting. Resident #9 stated they had not received a written summary of their baseline care plan since they had been admitted . On 08/15/2024 at 11:09 AM, an interview was conducted with Registered Nurse #2, who was the nurse manager, and stated that different team members complete the initial base line care plan, but they are not sure who gives the copy to the residents. On 08/15/2024 at 11:46 AM, an interview was conducted with the Director of Social Services. They stated that baseline care plan is completed within 48 hours of residents' admission by the interdisciplinary team members. They stated that a copy of the care plan summary should be printed and provided to the resident/resident's family during their initial care plan meeting. The Director of Social Services further stated that they could not locate the signed copy of Resident #9's base line care plan in the chart. The Director stated that there has been no specific person responsible for giving the summary to the resident. On 08/16/2024 at 12:02 PM, the Director of Nursing was interviewed and stated that the interdisciplinary team members meet within 48 hours of resident's admission to complete and review the resident's baseline care plan prior to meeting with the residents' and their family. The Director of Nursing stated they are not sure when the copy of the summary of baseline care plan is given but they know that social workers are responsible for ensuring that a copy is provided to the residents. 10 NYCRR 415.11 (c)

Based on observations, interviews, and record review conducted during the recertification survey from 9/19/22 to 9/26/22, the facility did not ensure a resident received a reasonable accommodation of their needs. This was evident for 1 (Resident #124) of 28 sampled residents. Specifically, Resident #124 was observed on multiple occasions without their call bell within reach. The findings are: The facility policy titled Fall Risk Management Program last revised 12/09 documented interventions may include functioning and available call bells to prevent the resident from overreaching for the bell and falling over. Resident #124 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #124 had moderate cognitive impairment, required extensive assistance of 2 people to complete most activities of daily living, and had no falls since their last admission to the facility. On 09/22/22 at 11:16 AM, Resident #124 was observed lying in bed and a call bell cord and button were tied around the siderail on the right side of the bed next to the resident's head. Resident #124 was interviewed and stated they use the call bell if they need to get the nurse. Resident #124 reached their right arm back, attempted to grab the call bell, and was unable to reach it. 09/22/22 at 11:51 AM, Resident #124 was observed sitting up in bed eating lunch from a tray on the overbed table in front of them. Certified Nursing Assistant (CNA) #5 was on the resident's right side adjusting the head of the bed. The call bell cord and button continued to be tied to the right siderail at the head of Resident #124's bed. CNA #5 finished adjusting Resident #124, exited the room, and stated they were not assigned to Resident #124 and were only serving the resident lunch. On 09/23/22 at 11:04 AM, Resident #124 was observed lying in bed and the call bell cord and button were on a bedside dresser against the wall on the right side of Resident #124's head of bed. The call bell was out of Resident #124's reach. The medication nurse entered the room, administered medication to Resident #124's roommate, provided water to Resident #124, and exited the room without addressing the call bell out of Resident #124's reach. On 09/23/22 at 11:56 AM, CNA #3 was observed wheeling Resident #124 from the shower room to the resident's room. Resident #124's wheelchair was placed in front of their lunch tray on an overbed table on the left side of their bed. CNA #3 assisted with tray setup. On 09/23/22 at 01:01 PM, Resident #124 was observed in their wheelchair in their room on the left side of their bed and the lunch tray was no longer present. The call bell button and cord were lying on the bed behind Resident #124's wheelchair and out of their reach. The Comprehensive Care Plan (CCP) related to Activities of Daily Living initiated 8/3/22 and last revised 8/28/22 documented staff to encourage Resident #124 to use the call bell for assistance. The CCP related to falls initiated 8/3/22 and revised 8/14/22 documented nursing intervention to reeducate Resident #124 to use call bell for staff assistance. On 9/11/22, the CCP was revised to include nursing intervention to reeducate Resident #124 to call for assistance with ambulation. Hospital Discharge Instructions dated 8/24/22 documented Resident #124 was a high fall risk. Fall Risk Assessment (FRA) dated 9/19/22 documented Resident #124 was a high risk for falls. Nursing Note dated 9/19/22 documented Resident #124 was found on the floor and call bell was actively working. Nursing Note dated 9/20/22 documented Resident #124 had their call bell within reach. On 09/23/22 at 02:54 PM, CNA #3 was interviewed and stated they were filling in for Resident #124's regular aide but has been assigned to Resident #124 previously. The CNA Accountability Record (CNAAR) informs CNA #3 of a resident's ambulatory status and fall risk. Resident #124 fidgets in their wheelchair and CNA #3 ensures Resident #124's phone is nearby when the resident is in bed. CNA #3 stated floor mats were in place to help prevent Resident #124 from getting injured because Resident #124 tends to get out of bed unassisted. On 09/26/22 at 11:36 AM, the nursing supervisor of Resident #124's unit, Registered Nurse (RN) #2, was interviewed and stated Resident #124 was alert and could follow instructions but began overestimating their abilities once they began a physical therapy program. Resident #124 has been observed getting up on their own and attempting to use the bathroom without assistance. Resident #124 is cognitively intact enough to understand how to use the call bell and there is no reason the call bell should be out of Resident #124's reach because it is one of the interventions to prevent Resident #124 from falling. Resident #124 must also be able to reach the call bell button while in their wheelchair. On 09/26/22 at 01:38 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated Resident #124 has fallen in the past, was considered at high risk or falls, and falls prevention interventions included reinforcing the resident's use of the call bell. The call bell should always be within Resident #124's reach. 415.5(e)(1)

Based on interviews and record review conducted during the recertification and complaint (NY00295454) survey from 9/19/22 to 9/26/22, the facility did not ensure all allegations involving abuse were reported immediately, but not later than 2 hours, to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #8) of 1 resident(s) reviewed for abuse out of 25 sampled residents. Specifically, the facility did not report an allegation of sexual abuse involving Resident #8 to the NYSDOH within 2 hours. The findings are: The facility policy titled Abuse last revised 4/2022 documented NYSDOH must be notified of incidents involving serious bodily injury within 2 hours after forming suspicion and all other incidents must be reported within 24 hours. Resident #8 had diagnoses of Dysphagia following Cerebral Infarction and Major Depressive Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #8 was moderately cognitively impaired and displayed physical and verbal behvioral symptoms 1 to 3 days prior to the assessment. The MDS dated [DATE] documented Resident #8 was severely cognitively impaired and displayed verbal and other behavioral symptoms 1 to 3 days prior to the assessment. The Interdisciplinary Care Conference meeting attendance documented Resident #8's family member, Registered Nurse (RN), Dietician, and Social Worker were in attendance on 5/4/22. The Incident Report Review initiated 5/4/22 and completed 5/7/22 documented Resident #8's care plan meeting was held on 5/4/22 at 11:30 AM via telephone with the resident's designated representative in attendance. The resident's representative reported Resident #8 stated a male transporter touched his/her genitals while transporting him/her from an activity. The Aspen Complaint Tracking System documented the facility reported this allegation of sexual abuse to NYSDOH on 05/05/2022 at 5:51 PM The Director of Nursing (DON) was interviewed on 09/26/22 at 02:26 PM and stated the case involving Resident #8 was reported to the NYSDOH within 2 hours. The DON was unable to provide documented evidence the case was reported sooner than 5/5/2022 at 5:51 PM. 415.4(b)(1)(i)

Based on observations, interviews, and record review conducted during the Recertification and Complaint Survey (NY00295977), the facility did not ensure a resident received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 1 (Resident #43) of 5 residents reviewed for Activities of Daily Living (ADL) out of a total sample of 29 residents. Specifically, there was no documented evidence Resident #43 received ADL care, including toileting, on 5/8/22. The findings are: Resident # 43 had diagnoses of anxiety disorder and decreased mobility. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #43 was cognitively intact and required the physical assistance of 2 people for bathing and toileting. On 09/19/22 at 11:30 AM, Resident #43 was interviewed and stated on 5/8/22, Mother's Day, nursing staff did not toilet the resident the entire day. Resident #43's daughter had to change the resident's diapers. Comprehensive Care Plan (CCP) related to ADLs initiated 9/5/19 documented Resident #43 required the extensive assistance of 1 person for toileting every 2 hours and as needed. The Certified Nursing Assistant (CNA) Accountability Record (AR) for 5/2022 did not document a CNA's signature indicating ADL tasks were performed with Resident #43 on 5/8/22. There was no documented evidence Resident #43 refused to be toileted or was toileted on 5/8/22. On 09/26/22 at 11:13 AM, CNA #3 was interviewed and stated Resident #43 required extensive assistance of 2 staff to complete ADLs. CNAs are responsible for documenting the care they provide to residents on the CNAAR. If there are omissions from the CNAAR. If the CNA does not document the care they gave the resident throughout the day, the CNAAR would have omissions. On 09/26/22 at 11:56 AM, Registered Nurse (RN) #3 was interviewed and stated there were a lot of staff that called out on Mother's Day, 5/8/22, but all residents were able to get ADL care. The CNA assigned to Resident #43 did not sign the CNAAR. The CNAs are told all the time to document ADL care provided to residents. On 09/26/22 at 01:56 PM, the Director of Nursing Services (DNS) stated that there were 3 CNAs that worked on Resident #43's unit on 5/8/22, and all residents received ADL care that day. The CNAs must have forgotten to sign off on the CNAAR. Nursing staff are required to complete the CNAAR after they provide ADL care to a resident. Resident #43 refused ADL care on 5/8/22 because the assigned CNA was male. 415.12(a)(3)

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure each resident receives adequate supervision to prevent accidents. This was evident for 1 (Resident #124) of 1 resident(s) reviewed for Accidents. Specifically, staff left the call bell out of reach for Resident #124, a resident with multiple falls and a care plan intervention to encourage the resident to call for help. In addition, the facility did not monitor care plan interventions for effectiveness or modify the interventions despite repeated falls, often repeating previous interventions of frequent monitoring, redirection, and education. The findings are: The facility policy titled Accidents and Supervision dated 12/16/21 documented staff will monitor the effectiveness and modify the interventions as necessary in accordance with the current standards of practice to prevent unavoidable accidents. Resident #124 had diagnoses of cerebral ischemia, fracture of clavicle, sacrum, pelvis, and vertebra. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #124 had moderate cognitive impairment, required extensive assistance of 2 people to complete most activities of daily living (ADL) , and had no falls since the last admission to the facility. On 09/22/22 at 11:16 AM, Resident #124 was observed lying in bed. The call bell cord and button were tied around the siderail on the right side of the bed next to the resident's head. Resident #124 was interviewed and stated they use the call bell if they need to get the nurse. Resident #124 reached their right arm back, attempted to grab the call bell, and was unable to reach it. Bilateral floor mats were in place. On 09/22/22 at 11:51 AM, Resident #124 was observed sitting up in bed eating lunch. Certified Nursing Assistant (CNA) #5 was on the resident's right side adjusting the head of the bed. The call bell cord and button continued to be tied to the right siderail at the head of Resident #124's bed. CNA #5 finished adjusting Resident #124, exited the room, and stated they were not assigned to Resident #124 and were only serving the resident lunch. Bilateral floor mats were in place. On 09/23/22 at 11:04 AM, Resident #124 was observed lying in bed and the call bell cord and button were on a bedside dresser against the wall on the right side of Resident #124's head of bed. The call bell was out of Resident #124's reach. The medication nurse entered the room, administered medication to Resident #124's roommate, provided water to Resident #124, and exited the room without addressing the call bell out of Resident #124's reach. Bilateral floor mats were also in place. On 09/23/22 at 11:56 AM, CNA #3 was observed wheeling Resident #124 from the shower room to the resident's room. Resident #124's wheelchair was placed in front of their lunch tray on an overbed table on the left side of their bed. CNA #3 assisted with tray setup. On 09/23/22 at 01:01 PM, Resident #124 was observed sitting in the wheelchair in their room on the left side of the bed. The resident's lunch tray was no longer in the room. The call bell button and cord were lying on the bed behind Resident #124's wheelchair out of reach. The Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADLs), initiated 8/3/22, documented the intervention to encourage resident to use call bell for assistance. The CCP related to Falls, initiated 8/3/22, documented Resident #124 had falls on 8/3/22, 8/14/22, 8/19/22, 9/11/22, 9/16/22, and 9/19/22. The CCP interventions initiated 8/3/22 included assess judgment and metal status, provide assistance in accordance with resident's needs, investigate cause of falls, bed in lowest position, keep items within reach, orient frequently, provide assistance with ambulation, provide an obstacle-free and save environment, and teach actions that minimize [CONDITION(S)] when changing positions. The interventions of re-education for resident and family to use the call bell for assistance with transfer and ambulation, frequent monitoring, and redirection were added 8/14/22. After the falls on 8/19/22, 9/11/22, 9/16/22, and 9/19/22, the CCP was updated with repeat interventions already on the care plan. The repeat interventions included frequent monitoring, re-education about call bell use, redirection, and education about safety. Accident/Incident (A/I) Investigation Reports dated 9/11/22, 9/16/22, and 9/19/22 documented Resident #124 fell in their room and was found lying on the floor next to their bed. The investigations dated 9/11/22 and 9/16/22 documented Resident #124 was found on the floor mat, and the investigation dated 9/19/22 did not document whether floor mats were in place. The documented plan to prevent recurrence for the falls on 9/11/22, 9/16/22, and 9/19/22 included ongoing monitoring, redirection, and staff teaching. A Physical Medicine Rehabilitation Doctor note dated 9/11/22 documented Resident #124 should have call bell at bedside, avoid clutter at bedside, and avoid trip hazards. A Nursing Note dated 9/19/22 documented Resident #124 was found on the floor with call bell working and the room was free of clutter. The CNA Kardex (instructions for the CNA) as of 9/13/22 did not include floor mats as an intervention to be implemented. The CCP did not include the bilateral floor mats in place during the observations, and there was no documented evidence Resident #124 was assessed for floor mat use to determine whether or not the floor mats would be a trip hazard. There was no documented evidence the facility attempted to re-evaluate the effectiveness of the care plan interventions and look at the circumstances of each fall to develop new interventions to prevent additional falls. In addition, staff did not implement the care plan by leaving the call bell out of Resident #124's reach on multiple occasions. On 09/23/22 at 02:54 PM, Certified Nursing Assistant (CNA) #2 was interviewed and stated Resident #124 has floor mats in place to protect them when they try to get out of bed. The nursing supervisor decides if a resident requires floor mats. The floor mats are not documented on the CNA Accountability Record for Resident #124 but CNA #2 knew the resident was supposed to have floor mats because they were already in place when CNA #2 came to take care of Resident #124 at the start of shift this morning. On 09/26/22 at 11:36 AM, Registered Nurse (RN) Supervisor, RN #2, was interviewed and stated Resident #124 is a high fall risk because they overestimate their abilities. Resident #124 can understand using the call bell and there is no reason the call bell should be left out of reach of the resident. Resident #124's last fall was on 9/19/22 and the resident did not suffer any injury so there were no changes in fall interventions and resident was only encouraged to use the call bell. Resident A/I reports are initiated by the RN Supervisor on duty when a fall occurs. The RN gathers statements from all staff working on the unit even if they are not assigned to the resident's area. The RN also updates the CCP related to falls with any new interventions. The A/I is then had delivered to the Assistant Director of Nursing (ADON) or Director of Nursing (DON). The RN or Physical Therapy (PT) can recommend a resident receive floor mats to prevent falls. They are kept in the nursing supply closet and can be used immediately if a resident is at high risk or falls. The CNA Accountability Record is updated to show CNA floor mats as a task. No other documentation needs to be made re: the assessment of or application of floor mats. Floor mats can be a hazard and should not be used with residents who attempt to get out of bed by walking. It is not safe if a resident walks on the floor mat. On 09/26/22 at 01:38 PM, the ADON was interviewed and stated they were responsible for reviewing and completing a thorough investigation into falls. The resident's CCP is reviewed and revised by the RN Supervisor and/or ADON. The ADON reviews the staff statements prior to concluding a A/I investigation, and the 9/11/22 A/I Report for Resident #124 does not include staff statements. Resident #124 was placed on frequent monitoring and re-educated re: use of the call bell. Staff should always ensure the call bell is reachable. The RN determines whether floor mats are necessary. The RN assesses for appropriateness and safety of floor mats. Floor mats are not indicated for everyone. PT evaluates for use of floor mats, documents, and lets the nurse know whether floor mats are indicated. The CNA Accountability Record should also document use of floor mats. There is no place for staff to document whether floor mats are in place. The ADON was unable to provide documented evidence Resident #124 was evaluated for floor mat use. The Medical Doctor also needs to be aware of floor mats being in place. Falls CCP would have documentation of floor mats as an intervention. ADON was unable to find documentation of floor mat intervention on Resident #124's CCP related to falls. On 09/26/22 at 02:17 PM, the Director of Rehabilitation (DOR) was interviewed and stated the RNs determine floor mat use and application. PT never does an assessment for floor mats. PT does not write the order for floor mats. Floor mats are in place for residents at risk for falls, periods of confusion, non-weight bearing status, and agitated residents. Floor mats are not appropriate for everyone. If the resident can walk or use a rolling walker, they can trip over the floor mat. The assessment of safety and appropriateness is solely done by the nursing dept. On 09/26/22 at 02:26 PM, the DON was interviewed and stated floor mat use is a nursing and PT decision and is based on the resident's ambulatory status. If a resident cannot walk but attempts to get out of bed often, floor mat use can put them at higher risk for falls. The CNA Accountability Record is updated by nursing or rehab to reflect floor mat intervention. Floor mats is an intervention and should be on the CCP. Resident environment needs to be assessed. Fall interventions are updated for appropriateness and after every fall. Sometimes the interventions are reused like monitoring. Facility tries to do new interventions but sometimes the next step would be something too restrictive for the resident. 415.14(a)(2)(7)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections was maintained. This was evident for 1 (Unit 4) of 3 units. Specifically, the Housekeeper on the 4th floor was observed wearing gloves and picking up garbage cans from multiple resident rooms without sanitizing their hands in between. The findings are: On 09/23/22 at 12:01 PM, the Housekeeper was observed with gloves on and resident garbage can in hand going from room [ROOM NUMBER] to the cleaning cart. The Housekeeper dumped the contents into a large black garbage bag tied to the end of the cart and returned the garbage can to room [ROOM NUMBER]. The Housekeeper went to room [ROOM NUMBER] and carried a resident garbage can in his hand to the cleaning cart. The Housekeeper emptied the resident garbage can into the garbage bag tied to the cleaning cart and returned the garbage can to room [ROOM NUMBER]. The Housekeeper repeated the same actions with a resident garbage can from 408 and did not remove their gloves or sanitize hands in between emptying garbage cans from each resident room. On 09/23/22 at 02:37 PM, the Housekeeper was interviewed and stated they wear gloves and sanitize their hands every time they enter a resident's room and when they exit a resident's room. They pick up the resident garbage can and dump it into the bag on the side of the cart and changes gloves and sanitizes their hands in between the resident rooms. 415.19(b)(4)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00287554), the facility failed to provide adequate supervision to prevent elopement. This was evident in 1 out of 2 Residents sampled. (Resident # 1). Specifically, on 11/25/21, Resident #1 was observed wandering in the hallway and stating, I want to go home to eat, why you want me stay in jail. Record review revealed that Resident #1 was not assessed for elopement risk and there were no interventions implemented to prevent Resident #1 from eloping. On 12/05/21, Resident #1 eloped from the facility undetected by staff. Licensed Practical Nurse (LPN) #2 discovered that Resident #1 was missing at 10:40 PM. On 12/05/21 at 11:55 PM, Registered Nursing Supervisor (RNS) #1 received a call from the hospital stating that Resident #1 was brought into the emergency room (ER) by the New York Police Department (NYPD). Resident #1 returned to the facility on [DATE] at 4:30 AM. The findings are: The facility's Policy and Procedure titled, Code Orange Elopement, dated 02/19, last reviewed on 12/05/21, documented: It is the policy of the facility to provide a safe, secure environment for all residents while maintaining their dignity and their highest level of function. Elopement from the facility or the disappearance of a resident, places the resident at high risk for actual injury/harm. Every effort will be made to identify residents who are at risk for elopement. An elopement plan of care will be developed for all resident identified at risk. It also documented the security staff should respond to the sounding alarm promptly, check the vicinity for any residents, reset the alarm and notify the nursing supervisor so the units can do a head count. Resident #1 with diagnoses that included Dementia with behavioral disturbance and Cerebral Infarction. The Minimum Data Set (MDS, a resident assessment tool) dated 11/18/21, documented Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score 04 out of 15, which is associated with severely impaired cognition. Resident #1 required one-person for physical assistance with bed mobility, transfer, and locomotion on and off the unit. A Wandering Risk Scale Assessment was done on 11/12/21, documented that Resident #1 had a score of 0 which indicated that Resident #1 had a low risk for elopement. A Nursing Progress Note, by LPN #1, dated 11/25/21 at 12:47 AM, documented that Resident #1 was alert and responsive with some confusion. No acute distress noted. Resident #1 observed with disturbing behavior of getting out of bed and wandering out in the hallways. Resident #1 was observed screaming in the hallway I want to go home to eat, why you want me stay in jail. Resident #1 was redirected, and emotional support provided. A facility document entitled Resident Visual Monitoring dated 12/03/21, documented that Resident #1, was on every 30 minutes monitoring for wandering and falls. The visual monitoring sheet was signed up to 11:00 PM while Resident # 1 already left the facility. A record review of Nursing notes from 12/25/21, showed no documented evidence that Resident #1 was reassessed for elopement. A Nursing Progress Note, RNS #1, dated 12/06/21 at 1:31 AM, documented that the night shift nurse (11:00 PM to 7:00 AM) informed them that Resident #1 was missing. Code orange was activated, and staff responded immediately. Staff conducted a search throughout the building, Assisted Living, and the vicinity of the nursing home. Resident #1 was last seen in the common area after 9:30 PM. At 11:55 PM, writer received a call from the hospital indicating that Resident #1 was picked up by an ambulance and taken to the emergency department (ED). A Progressive Discipline/Corrective Action dated 12/06/21, documented CNA # 1 was written up for failure to properly checked Resident # 1's whereabout. An observation conducted on 02/16/22, on the 2nd floor showed Resident #1 lying in bed with a wander guard on the left ankle. The two exit doors on the unit were equipped with coded keypads. Staff must enter a code before the exit doors can open. If the unit exit door alarm is activated, the sounding alarm can be heard on the unit, and someone must enter the code to reset the alarm. There were two elevators on the unit. Each elevators had a coded keypad and a wander guard censor. If a resident wearing a wander guard should enter the elevator, the elevator would stop, and someone would have to enter the code for the elevator to move. The exit door on the unit that Resident #1 utilized to exit the unit was approximately 50 feet from Resident #1's room. The exit door that Resident #1 exited through adjoins the Nursing Home and the Assisted Living Facility. Resident #1 used the exit door to the stairway, down to the kitchen back door and out to the street. When the exit door alarm on the unit is activated, staff on the unit and security guard can hear the alarm and see a flashing light. Two cameras were observed on the unit pointing to the two exit doors. There are no cameras in the stairways. There was a camera at the kitchen back door that captured videos on the outside and the adjacent street. The facility did not save any video recording from the elopement. During an interview on 02/16/22 at 12:35 PM, CNA #1, stated that they worked from 2:00 PM to 10:00 PM and from 10:00 PM to 6:00 AM and was assigned to Resident #1 on 12/05/21. CNA #1 stated that Resident #1 was going back and forth from the dining room to the bathroom in the room. CNA #1 stated that care was provided to Resident #1 after dinner at 5:45 PM and Resident #1went back to the dining room at approximately 6:00 PM. At approximately 8:25 PM, Resident #1 reported feeling tired and wanted to go to bed. Resident #1 was taken back to the room and placed in bed. At 9:30 PM, Resident #1 was observed out of bed and was walking in the hallway. CNA #1 encouraged Resident # 1 to get back in bed and Resident #1 went to bed. CNA # 1 continued to provide care to other residents and was later informed by LPN #2 that Resident #1 was not in their room. Everyone on the unit started looking for Resident #1, but Resident # 1 was not found. RNS #1 was notified and Code Orange an elopement code was called. CNA # 1 stated the 30 minutes visual check sheet, the monitoring sheet was pre-signed up to 11:00 PM. CNA #1 received disciplinary action for pre-signing the monitoring sheet. CNA # 1 stated that Resident # 1 was last seen at 9:30 PM by CNA # 1 when Resident #1 was redirected to go back to bed. CNA # 1 had never seen Resident # 1 make any attempts to go on the elevator or open the exit door. CNA # 1 has never hear that Resident #1 wanted to go home. CNA #1 stated doing resident's care and did not hear the exit door alarm. During an interview on 02/16/22 at 2:00 PM, LPN #1, stated that they worked on the 3-11 shift on 12/05/2021 on Resident #1's unit. LPN #1 stated that at approximately 8:50 PM, Resident #1 was given the 9:00 PM medication and went back to bed. LPN #1 handed over the keys and left the unit at 10:00 PM. LPN #1 stated that they did not check on Resident #1 prior to leaving the unit. LPN #1 stated at approximately 12:30 AM, received a call from the facility stating that Resident #1 was missing. LPN # 1 stated that Resident #1 never attempting to go on the elevator, go to the stairwell or go to the exit door. LPN # 1 has never hear Resident # 1 express the desire to go home. LPN #1 did not hear the alarm sound on the unit. During an interview on 02/16/22 at 3:00 PM, RNS #1 stated that LPN #1 left the unit at 10:00 PM and at approximately 10:05 PM, RNS #1 made rounds on the unit and did not observe anything unusual. RNS #1 stated that at approximately 10:40 PM, LPN #2 reported while making rounds Resident #1 was not on the unit. RNS #1 stated that an Elopement Code Orange was activated at 10:50 PM. RNS #1 stated all staff assisted in searching for Resident #1 on other units, outside grounds, and in the Assistive Living facility. Resident #1 was not found. The Director of Nursing (DON) was called at approximately 10:51 PM. RNS #1 stated they were about to call the Police, when RNS # 1 received a call from the hospital at 11:00 PM stating that Resident#1 was just brought into the emergency room (ER) by the New York Police Department (NYPD). RNS #1 stated the hospital reported that they did not know where the Police found Resident #1 and did not know the name of the precinct. RNS #1 stated that the Medical Doctor and the Resident's family member were made aware. RNS # 1 stated an elopement risk assessment was last done on 11/12/21 and Resident # 1 scored 0 which indicated a low risk for elopement. RNS #1 reported Resident # 1 was on 30 minutes visual check monitoring by the CNAs on the unit. RNS # 1 reported Resident # 1 was last seen by CNA # 1 at 9:30 PM. RNS #1 stated that when the 30 minutes visual check record was review, it was discovered that CNA # 1 pre-sign the visual check monitoring sheet resulting in CNA #1 receiving disciplinary action for pre signing the visual check sheet. RNS # 1 stated that rounds are done on the unit to monitor the staff and ensure that care was provided to residents. RNS #1 stated that the alarm on the exit door between the nursing home and the assistive living on the second floor did not alarm, RNS # 1 did not hear any alarm while on the unit. During an interview on 02/17/22 at 4:14 PM, the Director of Nursing (DON) # 1, stated received a call at 10:51 PM from RNS #1 informing that Resident #1 was missing. DON # 1 instructed RNS #1 to follows the elopement protocol. DON # 1 stated that there were cameras with range extending to both exit doors on all nursing units. DON #1 stated when the camera footage was checked, the quality of the image was extremely poor. They were unable to identify Resident #1 or validate the time as the cameras was not synced to the current time. The facility was unable to identify which staff member was the last entered or exited the door between the Assisting Living and the Nursing Home which Resident #1 used to leave the unit. DON # 1 stated that the alarm on the exit door between the assistive living and the nursing home on the unit did not sound. It was only when Resident #1 went through the kitchen back door, that the kitchen door alarm sounded. DON #1 stated the security guard responded to the alarm immediately. The staff on the unit did not hear the alarm. DON # 1 stated the cameras in the vicinity of the Assisted Living lobby clearly reflect the security guard promptly responding to the light at approximately 9:41 PM. The security guard was observed promptly checking all the doors in the Assisted Living Facility and then heading toward the kitchen back door. DON # 1 stated that the cameras in the vicinity of the kitchen back door could not replay. The kitchen is on the main floor of the facility, and there were no cameras in the stairwells. During an interview on 02/17/22 at 12:53 PM, the Administrator, stated prior to the elopement there were alarms on all the doors on the unit. Staff members must enter a code to open the door on the Nursing Home side but on the Assisted Living side, a staff member would push a button then pushed the door open to come through. The Administrator stated there are two exit doors that leads on the outside, and both exit doors have alarms. Staff can hear the alarm at the exit door on the unit when the sounded. A code must be entered by staff members for the alarm to be deactivated and then a code must be re-entered a second time to reactivate the alarm prior to the elopement. The Administrator stated that the last person who came through the exit door on the second floor between the nursing home and the assistive living did not reset the alarm a second time. This allowed Resident #1 to push the door and exit one flight down the stairs then exit through the kitchen back door. Resident #1 was not identified as an elopement risk; therefore, Resident #1 was not wearing a wander guard bracelet. The Administrator stated the alarm door worked as it supposed to be, stating the security guard heard the alarm and responded. The security guard checked all the doors but failed to notify the nursing supervisor or any staffs on the unit that the alarm went off. The Administrator stated that the facility changed the alarms system and replace it with a new system that requires staff to enter a code once and the door automatically reset itself. The facility also installed delayed egress to all alarmed exit doors. During an interview on 02/18/22 at 4:47 PM, the Director of Maintenance (DOM) #1, stated that all security guards received in-service training on elopement prior to start working at the facility. The old system consists of staff having to manually deactivate and reactive the alarm for the doors. All exit alarms doors have a flashing bright light that is triggered when the alarm is sounding, this included the exit door between the assistive living and the nursing home. The security guard will see the flashing light on the security monitors at the security's desk and will hear the alarm. The security must respond to the alarm and turn off the flashing light. The light does not automatically turn off. On 12/05/21, when the alarm system was activated, instead of the security guard going straight to the flashing light, the security guard went to check all the doors. The flashing was from the located of the first floor, kitchen back door. The Kitchen is on the first floor and that is where Resident #1 exited. Resident #1 walked through the exit door between the nursing home and the assistive living on the second floor. Resident #1 then walked down to the first floor, then pushed the kitchen back door exiting triggering the kitchen back door alarm. During an interview on 04/04/22 at 12: 30 PM. LPN #2, stated that Resident #1 was not in bed or in the bathroom on 12/05/2021 at start of the 11-7 shift. The CNA on the unit do not know the whereabout of Resident #1. The RNS was informed that Resident #1 was not on the unit. The RNS asked the security guard to call code Orange an elopement code and the search for Resident #1 started. LPN #2 stated that Resident # 1 never had exit seeking behaviors during the night shift. During an interview on 04/04/22 at 1:15 PM, LPN # 3, stated that on 11/25/21 at 12:47 PM, Resident # 1, wanted to go to the dining room for lunch, but the staff set up Resident # 1 to eat in the hallway and not in the dining room. Resident # 1 said want to go home to eat. LPN # 3 stated that Resident # 1 was making references to going into the dining room to eat. LPN # 3 stated that they never hear Resident # 1 wanting to go home, never witness Resident # 1 with any exit seeking behaviors. Resident #1 never attempted to go on the elevator, go in the stairwell, or to leave the unit. During a follow up interview on 05/18/2022 at 5:39 PM, RNS #1, stated that when the nurse documented that Resident #1 was observed with disturbing behavior of getting out of bed and wandering out in the hallways, usually the nurse must initiate an elopement risk assessment. There was no elopement risk assessment documented for Resident #1 on 11/25/2021. 415.12(h)(1)(2)

Based on observation, record review, and interviews conducted during an Abbreviated survey (NY00281980) the facility did not ensure that residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms. This was evident for 7 of 7 residents sampled for Physical Restraints (Resident #s 1, 2, 3, 4, 5, 6, and 7). Specifically: A resident (Resident #1), diagnosed with Dementia and moderately impaired cognition, was found to have a laceration between the left thumb and index finger and blood on side rails on 08/16/2021. The resident was transferred to the hospital and received seven stitches. There was no evidence that two 1/4 side rails, that were in place at the time of the incident, were re-evaluated after the incident. The side rails that were in place were not identified as restraints for the 7 of 7 Residents with Dementia reviewed. All 7 residents required extensive assistance for bed mobility and were unable to independently remove the side rails or use the side rails to turn from side to side or move up or down in the bed. There was no medical justification for restraint use, no restraint assessment, no alternatives attempted prior to implementing side rails, and no family consent or education regarding the risks and benefits of restraint use prior to 03/18/22. This resulted in Immediate Jeopardy with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents using side rails and or other devices that are potential restraints The findings include but are not limited to: The facility Policy and Procedure entitled Restraints revised on 11/01/2020 documented that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restrains shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. This document also revealed that practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. The facility Policy and Procedure entitled Abuse revised on 02/2019 documented that the facility is a restraint-free facility. A comprehensive assessment by the Restraint Evaluation Team will be conducted to determine the least restrictive device when initial alternative measures to restraint use have been unsuccessful. After consultation with the physician, a restraint order may be issued. The facility Policy entitled Bed Safety Entrapment Prevention with the original date 2/2017 documented that the purpose of the Bed Safety Program is to assist in the reduction of risk for bed entrapment using an intradisciplinary team approach. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses that include Right Hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis of the right side of the body), Vascular Dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and Corticobasal Degeneration (a rare progressive neurological disorder characterized by cell loss and deterioration of specific areas of the brain). A Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 06/18/2021 documented Resident #1 had moderately impaired cognition, required extensive assistance of two persons for bed mobility, and required total assistance of two people for transfer with a Hoyer lift. Physical restraints and side rails were not used for the resident. The Quarterly MDS dated [DATE] documented the same. On 03/18/2022 at 1:00 PM Resident #1 was observed, while their significant other was in the room, with two 1/4 side rails up with bilateral padding applied. Resident #1 was unable to remove the side rail or demonstrate using the side rail to move in bed. On 03/21/2022 at 10:30 AM, Resident #1 was observed in bed, while their significant other along with Certified Nursing Assistant #3 (CNA #3) and CNA #6 were in Resident #1's room, with two 1/4 side rails up. Resident #1 held onto the left side rail with the left hand but was not able to turn independently. CNA #3 and CNA #6 assisted Resident #1 with turning in bed, and Resident #1 held the side rail with the left hand. Resident #1 was not able to use the right hand to hold onto the side rail. A Physician's Order for two 1/4 side rails as an enabler for bed mobility remained active from 08/01/2021 to 03/18/2022, with the last renewal on 02/22/22. No medical symptoms were identified. Resident #1's Record Review reveals no side rails assessment was completed upon admission, quarterly, or after the incident. Side rails assessment was not completed until 03/20/2022. A Comprehensive Care Plan (CCP) for side rails initiated 01/14/2021, revised 03/12/2022, documented Resident #1 used two 1/4 side rails as an enabler for bed mobility, for turning and positioning related to decreased muscle strength, unsteady gait, and impaired mobility. Interventions included: applying side rails per Medical Doctor (MD) order and periodically re-evaluating the need for side rail use; monitoring for negative outcomes of side rail use and reporting to MD; monitoring for signs and symptoms of changes in cognition, behavior, bed mobility and notifying MD of abnormal findings; and re-assess the resident's needs and re-evaluate side rail use if an episode of entrapment or near-entrapment occurs, with or without serious injury. A Care Plan Conference Summary dated 01/13/2021 documented a conference call was done with the family about the Baseline Care Plan. The summary did not reflect education to the family about the benefits and risks of using side rails. A Physical Therapy (PT) Evaluation dated 08/16/2021 and the PT Discharge Note dated 08/29/2021 documented Resident #1 was dependent with rolling left to right and required maximum assist. A Rehabilitation Screening Form dated 02/03/2022 documented Resident #1 was screened with a recommendation for skilled PT service and increased assistance in bed mobility. It stated that Resident #1 requires extensive assistance by 2 persons, needs to continue using Hoyer lift x 2 persons for transfer, and needs to maintain two 1/4 enabler side rails for mobility and positioning. It also stated that Resident #1 sometimes follows instructions. A Physical Therapy (PT) Evaluation and Plan of Treatment Certification Period: 02/04/2022-03/04/2022 documented Resident # 1's baseline to roll left and right as Substantial / Maximal assistance. Review of the facility investigation revealed that on 08/16/2021 at approximately 12:15 PM the assigned staff reported to the nurse that Resident #1 was noted with a 2 cm x 2 cm laceration between their left thumb and index finger. The incident was not witnessed. The investigation revealed that Resident #1 tends to tightly grip the side rail and has dry skin. Staff indicated that at times a laceration was noted when the resident was tightly holding onto the side rail. Therefore, a return demonstration was done by several staff members to see if sufficient pressure can be applied to cause injury. It was determined that if the rail is grasped forcefully enough for a prolonged period, the extensive pressure can cause some opening of the skin at the same location on the hand as was incurred by Resident #1. The facility investigation reveals no side rail assessment was done after the incident. A Physician's Order dated 08/16/2021 documented order for PT/OT screen and evaluation; and transfer the resident to the hospital secondary to injury to the left hand. A Nurse Practitioner (NP) Note dated 08/18/2021 at 12:33 PM documented Resident #1 was examined after return from the emergency room (ER) on 08/17/2021. Resident #1 had a left-hand laceration between the thumb and index finger and received 7 stitches. A review of Resident #1's electronic medical record (EMR), which included, but was not limited to, the assessment section, care plan, Interdisciplinary Team (IDT) notes, and MD orders, determined that after the incident involving Resident #1 there was no documented evidence the 1/4 side rails were identified as a restraint. There was no restraint assessment and no family consent or education regarding the risks and benefits of restraint use. An Order Listing Report dated 03/18/2022 documented 133 residents have two 1/4 side rails. During an interview on 03/18/2022 at 3:50 PM assigned CNA #2 stated that Resident #1 needs 2 CNAs to turn from side to side and to hold side rails. Resident #1 cannot turn from side to side independently. Resident #1 cannot put side rails down. Resident #1needs side rails to help during care and for safety to prevent fall. Resident #1 can fall without side rails. During an interview on 03/21/2022 at 10: 40 AM, CNA #3 stated Resident #1 required 2 persons for bed mobility and transfer and was not able to turn him/herself independently. CNA #3 stated the side rails were needed for positioning and to prevent a fall. During an interview on 03/18/2022 at 12:55 PM, the Registered Nurse Supervisor/Unit Manager (RNS/UM #1) stated that he/she was called to Resident #1's room on 08/16/2021 around 12:30 PM and observed Resident #1 holding the side rail with the left hand. When Resident #1 opened his/her hand, RNS #1 observed a laceration between the thumb and index finger with no active bleeding. A trace of dried blood was on the side rail. Resident #1 requires side rails for positioning. Resident #1 uses both hands for repositioning, but right hand has limitation. Resident #1 holds onto the side rails too tight due to spasticity (a muscle control disorder that is characterized by tight or stiff muscles and an inability to control those muscles). RNS/UM was not able to say what level of assistance Resident #1 currently requires. An additional interview was conducted with RNS/UM #1 on 03/21/2022 at 10:45 PM and stated that the nursing and rehab department is monitoring side rail usage daily. If Resident #1 declined or improved in Activities of Daily Living (ADLs), the nurse made a referral to Rehab for evaluation. Resident #1 uses side rails for turning and positioning. Resident #! can do some movement, but for a complete turn on the side, Resident #1 needs assistance from 2 persons. After staff finish care, the side rails are up because Resident #1 can use them to move in the bed. RNS/UM #1 stated that he/she was not doing quarterly side rail assessment as it is Rehab's responsibility. During an interview on 03/18/2022 at 3:19 PM, the Director of Rehab stated Resident #1 came for short term rehabilitation, then became a long term resident. All residents who were admitted should be screened for use of bed rails, and then screened quarterly. The determination to use side rails is addressed as part of the bed mobility screening process. After screening, the MD order was placed for side rails. There is no space on the form to document the side rail justification order that should be placed for side rails after assessment. PT assessed the resident for the side rail use. Resident #1 is not able to turn from side to side independently. He/she needs assistance to turn on the side by 2 persons. Resident #1 still has the strength to hold onto the side rail. We do not recommend putting the side rail down after the care is completed because Resident #1 still is able to hold the side rails by left hand and depends on the side rails at times during the day. Resident #1 was on PT several times, and when discharged from PT the Resident #1 still required maximal assistance by 2 persons. During an interview on 03/18/2022 at 3:50 PM, the Nurse Practitioner (NP) stated that he/she was seeing Resident #1 daily until January 2022. NP observed Resident #1 using the side rails during care. Resident #1 holds onto the side rail during care. The NP was not able to say if Resident #1 can turn independently in the bed. The NP stated side rails are needed for safety, and in his/her opinion, Resident #1 needs them for turning and positioning. During an interview on 03/21/2022 at 5:40 PM, Physical Therapist #1 (PT #1) stated that Resident #1 needed help to reposition. We gave them a side rail to turn from one area to another to prevent pressure on the back. On 02/04/2022 he/she evaluated Resident #1 due to a recent Botox injection for the right-side impairment. MD ordered PT evaluation to attempt to improve Range of Motion (ROM) on the right side. Resident #1 is not able to reposition or turn from side to side independently. Resident #1 needs extensive assist with 2 people. Resident #1 can grab and hold the position during changing or ADL activities. Resident #1 is not able to completely turn but still benefits from holding onto bed rails and from moving a little bit in the bed to relieve pressure on the back. Resident #1 is not able to put side rails down or to remove the blue padding on the side rails. During an interview on 03/23/2022 at 12:30 PM, Medical Doctor #1 (MD #1) stated that he/she is the Primary Care Physician covering the 3rd floor including Resident #1. He/she evaluates the residents on a monthly basis and as needed. He/she assessed the residents for side rails use in conjunction with PT and Nursing. The side rails are used for resident safety to prevent falls and for bed mobility. He/she signed the order after PT evaluation. MD#1 stated that for resident safety side rails could be up and if PT decided that it is not necessary side rails can be down. Resident #3 Resident #3 was admitted to the facility on [DATE] with diagnoses that included Dementia, Cardiovascular Accident (CVA - a loss of blood flow to part of the brain, which damages brain tissue.), and Gastroesophageal Reflux Disease (GERD). The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #3's cognition is moderately impaired, no behavior present and no behavioral symptoms exhibited. The resident required extensive assistance with one-person physical assistance for bed mobility and eating, extensive assistance with two persons physical assistance for transfers and toilet use, and it documented bed rail not used. Certified Nursing Assistant (CNA) instructions for 03/2022 documented Resident #3 has devices for safety: floor mats when in bed, two 1/4 side rails up during care and during bed mobility activities secondary to a diagnosis of muscle weakness, lower the side rails after completion of care, initiated on 09/23/2017 and revised on 03/22/2022 while surveyors were on site. On 03/21/22 at 10:20 AM, Resident #3 was observed in bed asleep, side rail up with bed bolsters on either side of the bed, resident lying in the center of the bed. On 03/21/22 at 5:50 PM, Resident #3 was observed in bed asleep, side rails up, with bed bolsters, and resident lying in the center of the bed. On 03/22/22 at 10:50 AM, Resident #3 was observed lying supine in the bed with two 1/4 rails up, without bed bolsters attached to side rails. Resident alert and oriented to name. Side rails were not lowered after completion of care as per CNA instructions. The Comprehensive Care Plan (CCP), review date 03/07/2022, documented the resident needs to use side rail, two 1/4 side rails as enabler for bed mobility, for turning and positioning, to help define bed boundaries, for decreased muscle strength, and Impaired mobility. Goals include that the resident will be able to turn and position self-using side rails daily through the next review date. Interventions include apply side rails as per MD order and periodically re-evaluate the need for side rail use. Explain the rationale for side rail use and educate the resident/family/health care proxy (HCP) about possible side rail dangers. The Physician's orders dated: 03/14/2022 documented devices: Siderails, bed bolsters and bilateral (B/L) standard bolsters for optimal bed positioning, siderail: two 1/4 enabler for mobility. There is no documented evidence of any side rails assessment prior to 03/20/2022. The Quarterly Rehabilitation Screening Form dated 02/24/2022, with the date reviewed 03/02/2022, documented restraints as not applicable (n/a). Also documented that the resident requires increased assistance with self-feeding tasks and upper body (UB) secondary to decreased general B/L upper extremity (UE) strength, weak grasp, and poor functional activity. Resident #3 will benefit from skilled Occupational Therapy (OT) services to address specified deficits. Resident #3 is at a baseline functional level for bed mobility and transfers. There is no documented evidence of side rail usage for Resident #3 in the Physician's and or Optum NP progress notes prior to 03/22/2022. On 03/21/2022 at 6:22 PM an interview was conducted with CNA #5 who stated that Resident #3 has the bed bolster in place in order not to fall off the bed, as Resident #3 tends to slide down in the bed. It is also to protect Resident #3 from bumping into the rails. CNA #5 said that they use the bolsters, which are attached to the side rails, because without it, resident #3 would fall off the bed. CNA #5 also stated that once the bolsters are in place Resident #3 cannot hold onto the rail. On 03/21/2022 at 6:22 PM an interview was conducted with Licensed Practical Nurse (LPN)#1 who stated that Resident #3 needs 2 persons to assist. LPN #1 stated Resident #3 can use the side rail and is able to turn from side to side with staff assistance. LPN #1 stated that the staff takes off the bolster during care and Resident #3 uses the side rail and can turn from side to side. LPN #1 stated that Resident #3 needs two people for safety for positioning. Additional Interviews During an interview on 03/21/2022 at 11:30 AM, the DON stated that before 03/18/2022, Rehab was assessing side rails as a part of the bed mobility assessment. As of 03/18/2022, he/she assessed the side rails for each resident with the unit nurses using the new Side Rail Usage Assessment. The DON also stated that the risks and benefits of side rails are discussed with the family during the baseline care plan meeting for all residents, but it is not documented. The DON stated that 99.9% of residents are not able to remove the side rails independently but need side rails for mobility. The 4th floor has short-term rehab residents recovering after fractures, and those residents need side rails to enhance mobility. The facility does not use side rails for restraint. The DON also stated that they don't want to take side rails away from a resident who still can use side rails to maintain mobility or as a way to move. The DON questioned, how could the facility take away from Resident #1 the one thing that Resident #1 still can do with the left hand to hold the side rails and pull himself up. During an additional interview with the DON on 03/21/2022 at 4:45 PM, DON stated that for those residents who have no ability to turn from side to side and use bed rails independently, the side rails should be put down after staff completed the care. During an interview on 03/22/2022 at 3:01 PM the Medical Director (MD) stated that he/she was told today that the facility is in Immediate Jeopardy (IJ) regarding concerns over the use of side rails in the facility. MD stated he/she is shocked that the facility is in IJ. MD stated he/she is aware of the reason there is an IJ, but strongly feels that no one in the facility is restraining any residents. MD stated that the side rails are used for turning and positioning and help residents move in bed. MD stated that some of the residents in the facility barely use the side rails, but they need the side rails for turning. The MD added that when using the side rails no matter how minimally it can benefit the resident. MD stated he/she understands the regulations and believes as a physician that a side rail is never used or put in place to prevent falls, but if that was the reason then it would be a restraint. MD stated that all residents are referred to the Rehab Department and if they recommend/state the resident needs side rails they are put in place, not for falls, but to assist with mobility. MD stated no physician will agree to use the side rails for falls. During an interview on 03/23/2022 at 1:56 PM, the Administrator stated that he/she was aware that side rails were being used in the facility, but did not know the medical reasons for their use. The Administrator stated that he/she is not involved in the decision-making regarding the use of side rails. The Administrator added that when DOH staff advised that side rails were not being used properly, he/she began oversight of facility efforts in order to ensure that every staff was doing their part in implementing corrective actions to remove deficiencies. Immediate Jeopardy (IJ) was identified/declared, and the facility Administrator, DNS, and ADNS were notified on 03/21/2022 at 6:15 PM. The facility submitted a removal plan on 03/21/2022 at 9:59 PM. The plan was reviewed and accepted by NYS DOH. On 03/23/2022 at 5:00 PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: The facility-wide observation was conducted on all residents' units on 03/23/2022. Surveyors team observed Resident #1, #2, #3, #4, #5, #6, and #7 in their beds with side rails down. There were no observed concerns related to side rail use or other restraints. An additional observation was conducted on 4th short-term unit at 4:30 PM. There was no rehab activity or care activities at that time. All residents' side rails were down. Surveyors observed the residents awake, some out of bed clean dressed in appropriate clothing for the weather. No residents were observed with any restraints in place. Staff interviewed reported they were in serviced on side rails and restraints and they were able to verbalize the facility policy on side rails use, as well as the meaning of restraints. Record review revealed that the facility changed MD orders for Residents #1, #2, #3, #4, #5, #6, and #7 for two 1/4 side rails UP during care and during bed mobility activities secondary to Dx of Muscle Weakness. Lower the side rails after completion of care dated 03/22/2022. For all other residents, a full house audit will be conducted by IDT to review residents with minimal usage of side rails for mobility. Record review of Residents #1, #2, #3, #4, #5, #6, and #7 revealed that care plans, CNA accountability, side rails assessment, Rehab screening form, 3-day mobility study form, Psychiatrist screening for side rails usage order, skilled PT for therapeutic exercises, family/resident notification, and education of proper usage of side rails were implemented. Sample of the physician's Monthly Medical Evaluation assessment revised to include the MD assessment for the side rail usage reviewed. The facility implemented that Social Service will be part of IDT to determine residents' cognition status for side rail usage. As of 03/23/2022 Facility has 239 employees. 7 employees on leave and vacation. Actual staff: 232 As of 03/23/2022 at 3:00 PM the facility in-serviced 90% of staff and is ongoing. The Team reviewed in-service lesson plans and sign-in sheets to verify completion. The facility in-serviced staff in-person and over the phone. The team interviewed MD-3, NP-1, RNS/Unit Managers-3, RN-2, LPN-5, CNA-12, Social Service -3, ST-1, PT-2, OT-1, MDS Coordinator-1, Housekeepers-4, Recreation staff-1, and Maintenance -2. Interviews via phone was also conducted for staff who was in-serviced by the phone with no concern noted. Based on observations, interviews, and record review conducted on 03/23/2022, the facility fully implemented the revised Immediate Jeopardy Removal Plan, and the Immediate Jeopardy was removed as of 03/23/2022 at 5:00 PM. 483.12(a)(2)

Based on observation, record reviews and staff interviews conducted during a complaint (NY00281980) and Partial extended survey, the Medial Director did not ensure that the facility provided care in accordance with current standards of practice to meet the needs of 7/7 residents reviewed for Physical Restraints. Specifically, The Medical Director failed to ensure that side rails were identified as restraints for 7 of 7 Dementia residents reviewed. (Residents #1, #2, #3, #4, #5, #6, #7). All 7 residents required extensive assist for bed mobility and were unable to independently remove the side rails or use the side rails to turn from side to side or move up or down in bed. There was no medical justification for restraint use, no restraint assessment, no documentation of alternatives attempted prior to implementing side rails, and no family consent or education regarding the risks and benefits of restraint use prior to 3/18/22. This was evident of 7/7 residents reviewed for Physical Restraints, side rails use (Resident #1, #2, #3, #4, #5, #6, #7). The findings include but are not limited to: The Facility Policy & Procedure titled Physician Services dated last reviewed May 2018 documented The Attending Physician will determine the relevance of any recommended interventions from any discipline. The Physician is not obligated to accept these recommendations if he/she have clinically valid reason for not doing so. The policy further stated The Medical Director will identify attending Physician qualifications and responsibilities; based on clinical and regulatory requirements and the recommendations of relevant professional associations. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that include Right Hemiplegia, Vascular Dementia, and Corticobasal Degeneration. A Quarterly Minimum Data Set (MDS, a resident assessment tool) dated 06/18/2021 documented Resident #1 had moderately impaired cognition, required extensive assistance of two persons for bed mobility, and required total assistance of two people for transfer with a Hoyer lift. Physical restraints and side rails were not used for the resident. The Quarterly MDS dated [DATE] documented the same. On 03/18/2022 at 1:00 PM, Resident #1, a resident with Right Hemiplegia and Vascular Dementia, was observed with two 2 1/4 side rails up with bilateral padding applied. Resident #1 was unable to remove the side rail or demonstrate using the side rail to move in bed. On 03/21/2022 at 10:30 AM, Resident #1 was observed in the bed with two 1/4 side rails up. Resident #1 held onto the left side rail with the left hand but was not able to turn independently. Two Certified Nurse Assistants (CNAs) assisted Resident #1 with turning in bed, and Resident #1 held the side rail with the left hand. Resident #1 was not able to use the right hand to hold onto the side rail. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included Dementia, Cardiovascular Accident (CVA), and Gastroesophageal Reflux Disease (GERD). The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #3 cognition is moderately impaired, no behavior present and no behavioral symptoms exhibited. The resident required extensive assistance with one-person physical assistance for bed mobility and eating, extensive assistance with two persons physical assistance for transfers and toilet use and documented bed rail not used. On 03/21/22 at 10:20 AM, Resident #3 was observed in bed asleep, side rail up with bed bolsters on either side of the bed, resident lying in the center of the bed. On 03/21/22 at 5:50 PM, Resident #3 was observed in bed asleep, side rails up, with bed bolsters, and resident lying in the center of the bed. On 3/22/22 at 10:50 AM, Resident #3 was observed lying supine in the bed with 2 1/4 rails up, without bed bolsters attached to side rails. Resident alert and oriented to name. 3. Resident #6, was admitted to the facility on [DATE] with a diagnosis that includes Cerebral Ischemia, Dementia with Behavioral Disturbance, and Muscle Weakness (Generalized). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no resident mental status reviewed the resident is rarely/never understood. Resident with Long-term Memory and Short-term Memory problem with no memory/recall ability. Moderately impaired and no signs and symptoms of Delirium and required extensive assistance of one person for bed mobility. On 03/21/22 at 10:53 AM, Resident #6 was observed lying in bed with upper 2 1/4 side rails up. Resident #6 was unable to remove the side rails or demonstrate using the side rails to move in bed without staff assistance. On 03/21/2022 at 11:05 AM, Resident # 6 was observed with CNA #4 to demonstrate side rails use without assistance. CNA #4 gave Resident # 6 instructions to hold onto the side rails, while CNA used strength to pull the resident up in the bed to a sitting position. Resident #6 was able to hold onto the side rails with one hand and was not able to pull or move self without assistance from staff present. CNA #4 stated the resident cannot pull the side rails up or down, and only staff can pull the side rail up or down. During an interview on 3/18/2022 at 3:50 PM, Optum NP #1 stated that he/she was seeing Resident #1 every day until January 2022. NP observed the resident using the side rails during care. Resident holds the side rails when the staff cleans him. NP was not able to say if the resident independently can turn self in the bed. Resident was non-ambulatory but was able to understand simple instructions. Side rails are needed for safety also. In NP #1 professional opinion, the resident needs side rails for turning and positioning. During an interview on 3/23/2022 at 12:30 PM Medical Doctor (MD) #1stated that I am the Primary Physician covering the 3rd floor including Resident #1. I evaluate the residents on a monthly basis and as needed. I assessed the resident for side rails use in conjunction with Physicl Therapy (PT) and nursing. The side rails are used for resident safety to prevent falls and for bed mobility. I signed the order after the PT evaluation. For resident safety, side rails could be up and if PT decided that it is not necessary it can be down. During an interview on 3/22/2022 at 3:01 PM, Medical Director (MD) #2 stated, I am working in the facility for past [AGE] years. The facility has three units with a Primary Care Physician on each unit. The Physicians come at least 3-4 times weekly into the facility and it can be more frequent depending on the residents medical conditions. There is always a Physician on call that covers the facility 24/7 and if the doctors are not available I will cover the facility. I was told today that the facility is in Immediate Jeopardy (IJ) regarding the concerns of side rails use in the facility. I am aware of the Immediate Jeopardy (IJ) and am shocked that the facility is in IJ for side rails use. I am aware of the reason there is an IJ and am not new to the field. I strongly feel that no one in this facility is restraining any residents, and the side rails are used for turning, positioning, and moving in the bed. I am aware that some of the residents in the facility barely use the side rails but need the side rails for turning. When residents use the side rails no matter how small, it can benefit the resident. I understand the regulations. As a physician a side rail is never used or put in place to prevent falls. If this is the case it is a restraint. I have an excellent Rehab Department that worked through COVID-19 and all the residents are referred to the Rehab Department. If Rehab recommends the resident needs siderails, then it is implemented not for falls but to assist in mobility. No physician will agree to use the side rails for falls. I will meet with the doctors and explain and educate them when they are signing off on an order for side rails that there must be proper justification for the side rails use and to be aware of the language when side rails are used. This facility is not restraining anyone including physical or chemical restraints and it is very shocking that this facility is in IJ. I was not aware the staff are reporting using side rails for falls but noted side rails are beneficial to the residents. The doctor who was writing fall precautions and side rails up is not using an appropriate language and I will educated all the doctors. All doctors who come into the facility are credentialed by me and I supervise the doctors as well as other consultants that work in the facility. I consult regularly with all the doctors and have three attending doctors. I will educate all the doctors regarding the side rails as well as address the use of side rails in progress notes and monthly reports. I will start education of the doctors immediately. I never discussed side rails as a restraint with the doctors and the Director of Nursing (DON). The Medical Director failed to discuss and intervene (as appropriate) with health care practitioners regarding medical care that is inconsistent with current professional standards of care prior to the recertification survey. Specifically, side rails being used as a physical restraint. 415.15(a)

Based on record reviews and staff interviews during an abbreviated Survey NY00282169 on 02/17/2022 and NY00281980 on 03/18/2022 through 03/23/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health (NYSDOH) for 2 out of 2 sampled residents Resident # 9 and Resident # 1. Specifically, for Resident #9 the facility received a report of an allegation of abuse involving a Certified Nursing Assistant (CNA#1) on 08/24/2021 and did not report the incident to the NYSDOH until 08/27/2021. Additionally, an allegation of abuse involving Resident #1 and CNA#2 was reported to the facility on [DATE] and was not reported to NYSDOH until 08/24/2021. The facility failed to report the incidents timely. The findings include: The facility policy and procedure titled Abuse (Dated 02/2019) documented each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Report all alleged violations and all substantial incidents to the state survey agency and to all other agencies as required by regulation and take all necessary corrective actions depending on the results of the investigation. 1) Resident # 9 was admitted to the facility on [DATE] with diagnoses that includes Parkinson's disease and Dementia with Lewy Bodies. The Minimum Data Set (MDS) dated [DATE] documented that resident had a Brief Interview for Mental Status (BIMS) score of 8 which indicates moderately impaired cognition. Resident #9 requires two people assist with bed mobility, transfer, and toilet use. One person assists with eating, dressing, bathing, and locomotion on and off unit. Resident #9 Care Plan for potential victimization revised 01/10/2022 interventions include encourage resident to promptly report any negative interactions with behaviorally disturbed peers; immediately intervene to preventor minimize harm if any negative interaction occurs; provide supportive services and emotional reassurance as needed. A Nurse's note dated 08/24/2021 at 5:00PM documented that on 8/24/2021 at approximately 4:30PM Resident #9's family reported that the resident was struck by an employee during care on the evening of 08/23/2021. Facility's investigation dated 08/25/2021 documented Resident #9's family was visiting on 08/24/02921. The family informed the Registered Nursing Supervisor (RNS#1) that Resident #9 told them they were slapped in the face two days in a row by a staff member Certified Nursing Assistant (CNA#1). RNS #1 immediately assessed Resident #9 and observed no visible marks or bruising. Resident #9 offered no complaints of pain. Facility's investigation concluded; due to frequent handling of Resident #9 to dissuade Resident #9 from removal of the sacral pressure ulcer dressing and frequent repositioning this may have cause Resident #9 to feel roughed up by staff. However, considering Resident #9's complaint of been slapped by staff, team is unable to rule out abuse, neglect or mistreatment. Accused CNA # 1 was reassigned. The investigation lacked documented evidence that the incident was reported the NYSDOH timely. 2) Resident # 1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia affecting the right dominant side, Vascular Dementia and Parkinson's Disease. The Quarterly Minimum Data Set (MDS) dated [DATE] identified that Resident #1 has short -term memory deficit. The Resident # 1 requires extensive assistance with bed mobility, transfer with physical assistance of 2 people and extensive assistance by 1 person with dressing and eating. A Nurse's Note dated 8/16/2021 at 2:00 PM, documented that approximately 12:15 PM they were called to Resident # 1's room by assigned CNA # 2. Resident # 1 was observed lying in bed with blood on the left hand. Resident # 1 was noted with a laceration between the left thumb and index finger measuring 2 Centimeter(cm)cm x 2 cm. Resident # 1 was evaluated by NP # 1 who ordered Resident # 1 to be transferred to the hospital for sutures. Facility's investigation dated 8/16/2021 documented assigned (CNA) # 2 reported to the Registered Nurse (RN #1) that Resident #1 was observed with a laceration between the left thumb and index finger. Resident # 1 was assessed by RN # 1 and was noted with a laceration measuring 2cm x 2cm between the left thumb and index finger. Resident # 1 is Spanish speaking and required a translator. The family requested to interview Resident # 1 alone. Resident # 1 informed the family, that CNA # 2 attempted to pull their hand off the side rails, causing a laceration. The facility determined that if the rail is grasped forcefully enough for a prolonged period, the extensive pressure can cause some opening to the skin. As a result, the facility concluded that based on the severity of the laceration, the incident was not caused by staff prying the resident's fingers off the side rail. The investigation lacked documented evidence that the incident was reported the NYSDOH timely. A Nurse's progress note dated 8/17/2021 at 2:22 PM, documented Resident # 1 returned from the emergency room (ER) and was evaluated by a RN #1 and noted left hand laceration with 7 sutures in place. During an interview on 3/18/2022 at 3:19 PM the Director of Nursing (DNS) stated that they were responsible for reporting the incidents to the NYSDOH. The DNS further stated due to a COVID-19 outbreak in the facility in August 2021 they were unable to report the incident timely. The DNS stated that incidents related to abuse should be reported within 2 hours to New York State Department of Health NYSDOH. During an interview with the Administrator on 03/23/2022 at 1:56PM, they stated the DNS was responsible for reporting to the NYDOH all incidents of abuse. 415.4(b)

Based on observation, interviews, and record review conducted during an abbreviated Complaint Survey (Complaint # NY00281980) and Partial Extended Survey, the facility did not ensure that its management and administration are administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, (1) Resident # 1's Child stated that Resident #1' reported that a Certified Nursing Assistant slapped Resident #1 twice in the face two days in a row by the staff member who is assigned to them. (2) Resident # 2 was noted with a 2 cm x 2cm laceration between the left thumb and index finger. The open area was not bleeding profusely. Resident # 2 reported to their Child that a staff member attempted to pry his/her hand off the side rails resulting in a laceration. The facility did not report the suspected assault to law enforcement. This was evident of 2/3 resdeitn reviewed for alleged abuse. (Resdietn #1,#2). 3) The facility Administration failed to ensure that the facility reported to appropriate State Agency regarding an allegation of Abuse within the appropriate time frame for 2/3 resident reviewed for Abuse. The facility received a report on 08/24/2021 and reported it on 08/27/2021 and on 08/16/2021 and reported it on 08/24/2021 of alleged resident abuse. The facility failed to report the incidents timely (Resident #1, #2) 4) The facility administration failed to ensure that the facility is operated in a manner that the residents are free from restraint. Specifically 7/7 residents reviewed who was cognitively and physically impaired had side rails in use (Resident #1,#2, #3, #4, #5, #6, #7). This resulted in Immediate Jeopardy and Substandard Quality of Care with the potential for serious harm to all residents' health and safety. The findings are but not limited to: On entrance to the facility on [DATE] the facility with 3 units, census was 133 and capacity of 135. 133/135 residents had 2 1/4 side rails in use. On 3/21/2022 census 133 and 121of 133 had 2 1/4 side rails in use. 1. The facility did not ensure that an allegation of abuse was reported to the appropriate State agency including Law Enforcement in a timely manner. There was no documented evidence that the incident was reported to NYSDOH or local law enforcement within the time frame. Refer to citation text at tag F 609 for further information. During an interview with the Administrator on 03/23/2022 at 1:56 PM, the Administrator stated the Director of Nursing (DON) is responsible for reporting to the Department of Health (DOH) and to the police as necessary. The Administrator reported to discuss the different types of incidents and the DON will tell him/her to call the police. 2. The facility did not ensure an allegation of abuse was reported to Law enforcement. Refer ot citation tag F608 doe furthur information. During an interview on 3/23/2022 at 1:56 PM The Facility Administrator stated working as an Administrator for [AGE] years, but in the facility for the past 4 years. The Administrator stated is responsible for the entire facility and stated all person reports to the Administrator. The Administrator stated the Director of Nursing (DON) is responsible for reporting the Department of Health (DOH) and to the police as necessary. The Administrator stated the DON and Administrator will discuss at times and DON will tell the Administrator when to call the police or report. The Administrator stated when there is abuse the time frame for reporting is 2 hours if injury and all allegations must be reported within 24 hours. The Administrator stated the complaint that was reported late in August was because of COVID-19 and stated the facility had a COVID-19 outbreak at that time. 2. The facility did not ensure that resdietn were free from physical restriants and did not identify side rails as a restraint for cognitive and physically impaired residents. There was no documented evidence that an assessment was conducted, and the least restrictive intervention was tried before implementing side rails use. Refer to citation at rag F 604 for further information During an interview on 3/23/2022 at 1:56 PM The Facility Administrator stated was aware that side rails was being used in the facility and did not know the medical reasoning for the side rails use and is not involved in the decision making regarding the side rails use. The Administrator stated when DOH came was made aware of side rails not used properly. The Administrator stated is overseeing the entire facility to ensure that everyone is getting their job done and implementing the plan for the side rails. 415.26

Based on record review and interviews during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, the Discharge MDS assessment was not submitted and transmitted within 14 calendar days from the MDS Completion Date. This was evident for 1 of 1 resident reviewed for the Resident Assessment Facility Task out of a sample size of 28 residents. (Resident #1) The findings are: The CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR)), Chapter 5 titled Submission and Correction of the MDS Assessments documented the MDS completion date must be no later than 14 days after the assessment reference date (ARD) for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. Resident #1 was admitted to the facility on [DATE] and was discharged to the community on 8/16/19. The Discharge MDS assessment with an ARD date of 08/16/19 was completed on 08/29/19 and was not submitted until 01/03/20 after the surveyor made the facility staff aware that the assessment had not been submitted. The MDS confirmation page dated 01/03/2020 documented the discharge MDS was submitted on 1/3/2020. An interview was conducted with the MDS Coordinator (MDSC). The MDSC stated the MDS assessment was supposed to be submitted 7 days after the MDS was completed. The MDSC also stated that she periodically checks the CASPER report but unfortunately, she does not know why that one was missed. The MDSC further stated that the assessment had been completed but had not been submitted and would be submitted right away.

Based on observations, staff interview and record review conducted during a Recertification and Abbreviated survey, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Specifically, residents were observed without splint devices in place as ordered. This was evident for 2 of 2 residents reviewed for Position/Mobility out of 24 sampled residents. (Resident #8 and Resident # 46). The findings are: The Facility Policy Appliances- Splints, Braces, Slings revised (MONTH) (YEAR) documented in order to protect the safety and well-being of residents, and to promote quality care, this facility uses appropriate techniques and devices for appliances, splints, braces and slings. The policy also documented the Nursing ensures proper schedule for donning and doffing appliance is known by CNA staff and provides appropriately sign off of task options, ensure staff is aware where device is to be stored and cared for, check skin integrity at least before and after application, release devices/appliances per physician order. 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 12/30/2019 at 3:15 PM, resident was observed seated in a wheelchair in the dayroom. No hand devices were observed in either hand. On 12/31/2019 between 01:29 PM and 03:15 PM the resident was noted awake and seated in the dayroom. No hand devices were observed in place. On 01/02/2020 between 08:51 AM and 03:34 PM, resident was observed seated in the dayroom. No hand devices were observed in either hand. The Quarterly Minimum Data Set (MDS) Assessment 3.0 dated 09/19/2019 documented severe cognitive impairment, extensive assist of 2 persons for bed mobility, total dependence of 2 plus persons for transfer. Active [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) The resident has an alteration in musculoskeletal status realted to contracture of left hand initiated 01/03/2020 documented the following goal: the resident will remain free of injuries or complications related to presence of contracture of left hand and bilateral knees by review date. Interventions included apply left hand carrot to be worn at all times with removal for hygiene/skin care daily during AM/PM care. On 01/02/2020 at 04:31 PM, an interview was conducted with Certified Nursing Assistant (CNA # 2). CNA #2 stated that the resident has limitations in their hands and feet, is unable to comb her hair or brush her teeth and needs assistance with turning and positioning. CNA #2 also stated the resident should have a carrot device for her hands however, the resident refuses the carrot device for her hand. CNA #2 further stated that she reports changes to the nurse but had not reported the resident's refusal to wear the device. On 01/02/2020 at 04:59 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated the resident has contractures and is ordered a carrot splint device for her left hand. He stated that the resident was referred to rehabilitation for increased muscle tightness and poor sitting balance. RN #1 also stated that spot checks are done for the carrot splint device, but the resident takes it off sometimes but most of the time the resident is wearing the carrot splint device. 2. Resident #46 was admitted with [DIAGNOSES REDACTED]. Observations for Resident # 46, On 12/30/19 between 10:05 AM and 2:40 PM no hand roll or splint device was noted on residents' hands. On 12/31/2019 at 08:17 AM and 10:16 AM no hand roll was noted on the resident's right hand. On 12/31/2019 at 2:40 PM no hand roll on right hand and at 3:16 PM no hand rolls on either hand. On 01/02/2020 between 08:55 AM and 09:57 AM no devices were noted on residents' bilateral hands. On 01/02/2020 at 10:45 AM and 12:58 PM no devices were noted on the resident's right hand and at 02:47 PM no devices noted on residents' hands as resident was sleeping. On 12/30/2019 between 10:05 AM and 2:40 PM , resident was observed sitting in bed in her room. No hand devices were observed in either hand. On 12/31/2019 between 08:17 AM and 10:16 AM, resident was observed sitting in bed and between 2:40 PM and 3:16 PM resident was observed seated in dayroom. No hand roll was observed in either hand. On 01/02/2020 between 08:55 AM and 2:47 PM, resident was observed sitting on bed in bedroom, No hand devices were observed in either hand. The Quarterly Minimum Data Set (MDS) Assessment 3.0 dated 10/28/2019 documented no rejection of care, extensive assistance of 2 staff persons for bed mobility, total dependence of 2 staff persons for transfer, and upper and lower extremity impairment on both sides. [DIAGNOSES REDACTED]. The Occupational Therapy Plan of Care dated 6/13/2019 documented under Orthotic/Prosthetic STG under current level of function stated the resident is able to wear hand roll with daily skin checks and hygiene routine and the goal of the patient will safely wear hand roll with daily hygiene routine performed and skin checks. The Rehabilitation Screening Form on 10/29/2019 documented hand range of motion impaired on one side and limited range of motion to lower extremity (hip, knee ankle and foot, bed mobility and transfer - total dependence 2 plus persons physical assistance. The Orthotic/Prosthetic Devices documented bilateral hand rolls, remove for skin checks to be worn at all times, remove for hygiene. The physician's orders [REDACTED]. The physician's orders [REDACTED]. CNA Accountability for (MONTH) 2020 documented under Device-Protective/Positioning/Splint Right Hand Roll to Right hand and Left carrot hand splint to be worn at all times, taken off for routine skin checks and hand hygiene. On 01/02/2020 at 05:13 PM, an interview was conducted with RN #1. RN # 1 stated the resident receives physical therapy 5 times a week, and is ordered right hand roll splint and left-hand carrot roll splint. RN #1 also stated he performs spot checks for the resident devices. RN #1 stated that he had not been informed that the resident had been refusing the splint devices. 415.11 (b)

Based on staff interview and record review conducted during a Recertification and abbreviated survey, the facility did not ensure that each portion of the MDS assessment accurately reflect the resident's status. Specifically, the most recent MDS did not accurately document that the resident had mobility limitations. This was evident for 1 of 2 residents reviewed for Position/Mobility out of a sample of 28 residents. (Resident # 8). The finding is: 1) Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Rehabilitation Screening Form dated 9/16/2019 documented left-hand contracture, bilateral knee flexion contracture, bed mobility-extensive assist 2 plus persons assist and transfer-total dependence 2 plus persons assist. Medical [DIAGNOSES REDACTED]. Comprehensive Care Plan (CCP) The resident has an alteration in musculoskeletal status r/t contracture of left hand initiated 01/03/2020 documented the following goal: the resident will remain free of injuries or complications related to presence of contracture of left hand and bilateral knees by review date. The Quarterly Minimum Data Set (MDS) Assessment 3.0 dated 09/19/2019 documented severe cognitive impairment, extensive assist of 2 persons for bed mobility, total dependence of 2 plus persons for transfer. Active [DIAGNOSES REDACTED]. Section G- Functional Limitation in Range of Motion was coded no impairment and did not document the resident's impairment in Range of Motion. The MDS did not accurately document the resident's [DIAGNOSES REDACTED]. On 01/03/2020 at 09:06 AM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated the assessor who completed the assement was not availale for interview. The MDSC stated the resident has contractures and has had them for quite some time. The MDSC also stated that it is not possible to review every single MDS for accuracy as there are only three people in the MDS department one of whom works part-time. The MDS coordinator stated the staff that incorrectly coded the MDS when they checked no limitation in relation to range of motion. 415.11 (b)

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically: 1) An oxygen tubing was observed touching the floor during two observations made during the survey, and 2) hand hygiene was not performed appropriately during a wound care observation. This was evident for 2 residents out of a sample 29 residents. (Resident #92 & Resident #103) The findings are: 1. Resident #92 is a resident who was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is cognitively intact, requires extensive assistance of one person assist for transfer and is receiving oxygen therapy. During the survey on 12/17/18 at 09:16 AM and 01:02 PM, on 12/18/18 at 09:10 AM and on 12/19/18 at 08:53 AM, the resident's oxygen tube was observed touching the floor. On 12/19/18 at 08:44 AM, an interview was conducted with the Infection Control Preventionist who stated in-service trainings on donning, doffing, hand washing, and aseptic technique were provided to the staff. The ICP stated CNAs will monitor and inform the Nurse when the oxygen filter needs to be changed/washed. During the interview, the ICP and surveyor walked to the resident's room and observed part of the oxygen tubing on the floor and a faded inspection tag on the concentrator. The ICP confirmed that the tubing should not be on the floor and that staff should conduct rounds to ensure that the oxygen tubing is not touching the floor. Also stated by the ICP, the oxygen tube should be replaced and when not in use needs to be stored in a bag. Engineering was requested to inspect the concentrator's inspection tag and instructed to use a tool that will not fade, as per the ICP. 2. The facility Dressing Change Competency documented the following in steps #13 to #23: Wash hands. Don gloves and remove dressing. Wash hands, don gloves, cleanse wound with prescribed solution. Remove gloves, wash hands. Don gloves, apply treatment as per MD (Medical Doctor) orders. Cover with dry sterile dressing. Remove gloves, wash hands. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified the resident with severe impairment of mental status, but able to make needs known and completely dependent on staff for all Activities of Daily Living. On 12/18/2018 at 11:30 AM, a wound care observation was conducted on Resident #103. The Clinical Nurse Manager Registered Nurse (RN #2) accompanied by a Certified Nursing Assistant (CNA#1) entered the room, introduced themselves and explained to resident what was to be done. Both staff washed their hands with soap and water and donned on gloves. Resident was re-positioned on the left side, pants lowered down, diaper was removed. Both staff washed their hands with water and soap and donned gloves. RN#2 cleaned the table with an antiseptic towel and covered the table with a sterile drape to create a clean field. RN#2 removed gloves, washed hands and donned new gloves. The RN proceeded to place supplies including 4 x 4 gauze, Normal Saline Solution (NSS), Collagen, Hydrogel and bordered gauze on the drape. RN#2 removed her gloves, washed hands and donned gloves before removing the soiled dressing. The wound bed was observed to be clean with no odor, with minimal drainage. RN#2 removed her gloves, washed her hands and donned clean gloves. She then proceeded to cleanse the wound bed with 4 x 4 gauze moistened with NSS several times. The periwound area was patted dry. RN#2 then applied Hydrogel treatment followed with Collagen treatment to the wound bed and covered the wound with bordered gauze. RN#2 did not change her gloves, wash her hands with soap and water or use alcohol gel after cleansing of the wound bed and before application of treatment. RN#2 was immediately interviewed after the procedure and stated I thought I washed my hands and put on new gloves. 415.19(b)(4)

Based on observation, record review and staff interviews , the facility did not ensure that residents/families were informed and provided with written information concerning the right to accept or refuse medical or surgical treatment and at the resident's option to formulate an advance directive. Specifically, Resident #122 is cognitively impaired and has a family member involved in the care of the resident. A review of the resident's medical record did not have evidence that the issues concerning advance directives were discussed with family members, or that family members were provided with such written information. This was evident in 1 of 29 sampled residents. (Resident # 122). The facility policy on health care proxy /advance directives /DNR dated 08/20/2013 and revised on 06/20/2018 documented the following: It is the policy of the facility to inform all residents of their rights to formulate advance directives, including a heath care proxy and MOLST form with do not resuscitate order as per wishes. The facility's social work department provides ongoing education to all residents and/or health care agents/ families/ representatives/or surrogates at resident and or family council meetings and through mailing to families. The finding is: Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set 3.0) most recent quarterly assessment dated [DATE] identified the resident as severely cognitively impaired, and completely dependent to staff for all her activities of daily living. Resident was observed seated in her wheelchair, well-groomed in the dining room/activity room on 12/16/2018 at 12:00 PM and when approached and spoken to, smiled without answering. The comprehensive care plan (CCP ) dated 12/03/2018 identified advance directive as a care area. The CCP documented that the resident/family has been educated regarding advance directives. The targeted goal was that the advance directives were to be updated no less than every 3 months. The advanced directives are to be followed in accordance with the resident/ family member or designated representative's wishes as evidenced by discussion of MOLST (Medical Orders for Life Sustaining Treatments), DNI (Do Not Incubate), DNR (Do Not Resuscitate). The CCP also documented that advance directives would be reviewed by medical doctor and an ordered by a medical doctor. The CCP further documented that the advance directives would be maintained as part of the resident's medical records. The disciplines responsible for implementing this CCP were Social Work and Medical. Review of the interdisciplinary notes, specifically social service and physician notes revealed no documented evidence that facility staff discussed with the resident's family or designated representative issues concerning advance directives. There were no orders for advance directives in the resident's medical record. The most recent Social Service note documented in the resident's medical record was quarterly note dated 11/29/2018. The note did not provide documented evidence that the facility social worker discussed with, or provided written information to the family about advanced directives. The SSD (Social Services Director) was interviewed on 12 /17/2018 at 11:49 AM. The SSD stated that the advance directive discussion should be a part of the social services history portion of the resident's medical record. However, after reviewing the medical record the SSD determined that there was no documented evidenced that such issues had been discussed. On 12/18/2018 at 3:00 PM, the SSD stated to the State Surveyor that she contacted the resident's family member on 12/17/18. The family member stated that they would have a family discussion, a hard copy of the advance directive form and information packet was faxed to the family member. 415.3(e)(1)(ii)

Based on observations and staff interviews during the re-certification survey, the facility did not ensure that gloves were changed, and hands washed between tasks such as handling soiled and clean dishes which can contribute to cross-contamination. Specifically, a dietary aide was observed performing tasks and did not change gloves and perform appropriate hand hygiene between tasks. This was evident during the Kitchen/Food Service observation. The findings are: The facility policy Manual Washing and Sanitizing revised 5/14/18 documented to ensure that all pots, pans are cleaned and sanitized correctly to prevent food borne illnesses. On 12/17/18 at 02:37 PM, a Dietary Aide was observed during pots/pans washing. The aide was observed wearing long black rubber gloves that reached below the elbows. The aide removed an item from the first sink filled with a soapy solution, rinsed it off and placed it in the sink filled with a sanitizing solution. The aide then immersed the gloved hands into the sanitized water solution to remove the clean item which was then placed on a rack to dry. The aide did not change gloves when moving from dirty to clean items. On 12/17/18 at 04:21 PM, an interview was conducted with the Food Service Director (FSD) who stated the steps to wash pots/pans included washing the pots/pans in the first sink, remove from first sink and place them into the rinse sink also ensuring that the gloves are rinsed off as well, then placed the pot/pans into the sanitized water for two minutes. The FSD also stated it is too cumbersome to change the gloves. On 12/19/18 at 3:29 PM, a telephone interview was conducted with the Dietary Aide who has been employed at the facility for three years. The aide stated gloves are worn at all times during pot washing. The dietary aide also stated she was trained on pot washing when she first started working at the facility and has not been in-serviced or complianced related to pot washing. The dietary aide further stated she was not trained to change gloves once the dishes are cleaned and rinses off the gloves during the pot washing process. 415.14(h)

Based on observations and staff interviews conducted during a recertification survey, the facility did not ensure that all medications and biologicals were stored and labeled properly. Specifically, one opened insulin pen was observed in the Medication cart dated 4/24/18. This was evident during observations conducted for the Medication Storage Task. (Third Floor) The finding is: On 12/17/18 at 10:31 AM, during the medication storage task with LPN #1 a opened [MEDICATION NAME]pen was observed with a hand written open date of 4/24/18. LPN #1 stated that she was unable to provide information about the insulin pen and would inform the Nurse Manager. On 12/18/18 at 05:53 PM, an interview was conducted with LPN #2 who stated insulin pens are dated once opened. LPN #2 stated the date, initials and shift preferably should be documented on the insulin pen. Before administering medication to a resident, LPN #2 stated the expiration date is reviewed and insulin is discarded within thirty days of opening. On 12/19/18 at 01:30 PM, the Nurse Manager was interviewed and could not determine a start date for the insulin pen. On 12/19/18 at 03:43 PM, the Assistant Director of Nursing Services (ADNS) was interviewed and stated the insulin pen was dispensed from the pharmacy in (MONTH) (YEAR). The ADNS also stated that insulin is labeled and dated when it is opened. The ADNS further stated that the date was written poorly by the nurse and that the insulin pen was opened on 11/24/18. 415.18(e)(1-4)

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that financial quarterly statements were provided to cognitively intact residents. Specifically, a cognitively intact resident stated that she does receive quarterly statements. This was evident for 1 out of 1 resident reviewed for Personal Funds (Resident #55). The facility Skilled Nursing Care Facility Admission Agreement signed by the resident on 10/17/14 documented You will receive a quarterly statement showing: a. Balance at beginning of statement period; date and amount of deposits and withdrawals; interest earned, if any; ending balance. The facility policy and procedure Resident Personal Funds Management dated 9/2018 documented A statement detailing all transactions on the account will be provided to the resident quarterly. The finding is: Resident #55 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition. On 12/13/18 at 04:17 PM, an interview was conducted with the resident who stated she does not receive quarterly statements. On 12/14/18 at 04:11 PM, an interview was conducted with the Director of Social Services (DSS) who stated quarterly statements are given to residents who are alert and mailed to representatives of residents who are not alert. The social service department has not been involved in delivering or mailing quarterly statements; it is specifically done through the finance department. On 12/14/18 at 04:12 PM, an interview was conducted with the Chief Financial Officer (CFO) who stated all residents should receive a quarterly statement. On 12/14/18 at 04:12 PM, an interview was conducted with the Resident Trust Coordinator (RTC) who stated that as per the policy quarterly statements are mailed to the residents' families and residents residing in the facility are not provided with statements. The RTC stated he had no way of knowing which residents were alert and oriented and should receive their own statements. The RTC further stated that quarterly statements are mailed a week after being printed and there is no system in place for tracking when and to whom statements are sent. On 12/19/18 at 03:10 PM, a second interview was conducted with the RTC who stated that quarterly statements are mailed to resident representatives and usually all residents have representatives. If not the statement is then given to capable and cognitively alert residents. However, the RTC stated that he has been mailing the quarterly statements to resident representatives for the past fourteen years. 415.26(h)(5)(i)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that each resident received the necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. This was evident for 1 out 3 sampled residents (Resident #1). The facility did not provide orientation or education to Resident #1 ' s private companion. The facility did not inform the private companion that she was not authorized to transfer the resident. Subsequently, the private companion performed an unauthorized one-person transfer assist. During the transfer, the resident fell and sustained a [MEDICAL CONDITION]. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 968 The findings include: Resident #1 was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 (a resident assessment tool) dated 10/13/12 identified the resident ' s cognitive ability for daily decision making as modified independence with no short/long term memory problems. The resident required physical assistance of 1 staff member for transfers. A nurse ' s note dated 11/5/12, documented that Resident #1 fell in the bathroom while he was being assisted with transfer from his wheelchair to the toilet by his private companion. The facility investigation report documented that on 11/5/12 Resident #1 ' s private companion assisted the resident with a transfer for toileting. The resident fell in the process and was transferred to the hospital where he was treated for [REDACTED]. An undated facility Policy titled " Private Hire Resident Companions " documented that private companions are not permitted to ambulate or assist in the ambulation of a resident. The policy also documented that companions are not allowed to transfer a resident to or from a bed, chair, toilet, commode or wheelchair. According to the policy, when a resident or family hires a private companion, the Social Services Department is notified and facilitates all necessary paperwork. The policy included a Private Hire Companion Agreement Form designated for signatures by the resident/family and the companion. The agreement form documented that the companions are not allowed to ambulate or transfer residents. There was no evidence in the medical record that Resident #1's companion signed the Private Hire Companion Agreement Form. On 12/4/12 at 2:12PM an interview was conducted with Resident #1 ' s private companion, who was working with the resident on 11/5/12. She identified herself as a Home Health Aide (HHA) and stated that when she was working with Resident #1, she performed the duties of a HHA, which included assisting the resident with transfers for toileting. She stated that no one in the facility educated her on what she was not authorized to do. She stated that on 11/5/12 she transferred the resident to the wheelchair and wheeled him to the bathroom. During the transfer to the toilet, the resident slipped and fell . She stated that if she had been informed that she was not authorized to perform transfer assists, she would have requested for facility staff to come and assist the resident. On 12/4/12 at 11:50AM an interview was conducted with the covering Social Worker. The Social Worker stated that he did not provide education to the private companion related to the limitations in providing care to residents. He stated that prior to 11/05/12, he was not aware that the resident had a companion while he was in the facility. He stated that if he had known that Resident #1 had a companion, he would have informed the companion that she was not allowed to transfer the resident. On 12/4/12 at 12:09PM an interview was conducted with the Director of Nursing. She stated that the facility did not provide education or orientation to Resident #1 ' s companion. The facility did not notify this companion that she was not allowed to transfer the resident. She stated that it is the facility policy to educate all the private hire companions and inform them of their limitations in providing care to the residents. She stated that the private hire companions are provided education when they first start working at the facility. 415.12