Every finding on record at Pinnacle Multicare Nursing and Rehabilitation Cent

Based on observation, record review, and interview during the Recertification and Complaint Survey (Complaint #666294) conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure a resident received adequate supervision and assistance consistent with the resident's needs to prevent accidents. This was evident for one (1) (Resident #49) of seven (7) residents reviewed for accidents out of 35 total sampled residents. Specifically, Resident #49 fell and sustained major injury while being provided care in bed by Certified Nursing Assistant #2. This resulted in actual harm to Resident #49 that was not Immediate Jeopardy.The findings include:The facility policy titled Accidents/Incidents with a last revised date of 12/12/2022 documented Avoidable Accident - Resident had an accident and the facility failed to: 1) Identify environment hazards and individual resident risk for accident, including the need for supervision; 2) Implement interventions, including adequate supervision, consistent with resident's needs, goals and plan of care and recognized standards of practice, to reduce the risk of an accident; 3) Monitor the effectiveness of the interventions and modify the approaches as necessary, in accordance with relevant care standards.Resident #49 had diagnoses of Generalized Muscle Weakness, Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. ), and Cerebrovascular Accident (interruption in the flow of blood to cells in the brain). The Minimum Data Set (a resident assessment tool) dated 10/30/2024 documented Resident #49 had impaired memory, severely impaired cognitive skills, and had impairment on both sides of both upper and lower extremities. The assessment documented Resident #49 was dependent on staff (resident does none of the effort to complete the activity, staff does all the effort or requires the assistance of two (2) or more staff to complete the activity) for activities of daily living including upper and lower body dressing and rolling left and right. A comprehensive care plan for functional abilities was initiated on 11/20/2023. The care plan documented Resident #49 had self-care limitations and was dependent on staff for upper and lower body dressing. The care plan did not indicate the number of staff assistance required. The care plan was reviewed on 11/20/2024; the care plan notes documented by Minimum Data Set Assessor #1 stated plan of care was still applicable. A comprehensive care plan for mobility limitations was initiated on 07/29/2024. The care plan documented Resident #49 required substantial/maximal assistance (staff lifts or holds trunks or limbs and provides more than half the effort) for bed mobility or rolling left to right. The care plan did not indicate the number of staff assistance required. The care plan was reviewed on 11/20/2024; the care plan notes documented by Minimum Data Set Assessor #1 stated Resident #49 was non-ambulatory and required a mechanical lift for transfers. The Resident Nursing Instruction Form (contains instructions for Certified Nursing Assistants) documented on 01/11/2023, Resident #49 was totally dependent for bed mobility and required two (2) person physical assist; and was totally dependent for upper and lower body dressing and required one (1) person physical assist. The nursing instruction also documented Resident #49 was confused, at high risk for falls, and had left-sided weakness and left foot tremors. There was no documented evidence the comprehensive care plan nor the Resident Nursing Instruction Form was updated to include the Minimum Data Set assessment dated [DATE], indicating the resident was dependent, requiring two (2) or more staff for activities of daily living including upper and lower body dressing and rolling left and right.A plan of care notes by Registered Nurse #2 dated 12/18/2024 documented, Writer responded into a thud in Resident #49's room at 1:30 AM when resident was observed on the floor lying on their right side facing the bed with legs extended. Noted with nose injury and bleeding that appeared to be from the back of the head. As per staff assigned, Certified Nursing Assistant #2 was changing and removing resident's wet gown from feeding when the resident fell on the floor. Unable to fully assess the resident on the extent of injury due to their position on the floor. The resident was transferred to the hospital emergency room. The Nursing's Review of Accident/Incident Form completed by the Risk Manager dated 12/20/2024 documented that on 12/18/2024 at 1:30 AM, a thud was heard in Resident #49's room. The nursing supervisor and the floor nurse responded, and they observed Resident #49 on the floor lying on their right side, facing the bed with legs extended. The right side of the resident's nose was resting against the foot frame of the metal bed. The resident was nonverbal and unable to give an account. On assessment, the resident was noted with a nasal injury and bleeding that appeared to be from the right side of the head. 911 (emergency medical service) was immediately activated. According to Certified Nursing Assistant #2, they were changing the resident's wet gown and as they were removing the gown from the right hand, the resident reached over and began to slide off the bed. The Certified Nursing Assistant tried to pull the resident back to bed but was heavy and they slid off the bed. The facility investigation concluded that Resident #49 made an unpredictable maneuver during care as they reached over while the staff was removing their gown resulting in the resident sliding off the bed; there was no evidence to suggest that abuse or neglect occurred. The hospital Physician Discharge summary dated [DATE] documented Resident #49 was admitted on [DATE] and was discharged back to the nursing home on [DATE]. Resident #49 presented from the nursing home after a fall and was found to have nasal bone fractures (broken bones), right frontal scalp and right premaxillary (bones of the upper jaw) hematomas (areas of pooled blood), and with severe epistaxis (nose bleeding) as seen in the computed tomography scan (imaging test that uses a combination of x-ray and computer technology). The resident had high volume nosebleeds and was transferred to the intensive care unit for monitoring. The bleeding stopped on 12/24/2024 and had been stable since then. Resident #49 was also treated for lower lobe pneumonia (lung infection) while in the hospital. On 08/01/2025 at 8:01 AM, Certified Nursing Assistant #2, who was assigned to Resident #49 on the date and time of incident, was interviewed and stated they have been working in the facility for about a year and had Resident #49 in their assignment when they worked in the unit. They stated Resident #49 required assistance of two (2) staff for bed mobility. They stated on the day of the incident, the nurse asked them to change Resident #49's gown that got messed up with feeding. They stated, as they were changing the gown, the resident's hand swung, and the resident fell on the floor. They stated they were not able to hold the resident because the resident was too heavy. Certified Nursing Assistant #2 stated they thought they could change Resident #49's gown alone because the resident does not require a lot of turning. On 08/01/2025 at 8:13 AM, Registered Nurse #2, who was the nursing supervisor on duty on the day of the incident, was interviewed and stated they were at the nursing station during shift rounds when they heard a sound coming from Resident #49's room. They stated they went into the room and saw the resident on the floor, Certified Nursing Assistant #2 was on the opposite side of the resident's bed. They stated, according to Certified Nursing Assistant #2, they were trying to change the resident's gown when the resident fell off the bed. Registered Nurse #2 stated Resident #49 required one (1) assist for dressing, but based on resident's mobility and weight, the Certified Nursing Assistant should have asked for assistance from a second staff to prevent the resident from falling.On 08/01/2025 at 10:08 AM, Registered Nurse #3, who was the Unit Manager, was interviewed and stated the incident occurred overnight, and from the incident report, Certified Nursing Assistant #2 was trying to do resident care by themself during the night when Resident #49 fell from the bed and sustained injuries. Registered Nurse #3 stated that the fall could have been prevented if Certified Nursing Assistant #2 had another staff to assist them in the care that required moving the resident in bed. Registered Nurse #3 also stated Resident #49 needed total assist of one (1) for dressing but would require assistance of two (2) staff for bed mobility. On 08/04/2025 at 11:23 AM, the Risk Manager was interviewed and stated the investigation revealed Certified Nursing Assistant #2 followed the instructions on the Certified Nursing Accountability Record that documented Resident #49 required one (1) staff assistance for dressing and two (2) staff assistance for bed mobility. They stated Resident #49 moved and rolled out of bed when Certified Nursing Assistant #2 was taking off the resident's gown. On 08/01/2025 at 8:50 AM, Minimum Data Set Assessor #1 was interviewed and stated that based on the input from the staff and rehabilitation department, Resident #49 was assessed to be totally dependent of staff with two (2) staff assistance for bed mobility and dressing. They stated this was reflected on the Certified Nursing Assistant Instructions. The Assessor stated they cannot explain why the resident's bed mobility and dressing was done by only one (1) staff that resulted in fall and injury, because the instruction was clear. On 08/04/2025 at 11:44 AM, the Director of Nursing was interviewed and stated Resident #49 was assessed to be one (1) assist for dressing at the time of the incident, and they thought resident just moved while being dressed causing the resident to fall. The Director of Nursing stated it could have been better and safer if two (2) staff had given the care to the resident at the time.On 08/04/2025 at 11:50 AM, the Administrator was interviewed and stated the incident with Resident #49 occurred before they assumed office. The Administrator stated that if the resident required the assistance of two (2) staff and only one (1) staff was giving the care, there is going to be a problem.10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that residents who needed respiratory care were provided care that was consistent with professional standards of practice. This was evident for 3 (Residents #27, #451 and #412) of 5 residents reviewed for respiratory care out of 35 total sampled residents. Specifically, 1.) Nebulizer mask, oxygen cannula, and oxygen tubes were observed in residents' bedside that were not dated and were exposed or not kept in a bag. 2.) Resident #412 was observed receiving oxygen without a physician's order.The findings include: The facility's policy titled Oxygen Therapy with a last reviewed date of 07/2018 stated that Oxygen therapy must be ordered by a physician except during emergency when a Registered Nurse may initiate oxygen therapy without a physician's order and then obtain the order by telephone. The policy stated a sealed package with a nasal cannula will be attached to the oxygen tank. Nasal catheters, masks, tubings and cannulas are to be changed every week. 1. Resident #27 was admitted to the facility with diagnoses that included Cerebral Palsy, Chronic Obstructive Pulmonary Disease, and Respiratory Failure. The comprehensive Minimum Data Set assessment dated [DATE] documented that Resident #27 had severely impaired cognition for daily decision making, shortness of breath when lying flat and required oxygen administration on admission and while a resident at the facility. A care plan for oxygen therapy was initiated on 04/04/2025. The facility interventions included to provide oxygen as ordered by the medical doctor. A physician's treatment order dated 04/06/2025 documented oxygen administration via nasal cannula / mask at two (2) to three (3) liters per minute as needed for shortness of breath. During observation on 07/29/2025 at 12:19 PM and on 07/30/2025 at 11:54 AM, an undated and unlabeled nebulizer mask with tubing, and an oxygen concentrator with an undated nasal cannula containing a one half (1/2) bottle of two hundred fifty (250) milliliters sterile water dated 06/15/2025 were observed at Resident #27's bedside. The nebulizer mask and tubing were exposed and not stored in a bag. A review of Resident #27's physician's treatment order revealed no active order for nebulization. An order for Ipratropium and Albuterol solution, three (3) milliliters to be inhaled every six (6) hours for ten (10) days has been discontinued on 04/06/2025. 2. Resident #451 was admitted to the facility with diagnoses that included Cerebral Vascular Accident with Hemiplegia and Orthopnea. The comprehensive Minimum Data Set assessment dated [DATE] documented that Resident #451 had severely impaired cognition for daily decision making and had shortness of breath when lying flat. A physician's treatment order dated 07/27/2025 documented Oxygen administration via nasal cannula or mask two (2) liters per minute as needed for shortness of breath. During observation on 07/29/2025 at 11:48 AM and on 07/30/2025 at 8:45 AM, an undated oxygen nasal cannula connected to and hanging from an oxygen tank was observed at the bedside of Resident # 451. The nasal cannula was exposed and was not kept in a bag. A review of medication and treatment administration record had no documentation as to when the nasal cannula was last changed. On 07/30/2025 at 8:45 AM, Licensed Practical Nurse #4 was interviewed and stated the oxygen tubing should have been changed and dated by night shift nurses. On 07/30/2025 at 8:54 AM, Registered Nurse #8, who was the Nursing Supervisor, was interviewed and stated that the oxygen tubing should have been labeled and dated by the night shift nurses, and all staff should be ensuring that all the tubings are labeled and dated when they are providing care, treatments and medication administration. Registered Nurse #8 stated they missed the undated oxygen tubing when they performed rounds. On 08/04/2025 at 8:17 AM, the Director of Nursing was interviewed and stated that oxygen nasal cannula tubing and masks utilized for nebulizer treatment administration should be dated and changed weekly by the night nurses. The Director of Nursing also stated that the distilled water utilized for the administration of oxygen should have been discarded within 24 hours and the rounding nurse supervisor and possibly the respiratory staff should have observed that the tubing was undated and the oxygen bottle old. The Director of Nursing further stated that the registered nurse supervisors and managers should be performing rounds to ensure that care and maintenance of oxygen tubing and nebulizer treatments are performed and that oxygen tubes are dated. 3. Resident #412 was admitted to the facility with diagnoses that included Alzheimer's Disease, Atrial Fibrillation, and Hyperlipidemia. The Minimum Data Set (a resident assessment tool) dated 06/30/2025 documented that the resident had no respiratory diagnoses, was not short of breath and was not receiving oxygen therapy. On 07/27/2025, Resident #412 was observed using oxygen via nasal canula at 2 liters per minute. The resident was observed using oxygen daily from 07/27/2025 through 08/04/2025. Resident # 412's medical orders were reviewed and contained no orders regarding oxygen delivery, change of canula tubing or pulse oximetry. On 08/01/2025 at 11:48 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #412 had some shortness of breath recently and is currently using oxygen around the clock. They stated that Resident #412 refuse to remove the oxygen. Licensed Practical Nurse #3 stated they had not seen an order to administer oxygen for Resident #412. On 08/04/2025 at 11:23 AM, Registered Nurse #7, who was the Nurse Manager, was interviewed and stated Resident #412 had infection recently and in that case the nurses automatically start an order for oxygen or get a telephone order from the doctor to administer oxygen. They stated they made a mistake and will fix it. On 08/04/2025 at 2:50 PM, the Director of Nursing was interviewed and stated that Resident #412 should have a care plan for oxygen use. They stated that the physician can enter the order for the resident, or they can also give a telephone order to the nurse and the nurses can enter it. On 08/04/2025 at 3:02 PM, Physician #1 was interviewed and stated they last evaluated Resident #412 in July and found the resident was stable and has no need for oxygen. They stated they had treated Resident #412 3 or 4 months ago for a respiratory infection and had ordered oxygen at that time because the resident's oxygen saturation level had decreased to 82-84 percent, but the order was cancelled when Resident #412's respiratory status improved. Physician #1 said they had not been made aware that Resident #412 was receiving oxygen at this time. 10NYCRR415.12(k)(6)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the New York State Department of Health. This was evident for 1 (Resident #318) of 7 residents reviewed for Accidents out of 35 total sampled residents. Specifically, the facility did not report to the New York State Department of Health an unwitnessed incident on 07/10/2025 when Resident #318 was observed on the floor with a laceration to the forehead that required 5 sutures. Resident #318 was unable to explain the occurrence. The findings include:The facility's policy and procedure titled Accidents/Incidents with a last reviewed date of 12/12/2022 stated the purpose of the policy was to investigate the cause of all marks, discolorations, skin breaks, and injuries that has not been witnessed. The policy stated if a licensed nurse becomes aware of an event whether it was witnessed, alleged, an injury of unknown origin, or a suspicion that abuse, neglect, or mistreatment may have occurred, immediate action will be taken. The Department of Health and other regulatory agencies will be notified as per the regulations. Resident #318 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Depression, and Hypertension.The Minimum Data Set, dated [DATE] documented Resident #318 had severely impaired cognition. The nurse's progress note dated 07/10/2025 documented at approximately 5:00 AM, nursing staff observed Resident #318 on the floor in a supine position. Upon assessment, Resident #318 noted with a laceration on the left forehead and was unable to give account of what happened. The family and medical doctor were notified and ordered transfer to hospital for further evaluation.The Accident Incident Report dated 07/10/2025 documented on 07/10/2025 at 5:00 AM, Resident #318 was observed on the floor in a supine position, noted with a laceration on the left forehead. Resident was unable to give account of what happened. Representative and Medical Doctor were notified and ordered transfer to the hospital for evaluation and treatment. The investigation concluded there was no reasonable suspicion to believe that abuse, neglect or mistreatment occurred. The investigation summary with conclusion was signed by Director of Nursing, Administrator, and Medical Director on 07/16/2025. The Hospital Discharge summary dated [DATE] documented Resident #318 sustained a laceration to the forehead from an unwitnessed fall at the nursing home. The laceration measured 3 centimeter in length and 0.5 centimeter in depth. The laceration was repaired with 5 sutures. Resident #318 was treated and returned to the nursing home.There was no documented evidence the facility reported Resident #318's unwitnessed incident resulting to an injury to the New York State Department of Health.On 08/04/2025 at 11:54 AM, Registered Nurse #6 was interviewed and stated they were the covering nurse supervisor on the night shift on 07/10/2025 when they were notified of Resident #318's incident. Registered Nurse #6 stated Resident #318 was found on the floor next to their bed in the room and was noted with a laceration on the forehead. Resident #318 could not provide explanation about the incident. Resident #318 was ordered to transfer for hospital evaluation. Registered Nurse #6 initiated the incident report and immediately notified the Director of Nursing because the incident was unwitnessed resulted in a major injury. Registered Nurse #6 stated they do not know if this incident was reported to the Department of Health.On 08/04/2025 at 09:40 AM, the Risk Manager was interviewed and stated Resident #318 was found on the floor with a laceration on the forehead on 07/10/2025 at 5:00 AM. They stated the incident report was reviewed and determined there was no abuse or neglect that occurred with Resident #318 that was why it was not reported to the New York State Department of Health. On 08/04/2025 at 10:19 AM, the Director of Nursing was interviewed and stated they are responsible for reporting incidents involving abuse, neglect or incidents resulting in major injury to the New York State Department of Health. The Director of Nursing stated this incident involving Resident #318 was not reported to the New York State Department of Health because they concluded that Resident #318 sustained a laceration from a fall.On 08/04/2025 at 11:25 AM, the Administrator was interviewed and stated any reportable incidents are reported to the New York State Department of Health by the Director of Nursing or designated staff by the Director of Nursing. The Administrator stated that they worked on 07/10/2025 but does not recall this incident.10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that parenteral fluids were administered consistent with professional standards of practice. This was evident in 1 (Resident #451) of 2 residents reviewed for hydration, out of 35 total sampled residents. Specifically, Resident #451 was observed with undated peripheral intravenous catheter insertion site dressing and tubing. The intravenous solution was also not dated and was not labeled with the resident's name and flow rate. The findings include:The facility's policy and procedure titled Intravenous Infusion with a last reviewed date of 01/2022 documented that intravenous fluids should be labeled with the resident's name, the time, date, and rate of flow. The policy stated intravenous catheters are left in for no longer than 72 hours unless otherwise ordered by a physician. If intravenous therapy is ordered for greater than 72 hours, the site must be changed every 72 hours, unless otherwise indicated/ordered by a medical doctor or nurse practitioner with a reason/diagnosis.Resident #451 was admitted to the facility with diagnoses that include Seizure Disorder and Intracranial Lesions.The Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #451 had severely impaired cognition and received medication administration intravenously.A physician's order for Resident #451 dated 07/27/2025 at 10:26 PM documented to infuse 1000 milliliters of Dextrose 5 percent and 0.45 percent Sodium Chloride intravenous solution every shift for 2 days for other seizures.On 07/28/2025 and 07/29/2025 at 11:48 AM, Resident #451 was observed with a left upper extremity peripheral intravenous catheter dressing that was undated, the peripheral infusion line tubing was undated and the 1-liter fluid of Dextrose with Normal saline was undated and unlabeled.A care plan for Intravenous Therapy was initiated for Resident #451 on 07/28/2025. The care plan documented Resident #454 had a need for intravenous therapy secondary to decreased fluid intake. The interventions documented to monitor the intravenous site every shift.On 07/30/2025 at 8:45 AM, Licensed Practical Nurse #4 was interviewed and stated the nursing staff who inserted the peripheral intravenous catheter should have labeled the dressing and tubing with the date so that they could be changed within 72 hours. Licensed Practical Nurse #4 also stated that they had forgotten to label the intravenous fluid bag with the resident's name, the date, and time of administration and the flow rate.On 07/30/2025 at 9:05 AM, Registered Nurse #8, who was the Nursing Supervisor, was interviewed and stated nurses should ensure that the intravenous site dressing, associated tubing or lines and hydration fluids are all labeled and dated when they are providing care, treatments and medication administration. Registered Nurse #8 further stated they performed daily rounds but missed the observation that Resident #451 had undated and unlabeled intravenous dressing, tubing and hydration bags. On 08/04/2025 at 7:59 AM, the Director of Nursing was interviewed and stated the intravenous insertion site dressing should have been labeled with the date of insertion and initials of the nurse to ensure that the dressing is changed every 72 hours. The intravenous tubing should have been labeled with the date of insertion and the intravenous hydration bags should have been labeled with resident information, date and time, and flow rate of the solution. The Director of Nursing further stated that nursing supervisors and managers should be rounding to ensure that these tasks are completed, and night supervisors should be documenting observations of resident care and treatments on an observation checklist. The observation checklist was requested but not provided.10 NYCRR 415.12(k)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that food were served at a safe and appetizing temperature. This was evident for 1 (Unit 5) of 13 units observed. Specifically, on 07/30/2025, foods served during breakfast in Unit 5 were not maintained at palatable and appetizing temperature. The findings include:The facility's policy and procedure titled Food Temperature Policy with a last revision date of 05/2025 documented all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 140-degree Fahrenheit. The facility's policy titled Food Temperature Policy with a last revision date of 05/2025 documented the purpose of the policy was to ensure all meals are consistently prepared and served in a manner that is appealing in taste, texture, aroma and presentation, promoting resident satisfaction and nutritional intake.Resident #20 was admitted to the facility with diagnoses include Diabetes Mellitus, Hypertension and End Stage Renal Disease. The Minimum Data Set assessment dated [DATE] documented Resident #20 was cognitively intact and independent for eating.During an interview on 07/29/2025 at 09:01 AM, Resident #20 stated hot foods were delivered at lukewarm temperature most of the time and sometimes hot foods were cold.n 07/30/2025 at 07:46 AM, test trays for Unit 5 were requested. On 07/30/2025 at 08:25 AM, meal carts arrived on Unit 5 and distribution of the meal trays continued until 08:57 AM.On 07/30/2025 at 08:57 AM, the food temperatures on the test trays were conducted with the Food Service Director. The following were observed:For the regular diet tray, oatmeal had a temperature of 112 degrees Fahrenheit, cheddar eggs at 94 degrees Fahrenheit, and coffee 132 degrees Fahrenheit.For the puree diet tray, cinnamon oatmeal had a temperature of 120 degrees Fahrenheit, puree turkey at 90 degrees Fahrenheit, and purees eggs at 100 degrees Fahrenheit.On 08/01/2025 at 10:19 AM, the Food Service Director was interviewed and stated the temperatures were not appropriate for hot foods during the temperature checks on 07/30/2025. The Food Service Director stated the ideal temperature for hot foods should be above 140 degrees Fahrenheit. On 08/04/2025 at 10:19 AM, the Director of Nursing stated they have not heard of any food related issues until recently. On 08/04/2025 at 11:22 AM, the Administrator stated they were recently hired and was not aware of any food quality issues prior to the current survey.10 NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573 & NY00364335), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for two out of seven residents (Resident #1 and Resident #3) sampled for abuse. Specifically, On 12/18/2024 at 3:35 PM, Resident #1's adult child reported to Nurse Manager #1, on 12/18/2024, that they witnessed Certified Nursing Assistant #1 used the dining room table to shove Resident #1 to sit in their wheelchair on 12/18/2024 at 3:28 PM. The facility investigated the alleged allegation of abuse and concluded that abuse did not occur. The facility did not report the alleged allegation of abuse to New York State Department of Health within two hours. Additionally, the facility did not report the suspicion of abuse to local law enforcement within two hours. The facility reported the alleged abuse to New York State Department of Health and to local law enforcement on 01/03/2025 at 5:04 PM while the Department of Health Surveyors were onsite. On 12/10/2024 at 3:50 PM, Resident #3 was observed with swelling and discoloration to their left middle finger. An x-ray result dated 12/10/2024 documented an acute comminuted fracture (a broken bone splintered into more than two pieces) of the 3rd proximal phalanx shaft extending to the base. Resident #3 was transferred to the hospital on 12/10/2024 for further evaluation. The facility became aware of the fracture on 12/10/2024 and reported it to New York State Department of Health on 01/03/2025 at 7:15 PM while New York State Department of Health surveyors were onsite conducting the investigation. The findings are: The facility Policy and Procedure titled Abuse Prevention superseded on 10/2022 documented the Director of Nursing, Administrator or designee will notify local law enforcement and the New York State Department of Health immediately but no later than two hours if the alleged violation involves abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property after the allegation is made which involves abuse or resulted in serious bodily injury. Resident #1 was admitted to the facility with diagnoses including Dementia, Persistent Mood Disorder, and Depression. A Social Service assessment dated [DATE] documented Resident #1 had severe cognitive impairment. An Incident/Event Intake Form dated 12/18/2024 documented Resident #1's child reported on 12/18/2024 at 3:35 PM that they witnessed Certified Nursing Assistant #1 pushed a table against Resident #1 in the day room. Nurse Manager #1 conducted an assessment, and there were no visible injuries. Certified Nursing Assistant #1 was removed from the schedule the pending investigation. Certified Nurse Assistant #1 was interviewed on 12/20/2024 and stated Resident #1 was assisted to sit down due to the risk of falls. Based on investigation and re-enactment, the facility concluded there were no evidence of abuse. An email with Resident's #1 child feedback dated 12/18/2024 at 6:00 PM documented they came to the day room and witnessed Certified Nursing Assistant #1 shoved Resident #1 with a table. Certified Nursing Assistant #1 shoved Resident #1 with the table to show the resident how to sit in their wheelchair. A Webform Submission from: Nursing Home Facility Incident Report dated 01/03/2025 showed the facility submitted the report to the New York State Department of Health on 01/03/2024 at 5:04 PM. A Security Log dated 01/03/2024 documented two Police Officers came on site at 6:52 PM. During an interview on 01/02/2024 at 1:07 PM, the Director of Nursing stated Nurse Manager #1 reported the allegation to them on 12/18/2024 after 3:30 PM and the Administrator was notified on 12/18/2024 at around 3:47 PM. The Director of Nursing stated they immediately removed Certified Nursing Assistant #1 from the schedule. The Director of Nursing stated that a re-enactment of the incident was done on 12/20/2024 by Certified Nurse Assistant #1. The Director of Nursing Stated Certified Nursing Assistant #1's body did not move the table forward when Certified Nursing Assistant #1 leaned over the table. The Director of Nursing stated the allegation was investigated and they concluded there was no evidence of abuse after the re-enactment. The Director of Nursing stated Certified Nurse Assistant #1 was terminated because they did not report the family's allegation of abuse to the nurse. The Director of Nursing stated they did not suspect that a crime had occurred, therefore, they did not report the alleged abuse to New York State Department of Health or to local law enforcement. During an interview on 01/03/2024 at 1:15 PM, the Administrator stated they became aware of the alleged incident on 12/18/2024 at around 3:47 PM. The Administrator stated they did not call the police or report the incident to New York Department of Health because there was no evidence of abuse. Resident #3 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Depression. The Minimum Data Set, dated dated dated [DATE] documented that Resident #3 had severe cognitive impairment. A Nursing Progress Note dated 12/10/2024 dated 12/10/2024 at 3:50 PM, by Registered Nurse #1, documented Resident #3 was observed with a slight swelling and discoloration to their left middle finger. An x-ray result dated 12/10/2024 documented an acute comminuted fracture of the 3rd proximal phalanx shaft extending to the base. Resident #3 was transferred to the hospital on 12/10/2024 for further evaluation. An Incident /Event Intake Form dated 12/16/2024 documented abuse did not occur and that Resident #3 most likely sustained injury to their left hand while ambulating without assistance looking for their wheelchair. Resident #3 reenacted the fall event, and it appears that Resident #3 broke their fall by grabbing on to an object (table). Resident #3 could have either squeezed or bent their finger causing them to sustain a fracture. Resident #3 was transferred to the hospital and returned with a splint and orthopedic follow-up. A Webform Submission from the Nursing Home Facility Incident Report showed the facility reported the fracture to the New York State Department of Health on 01/03/2025 at 7:15 PM. During an interview on 01/03/2025 at 12:50 PM, the Director of Nursing stated when Resident #3 returned from the hospital, the discharge summary documented Resident #3's fracture was due to abuse. The Director of Nursing stated the facility did an investigation but did not call the police, and they do not recall calling the Department of Health. The Director of Nursing stated the Risk Manager is responsible for reporting abuse to the Department of Health. During an interview on 01/03/2025 at 1:25 PM, the Administrator stated they are obligated to report all abuse allegations to the Department of Health. The Administrator stated the hospital discharged paperwork alleged Resident #3 was abuse in the facility, therefore, the facility should have reported the allegation of abuse to the Department of Health. During an interview on 01/03/2025 at 2:30 PM, the Risk Manager stated they did not report abuse to the Department of Health because they did not suspect abuse. The Risk Manager stated Resident #3 was interviewed and they reported they fell prior to going to the hospital. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573), the facility failed to thoroughly investigate an alleged violation of abuse. This was evident for one out of seven residents (Resident #1) sampled for abuse. Specifically, Resident #1's adult child reported to Registered Nurse Supervisor #1, on 12/18/2024, that they witnessed Certified Nursing Assistant #1 used the dining room table to shove Resident #1 to sit in their wheelchair on 12/18/2024 at 3:28 PM. The facility investigated the alleged allegation of abuse and concluded that abuse did not occur. The facility did not interview residents that were in the dining room and other staff that were on the unit to ascertain if there were any potential witness. The findings are: The facility Policy and Procedure titled Abuse Prevention supersedes on 10/2022 states that allegations of resident abuse, neglect, mistreatment, exploitation, and/or misappropriation of property will be thoroughly investigated; documented by the Administrator (or designee) and reported to the appropriate state agencies, physicians, families and /or representative. The Director of Nursing /designee will conduct the interviews with potential witnesses or staff who might be able to share needed information in a private room to establish lines of communication. Resident #1 was admitted to the facility with diagnoses including Dementia, Persistent Mood Disorder, and Depression. A Social Service assessment dated [DATE] documented Resident #1 had long and short-term memory problems and severely impaired cognition. An Incident/Event Intake Form dated 12/18/2024 documented Resident #1's child reported on 12/18/2024 at 3:35 PM that they witnessed Certified Nursing Assistant #1 pushed a table against Resident #1 in the day room. Nurse Manager #1 conducted an assessment, and there were no visible injuries. Certified Nursing Assistant #1 was removed from the schedule the pending investigation. Certified Nurse Assistant #1 was interviewed on 12/20/2024 and stated Resident #1 was assisted to sit down due to the risk of falls. Based on investigation and re-enactment, the facility concluded there was no evidence of abuse. An email, with Resident's #1 child feedback, dated 12/18/2024 at 6:00 PM documented they came to the day room and witnessed Certified Nursing Assistant #1 shoved Resident #1 with a table. Certified Nursing Assistant #1 shoved Resident #1 with the table to show the resident how to sit in their wheelchair. The Resident Demographic Detail Report revealed there were 12 residents in the day room on 12/18/2024. Resident #2 was alert and oriented x3. During an interview on 01/02/2024 at 1:07 PM, the Director of Nursing stated Nurse Manager #1 reported the allegation to them on 12/18/2024 after 3:30 PM and they immediately removed Certified Nursing Assistant #1 from the schedule. The Director of Nursing stated that they did a re-enactment of the incident and Certified Nurse Assistant #1's body did not move the table forward. The Director of Nursing stated the investigation concluded there was no evidence of abuse. The Director of Nursing stated they did not interview other residents who were sitting in the dining room, nor did they interview other staff members before ruling out abuse. During an interview on 01/03/2024 at 1:15 PM, the Administrator stated they became aware of the alleged abuse incident on 12/18/2024 at around 3:47 PM. The Administrator stated that the Director of Nursing is responsible for the investigation and should have interviewed residents who were in the dining room and other staff members. 10 NYCRR 415.4 (b)(3)

Based on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that garbage was properly disposed. Specifically, garbage was not covered while being removed from the kitchen to the disposal area. This was evident during the Kitchen task. The finding is: The facility policy and procedure titled Waste Disposal created 4/2018 and last revised 3/2023, documented garbage will be disposed of as needed throughout the day and at the end of each day. The policy further stated that prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers, trash bags shall be sealed prior to removing them from the facility, and trash will be deposited into a sealed container outside the premises. On 06/07/23 at 10:36 AM, Food Service Worker (FSW) #1 was observed disposing of kitchen garbage. FSW #1 removed tied, clear plastic bags from a covered garbage bin, placed them in a large, grey, rectangular wheeled container, then pushed the wheeled container through the back of the kitchen, behind the tray line where lunch was being served at the time. The container was not covered. FSW #1 pushed the container approximately 100 feet through a hallway and to a back door, out of the building to the compactor area. FSW #1 placed the garbage bags in the compactor and closed the compactor door. FSW #1 was immediately interviewed and stated they had not been trained that the trash container needs to be covered during transport to the compactor area. During an interview on 06/07/23 at 10:46 AM, the Director of Food and Nutrition (DFN) stated staff are supposed to take the garbage through the back of the kitchen, and the bags should be tied and covered. The DFN stated they thought the tied bags were enough as a cover and did not realize the container itself needed to be covered. On 06/07/23 at 04:25 PM, the Facility Administrator (FA) was interviewed and stated that trash from the dietary department goes in a garbage barrel, where it is secured and sealed so that garbage does not come out of the barrel,. The FA also stated that they were not aware that the transport container should be covered. 415.14 (h)

Based on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, multiple items were observed in freezers and refrigerators without proper labeling and dating. This was evident during the Kitchen task. The findings are: A facility policy and procedure titled Food safety, last reviewed 5/22, documented that all aspects of food handling, from receiving and storing, are done according to guidelines, and monitored to keep foods free from harmful microorganisms, contaminants and ensure quality and freshness is preserved. The policy further stated that food items with expiration dates or best by or use by dates should be discarded once the date has passed. On 06/01/23 at 09:49 AM an initial tour of the kitchen was conducted with the Director of Food and Nutrition (DFN), and the following was observed: in the sandwich refrigerator there were individually wrapped sandwiches (which were not on a tray) with no dates; in the walk-in refrigerator #1, multiple packages of bread were open and out of delivery boxes with no dates. In the vegetable ice chest, there was an unidentified package with no date, 6 bags of broccoli florets out of the box, undated, and 2 open bags of French fries out of the box, and undated. In another ice chest there was an open box of cookie dough with no open date. In a freezer there were 3 bags of broccoli florets out of the box, undated, and a veggie burger box was open so that the item was exposed. In the salad area fridge, an open tub of macaroni salad was observed with no open date and no manufacturer expiration date. On 06/01/23 at 10:15 AM, the DFN was interviewed and stated they were aware all stored foods had to be dated and labeled. The DFN stated sometimes kitchen workers forget to label or date the food items. On 06/08/23 at 12:48 PM, Food Service Worker (FSW) #2 was interviewed and stated they receive deliveries from the loading dock and organize items in the kitchen. FSW #2 also stated they date the items with delivery dates, check delivery and expiration dates, and they carry a marker as they are supposed to write in the date an item was opened. FSW #2 further stated it is mainly their job to label the items, but other people sometimes go in the fridge and open packages which they are supposed to date. The FSW stated that everything needs to be dated, and if it is more than 3 days old, it is discarded. 415.14(h)

Based on observation, interviews and record review conducted during an abbreviated survey (NY00315145), the facility failed to protect residents from physical abuse. This was evident in 1 out of 3 residents reviewed for abuse (Resident #1). Specifically, Resident #1 was observed being hit in the head by Certified Nursing Assistant (CNA) #1 on 4/18/2023 on the 7:30 AM-3:30PM shift. Additionally, CNA #2, who witnessed the abuse, reported it on 04/20/2023. CNA #1 was on the assignment and provided care to residents from 04/18/2023 through 04/20/2023. Resident #1 did not sustain any visible injuries. The findings are: The Policy and Procedure titled Abuse Prevention was reviewed on 10/2022. The policy states that Each Resident of this facility shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Examples: An employee strikes, pokes or punishes a Resident. Resident #1 was admitted to the facility with diagnoses including Chronic Pain and Dementia. The Quarterly Minimum Data Set Assessment (MDS, a resident assessment tool) dated 04/10/2023 documented that Resident #1 had a short and long-term memory problems and was severely impaired. Resident #1 required extensive assistance of two people with bed mobility, transfer, and toileting, and extensive assistance of one person with dressing, eating, and personal hygiene. The Incident Report Summary dated 04/21/2023 documented that on 04/20/2023 at about 1:00 PM a staff member (CNA #2) reported that on 04/18/2023 during care they observed the CNA #1 being rough with Resident #1. CNA #2 stated that CNA #1 transferred Resident #1 from the bed to the wheelchair and cried out about breaking a nail. CNA #1 started hitting Resident #1 in the head. Resident #1 was seen and examined by the Registered Nurse Manager (RNM) and no signs or symptoms of injury was noted - no redness, swelling, bruise, or discoloration. Resident #1 was unable to give an account of the occurrence, no change in behavior/condition was evident at the time of assessment. The investigation concluded that there was insufficient and unsubstantiating evidence suggesting that abuse had occurred. A Care Plan titled Cognitive Loss/Dementia or Other: Abuse risk related to Dementia dated 11/08/2022 documented interventions for staff to provide adequate timing during resident care and meals; task segmentation/cues; monitor for any changes in mood, body injuries. A Medical Note dated 04/24/2023 (Late entry) documented that Resident #1 was seen on 04/20/2023. A head-to-toe assessment revealed no visible injuries. The Resident was nonverbal at baseline and vital signs were stable. There were no facial grimaces while palpating various parts of the body that would indicate pain or discomfort. There was no change in the Resident from baseline status. Specifically, no evidence to indicate fresh injuries. During an interview on 04/26/2023 at 9:41 AM, CNA #2 stated that they worked on 04/18/2023 on the 7:30 AM-3:30 PM shift and was assigned to Resident #1. CNA #2 stated that CNA #1 instructed them to provide care to the Resident at about 1:10 PM, and that CNA #1 assisted them with the Resident care. CNA #2 said that the Resident was not combative, agitated, or feeling scared during the care, but during care, they observed CNA #1 rough handled and dragged Resident #1 inappropriately to position the Resident in bed. CNA #2 stated after care they both manually transferred the Resident to the wheelchair. CNA #2 stated that after the Resident was seated in the wheelchair, CNA #1 shouted and started hitting the Resident in the head. CNA #2 said that they stopped CNA #1 from striking the Resident a third time and that they asked CNA #1 what are you doing. CNA #1 replied, Resident #1 made them broke a fingernail. CNA #2 said that the Resident did not scream but was shaking. CNA #2 said that CNA #1 told them to care for Resident #1 by themselves and left the room. CNA #2 said that they should have reported the incident immediately, but they were shocked. During an interview on 04/26/2023 at 11:40 AM, CNA #1, stated that they worked on 04/18/2023 on the 7:30 AM-3:30 PM shift and was not assign to Resident #1. CNA #1 said that they were familiar with Resident #1 and took care of the Resident for one month prior to the incident. CNA #1 stated that they offered to assist CNA #2 in caring for Resident #1, and that they gave Resident #1 a proper bed bath, changed their brief, and dressed them while CNA #2 observed. CNA #1 said that they both transferred Resident #1 from the bed to the wheelchair, and that they combed the Resident's hair and wheeled the Resident to the dining room. CNA #1 said that they did not drag Resident #1 to position the Resident, they did not break a fingernail, and they did not hit the Resident in the head. CNA #1 stated that they provided a picture of their nails to the facility. During an interview on 04/26/2023 at 11:52 AM, CNA #3 said that on 04/18/2023 at about 12:30 PM they were in the day room when CNA #2 called them and said, I can't believe, I can't believe it. This is the first time seeing something like this happened. CNA #3 said that CNA #2 told them that CNA #1 used force while they were giving care and was being rough with Resident #1. CNA #3 said that CNA #2 was crying and said that they wanted to go home. CNA #3 stated that they told CNA #2 to report the incident to nursing supervisor and CNA #2 said okay. During an interview on 04/26/2023 at 2:25 PM, the Risk Manager (RM) stated that CNA #2 reported to them on 04/20/2023 at 1:00 PM, that on 04/18/2023 at about 12:30 PM they observed CNA #1 hitting Resident #1 in the head during care. The RM said that CNA #1 was interviewed and denied the allegation. The RM said that Resident #1 was assessed and there were no visible injuries. Resident #1 was not able to give an account of the occurrence due to cognitive impairment. The RM stated that Resident #1 was not observed with any change in behavior or mood. The RM stated that CNA #2 reported that CNA #1 cried out about breaking their fingernail and then hit the Resident in the head. The RM stated that CNA #1's nails were examined and there were no broken, missing, or chipped nails. The RM stated that CNA #1 said that while they were transferring Resident #1 from the bed to the wheelchair, the Resident held on to their uniform and CNA #1 pulled the Resident's hand off their uniform. During an interview on 04/26/2023 at 1:30 PM, the Registered Nurse Manager (RNM) for the 3rd floor, stated that they were informed by the Director of Nursing (DON) that CNA #2 reported that CNA #1 was rough with Resident #1 and hit the Resident in the head. The RNM stated that Resident #1 was usually calm, and they have never observed Resident #1 being agitated, combative or afraid. The RNM stated that the Resident was assessed after the alleged incident was reported and there were no injuries. During an interview on 04/26/2023 at 1:40 PM, CNA #4 who worked on 4/18/2023 on the 7:30 AM - 3:30 PM shift, stated that on 04/18/2023 at about 12:15 PM, they observed CNA #2 crying while telling a co-worker (CNA #3) that CNA #1 was rough with Resident #1 during care. CNA #4 stated that they observed CNA #2 demonstrating how CNA #1 hit Resident #1 with a hand in the head. CNA #4 said that they advised CNA #2 to report the incident to the nurse manager. During an interview on 04/26/2023 at 2:00 PM, the Director of Nursing (DON) stated that CNA #2 reported on 04/20/2023 that they witnessed CNA #1 hit Resident #1 in the head during care on 04/18/2023 after CNA #1 broke their fingernail. The DON said that the RNM and the Medical Doctor assessed Resident #1 on 04/20/2023 with no injuries. The DON stated that Resident #1 was not observed with any pain or emotional distress at the time of the assessment. The DON stated that CNA #1 was removed from schedule right away and remained on suspension. The DON stated that CNA #1 denied the allegation and provided a picture of their intact nails to the facility. The DON stated that they investigated the allegation and concluded there was not enough evidence to substantiate abuse. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during an abbreviated survey (NY00301318), the facility did not ensure that a resident's Next of Kin (NOK) was immediately informed of a significant change in the resident's condition. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 08/08/2022, Resident #1 was observed with black toes on the left foot. Resident #1's NOK was not notified. On 08/23/2022, Resident #1 was transferred to the hospital for an amputation of the toes. The findings include: The facility's Policy and Procedure entitled Significant Change in Resident Condition, last reviewed on 3/2022, documented that at the time a significant change in condition is identified the nurse or clinical staff will notify the designated representative as appropriate. The facility's Policy and Procedure entitled: Preventing and Healing Pressure and Vascular Ulcers and Open Wounds, last reviewed on 06/23/2022, documented that a Registered Nurse (RN) on duty when a Pressure Ulcer, stasis ulcer, or open wound is identified will notify the RN Coordinator/Supervisor. The Supervisor will notify family/designated representative and document in the nurses' note. Resident #1 with diagnoses that included Peripheral Vascular Disease (PVD), Hypertension, and Diabetes Mellitus. A Minimum Data Set (MDS, a resident assessment tool) dated 07/20/2022, documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) scored 5 out of 15, indicating that Resident #1 had severely impaired cognition. A review of Resident #1's Face Sheet revealed that Resident #1's children # 1 and # 2 are Next of Kin (NOK). The Complainant was not listed as an emergency contact. A Wound Care Consult Note dated 08/08/2022, documented that the wound on the left second toe was an Arterial Ulcer (open skin due to poor blood circulation). There were no signs or symptoms (S/S) of infection, the toes had dry gangrene (dead tissue due to poor blood flow). The wound on the left third toe was a vascular wound with no S/S of infection. The wound on the left fourth Toe was a vascular wound with no S/S of infection. Resident #1 was in no acute distress. The treatment for the wounds was to apply betadine solution daily, place Resident #1 on a low air loss mattress, and apply a heel protector to Resident #1. A review of Resident #1's medical record revealed that there was no documented evidence that the NOK was notified when Resident #1's three toes the left foot became black on 08/08/2022. A Comprehensive Care Plan (CCP) Skin Integrity Arterial ulcer initiated on 08/08/2022, documented that on 08/08/2022, Resident #1 was seen by a Wound Medical Doctor (MD) for changes to the left second toe. As per the MD's documentation, the Left second toe had a Gangrene Arterial wound, 100% Dry Gangrene. The Treatment was to apply Betadine/Dry Protective Dressing (DPD) daily. The left third toe had a dry Vascular Arterial ulcer, measuring 1cm x 1cm x 0 with 100% Gangrene. The treatment with to apply Betadine/DPD daily. A M.D note on 08/15/2022, documented that Resident #1 was seen by wound MD for Left 4th toe Vascular Arterial wound, measuring 2cm x 1cm x 0 100% Dry Gangrene, the treatment was to apply Betadine/DPD daily. The MD documented that PVD is a severe arterial disease of the left lower leg with Dry Gangrene and pain at rest. The recommendation was for a Vascular consult for possible Below the Knee Amputation (BKA). The interventions included monitoring the site for healing or deterioration of the ulcer, monitoring the skin integrity every shift, observing, documenting, and reporting signs of ischemia (reduced blood flow). A Wound Care Consult note dated 08/15/2022 documented: Wound to the Left second toe is an Arterial Ulcer. The measurement was 2 cm x 2cm with no s/s of infection. The dry gangrene wound on the left third Toe was a Vascular wound which measured 1 cm x 1 cm with no s/s of infection. It was Dry Gangrene. A wound on the left forth toe was a vascular wound 2 cm x 1 cm with no s/s of infection. The treatment for wounds were to apply betadine daily. Resident #1 was referred to Vascular Surgery for severe arterial disease, with recommended for possible BKA. During an interview on 08/30/2022 at 2:00 PM, Registered Nurse (RN)/Unit Manager (UM) #1 stated that prior to 08/08/2022, he/she work on the weekend and noted that Resident #1 toes were black during the morning wound rounds with the Wound Doctor on 08/08/2022. The UM #1 stated that he/she thinks that they spoke with the family but forgot to document the conversation in the medical record. The family should be notified when the Resident #1 toes turned black and documented in the Resident #1's chart. The UM #1 stated that he/she thinks that the black toe started with one toe and progressed to other toes. The Wound Doctor ordered treatment and followed up on 08/15/2022 and 08/23/2022. On 08/23/2022 the Medical Doctor assessed Resident #1 and recommended that Resident #1 be transferred to the hospital for possible amputation. During an interview on 08/30/2022 at 3:20 PM, the Nurse Practitioner (NP) stated that Resident #1 was at risk for ulcers due to DM, Neuropathy, and cardiovascular disease. When Resident #1 was noted with a black toe on the left foot the family should be notified but acknowledged that this did not occur. During an interview on 08/31/2022 at 4:30 PM, the NOK #2 stated that they live out of State and call their parent frequently. The parent complained of pain to their legs. The NOK #2 knew that their parent has problems with their legs but did not know that Resident #1's toes are black. They only knew that the parent had a sore on the heels. The NOK #2 stated that the facility called them on the day of the transfer to the hospital and inform them that their parent has a swollen leg and poor circulation. The facility did not tell them that their parent has black toes on 08/08/2022. During a follow-up telephone interview on 09/07/2022 at 10:51 AM, the DON stated that if a resident was noted with a change in condition the Unit Manager, Supervisor or MD should notify the resident's representative and document in the resident's medical record. The DON stated that they did not recall if they were made aware that Resident #1 developed Dry Gangrene of the left foot on 08/08/2022. 415.3(e) (2) (ii) (b)

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Specifically, metal trays of raw fresh chicken were observed placed on top of cardboard boxes in the refrigerator and sandwiches were not maintained at an appropriate temperature. This was evident during the Kitchen Observation Task. The findings are: The facility policy and procedure titled, Food Handling Temperature Guideline, reviewed October 2020 documented to maintain all potentially hazardous cold foods, i.e. meats, milk products, at 40 degrees F. or below to prevent spoilage and contamination. On 07/15/21 at 09:55 AM, a metal pan of seasoned chicken covered with plastic wrap was observed stored in the refrigerator on top of other boxes of raw chicken. On 07/20/2021 at 11:10AM, a metal tray with raw fresh chicken was observed placed on top of cardboard boxes in the refrigerator. On 07/20/2021 at 12:43 PM, the Food Service Director removed a turkey sandwich from the refrigerator and tested the temperature. Thermometer registered the temperature of the sandwich at 60 degrees F. The temperature of a cheese sandwich was also checked and registered at 50 degrees F. On 07/22/2021 at 12:16 PM, the Food Service Director removed a ham sandwich from the refrigerator and tested the temperature of the sandwich which registered at 59 degrees F. The temperature of an egg salad sandwich was also tested and registered at 50 degrees F. Sandwiches were observed being placed on resident trays after temperature was observed to be out of range. On 07/22/2021 at 12:24 PM, an interview was conducted with the Dietary Aide (DA) who prepared the sandwiches. The DA stated that sandwiches for lunch are usually prepared around 10:30am and then are placed in the trayline refrigerator. The DA also stated they do not check the temperature of the refrigerator before placing the sandwiches in. On 07/22/2021 at 12:47 PM, the Food Service Director (FSD) was interviewed. The FSD stated that after sandwiches are prepared, they are stored in the refrigerator for 2 hours prior to being served. The FSD also stated that sandwich temperatures are not checked as part of the tray line temperature checks. The temperature of sandwiches are checked by the supervisor and today were checked by the FSD around 11:30am and were at 40 degrees. The FSD further stated that the temperature of the sandwiches is not recorded anywhere. Sandwiches that are not within an acceptable range should be discarded and new sandwiches prepared. The FSD was asked why sandwiches had not been discarded and were being served and stated they forgot and would go remove them now. The FSD also stated that pans of meat should not be placed on boxes in the refrigerator as there was a risk of causing cross-contamination. 415.14(h)

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that residents received their personal needs account statements on a quarterly basis. Specifically, there was no documented evidence that 2 residents received their account statements on a consistent basis. This was evident for 2 out of 2 residents reviewed for Personal funds out of 38 sampled residents (Resident #180 and #388). The findings are: The facility policy Resident Funds Accounts (RFA), revised November 2020, documented the facility will provide on request, and at least quarterly to the resident or the resident's designated or legal representative, a statement showing the account balance including funds deposited and withdrawn and interest accrued. 1) Resident #388 was diagnosed with [CONDITION(S)] (PVD) and Depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #388 had intact cognition. An interview was conducted with Resident #388 on 07/15/21 at 12:06 PM. Resident #388 stated the facility has not provided quarterly statements of their patient needs account activity. The Resident Funds Ledgers dated 1/16/2020, 7/20/2020, 11/11/2020, and 1/26/2021 documented Resident #388 signed for quarterly statements on 1/20/2020, 7/21/2020, 11/19/2020, and 2/10/2021 respectively. There was no documented evidence Resident #388 received a Resident Funds Ledger for 4/2020 and 4/2021. An interview was conducted with the Executive Assistant (EA) responsible for patient accounts on 07/20/21 at 01:55 PM. The EA stated residents are provided with quarterly statements of their patient accounts by the Social Work (SW) Department. The social workers determine whether a resident is cognitively intact. Residents who are cognitively intact have their statements hand delivered by the social worker and sign that they received it. A record of the signed and delivered quarterly statements are kept in the social work office. An interview was conducted with the Director of Social Work (DSW) on 07/20/21 at 02:11 PM. The DSW stated the SW Department receive the Resident Fund Ledgers from the business office and hand deliver the statements to those residents who are cognitively intact. This is determined by a resident's Brief Interview for Mental Status score of 11-15. A signed copy of resident receipt of statement is kept on file in the social work office and a second copy is left with the resident for their record keeping. The DSW will review and provide documentation of Resident #388 ledger receipts. An interview was conducted with the Social Worker (SW) assigned to Resident #388 on 07/22/21 at 01:01 PM. The SW stated that the SW Department will continue to look for the missing statements from April 2020 and April 2021 for Resident #388. On 07/23/ 21 at 11:53 AM, the SW stated they were unable to locate documented evidence Resident #388 received a copy of their Resident Funds Ledger in April 2020 and April 2021. The SW was certain the resident was provided with these statements but may not have signed for them. The SW does not document receipt of quarterly statements anywhere else in the record. 2) Resident #180 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] and Annual MDS dated [DATE] documented the resident had intact cognition and had impairment on one side of upper extremity. On 7/16/21 at 9:42 AM, an interview was conducted with Resident #180. Resident #180 stated they did not receive quarterly statements. On 07/23/21 at 09:16 AM, the Director of Social Work (DSW) was interviewed. The DSW stated that statements are obtained from the Finance Department and if the resident has a BIMS score of 11 or higher, they are provided the statements by the Social Worker which they sign for. The DSW also stated that Resident #180 was provided with statements but because of the resident's physical condition they are not able to use their hands and so could not sign for the statement. The DSW further stated they would provide copies of the statements that were provided to the resident. Around 11:30 AM, 4 Resident Funds Ledger were provided for the following time periods: 4/1/20-6/30/20, 7/1/20-9/30/20, 10/1/20-12/31/20 and 1/1/21-3/31/21. Each document contained the note resident unable to sign. and were initialed and dated by the DSW. There was no statement provided for 4/1/21-6/31/21 period. On 7/23/21 at 1:05 PM, Resident #188 was observed seated at a table in the day room. Resident had a pen in hand and was completing a word search puzzle. Resident was able to sign name on paper provided and maintained that they had not been provided with quarterly statements. Review of the Resident Influenza Vaccine Consent/Declination Form dated 8/26/20 documented that resident's signature was affixed. On 7/23/21 at 1:41 PM, a follow-up interview was conducted with the Director Social Worker (DSW). The DSW stated that they documented on quarterly paper that resident was provided a statement by signing and dating the document. The DSW was asked to clarify the discrepancy that the resident could not sign for statements as other signed documents were located in the resident's medical record and the resident was observed with a pen completing a word puzzle. The DSW then stated that the resident had refused to sign the documents when presented. The DSW also stated that they did not document the resident's behavior in the medical record and could not explain why unable to sign instead of refused to sign was documented on each statement. 415.26(h)(5)(i)

Based on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility failed to ensure expired medications were identified timely and removed from current medication supply for disposition. Specifically, bags of intravenous fluids in the medication room on the 5th Floor and expired [MEDICATION(S)] medication was observed in the medication cart on the 14th Floor past the expiration date. This was evident on 2 of 12 units reviewed for Medication Storage (Unit 5 and Unit 14). The facility policy and procedure titled Medication Storage reviewed 08/2020 documented medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. 1). On 07/19/2021 at 03:34 PM, an observation of the medication room on the 5th Floor conducted with Licensed Practical Nurse (LPN) #2. A cardboard box located inside the bottom cabinet located to the left of the door contained the following expired items: A 1000 ml (milliliter) bag of intravenous fluid (IV) [MEDICATION(S)] and [MEDICATION(S)] injection USP with a manufacturer expiration date of 02/2021. There were four 50 ml bags of [MEDICATION(S)] injection USP with a manufacturer expiration date of 08/2020. An intravenous start kit with a manufacturer expiration date of 04/30/2021. On 07/19/2021 at 3:57 PM, an interview was conducted with LPN #2. LPN #2 stated that LPN #2 check's the medication room every two weeks before the pharmacy comes for their monthly check. LPN #2 checked the IV fluids in the cabinet last month, but sometimes items at the bottom are overlooked. LPN #2 stated the medication room should be checked daily, and they are not sure what the policy is. It is important to remove expired medication so they are not administered to residents. Expired medications may cause a resident to get sick or have an allergic reaction. On 07/20/2021 at 12:58 PM, an interview was conducted with the Registered Nurse Manager (RN #1) assigned to the 5th floor. RN #1 stated they check the medication room during rounds weekly, and the night supervisor also checks the medication room. RN #2 stated the expired IV fluids were discarded. The expiration dates of the IV fluids and the IV starter kits are checked during the weekly rounds. RN #2 stated perhaps it was overlooked. Expired medication is not kept in the medication room to maintain the health and safety of the residents. No log is kept of the weekly rounds. On 07/21/2021 at 11:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the DON conducts rounds on two to three units daily. The DON checks the medication rooms during rounds sometimes. The DON stated the DON looks to ensure staff personal items are not stored in med rooms. The DON also reviews the narcotic book and checks to see if the narcotic box is locked. The DON also looks under the sink to make sure items are not stored there inappropriately. The DON does not check IV bags. The DON stated expired items should be sent back to central supply to ensure the items are not used. Anything expired is a potential risk. The Pharmacy comes in once a month to look at the medication room, and the DON receives reports of their findings every time they come to inspect. On 07/22/2021 at 3:26 PM, a phone interview was conducted with the Pharmacy Consultant who stated they check the medication rooms once per month on each floor, including the medication cart. The Pharmacy Consultant stated the last inspection of the 5th floor was done on 7/19/2021. They checked the cabinets in the medication room for medication and also looked at the IV solutions. The Pharmacy Consultant stated that the Pharmacy Consultant did not see the items that were expired during their inspection. Any findings, including expired items, are put on the monthly report for nursing to prevent potential medication errors. 2. On 7/20/21 at 8:57AM, an observation of the 14th floor medication cart was conducted with LPN #4. A packet of Healthylax was observed in the medication cart with an expiration date of 4/2021. LPN #4 was interviewed immediately and stated they did not know why expired Healthylax is in the medication cart and this item should have been removed. On 7/23/21 at 9:29 AM, RN #2 was interviewed. RN #2 stated they check medications once a month for expiration dates. RN #2 also stated that although this is the responsibility of nurses on floor, they do random checks also. RN #2 further stated that the nurses on overnight shifts check the medication cart and discard what is not being used and is expired. The expired Healthylax may have been there because there was one packet left and this may have been an oversight. On 7/23/21 at 1:14 PM, an interview was conducted with the DON. The DON stated the nurses check the carts for medications that are not in use or expired. The DON also stated that an honor system is used and there is no documentation done when carts are checked. 415.18(a)

Based on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that a cognitively impaired resident's designated representative was informed of a change in medication. Specifically, a resident's medication to treat dementia was discontinued without documented evidence the family was made aware. This was evident for 1 of 2 residents reviewed for Notification of Change (Resident #55). The findings are: The facility policy and procedure titled Family Notification dated 2/4/21 documented the facility would notify a resident's family or responsible party upon a change in treatment. Family notification will be documented in the medical record. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessments dated 12/04/2020 and 5/4/2021 documented Resident #55 was severely cognitively impaired. The resident and the resident's representative participated in the assessment. A telephone interview was conducted with the designated representative for Resident #55 on 07/16/21 at 01:06 PM. The representative stated they were not informed by the facility that the [MEDICATION(S)] patch ordered to treat Resident #55's Dementia was discontinued several months ago. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Care Plan (CCP) related to Multiple Medication Use was initiated 6/14/2020 and documented the Medical and Nursing staff would discuss with the responsible party the number of medications the resident is receiving and the potential for drug interactions. A Neurology Consult dated 12/13/2020 documented Resident #55 was assessed on 12/11/2020, and the Neurologist recommended to decrease [MEDICATION(S)] patch to 4.6 mg once daily for 10 days and then discontinue the medication. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive a [MEDICATION(S)] patch after 12/30/20. There was no documented evidence in the Nursing, Medical Doctor, or Nurse Practitioner notes that the designated representative was notified that Resident #55's [MEDICATION(S)] was discontinued. An interview was conducted with the Medical Director (MD) of the facility on 07/22/21 at 10:17 AM. The MD stated the MD is responsible for overseeing the Nurse Practitioner (NP) and any significant changes the NP makes to a resident's treatment regimen. The change in [MEDICATION(S)] order was recommended by the neurologist, reviewed by the NP, and changed accordingly. The family should be made aware if there are any changes in a resident's treatment plan or medication. The MD did not inform the family that a change in Resident #55's [MEDICATION(S)] order had been made. The prescribing NP or the Registered Nurse (RN) manager on the unit would be responsible for ensuring the designated representative was notified. An interview was conducted with the NP on 07/22/21 at 11:04 AM. The NP confirmed the NP made the changes to Resident #55's [MEDICATION(S)] order as per the Neurologist's recommendation on 12/11/20. The NP did not recall informing the family that a change in medication had taken place and was unable to produce documented evidence the NP notified the family of this medication change. The facility policy is that NP, MD, or RN would notify the family of a resident any time there is a change in the resident's treatment plan. The NP would have documented this conversation with the resident's family in the medical record if it occurred. An interview was conducted with RN #1 on 07/22/21 at 11:58 AM. RN #1 stated the RN unit manager or NP/MD are responsible for informing resident family members of changes in resident's medications. Although the NP may call and inform the family, the RN is responsible for calling to ensure the family/designated representative understands the changes to the resident's treatment plan. RN #1 did not recall notifying the designated representative of Resident #55 of the change and discontinuation of the [MEDICATION(S)] patch. RN #1 was unable to produce documented evidence that the designated representative was made aware. 415.3(e)(2)(ii)(c)

Based on observations, interviews and record reviews conducted during the recertification survey, the facility failed to ensure a resident's equipment was maintained in good condition. Specifically, a resident's wheelchair had faulty hand brakes preventing it from being in the locked position, and resident rooms and common areas were observed with dirty walls, short privacy curtains, dusty vents and AC units, unfinished plastered areas on the walls, rust and stains in the showers, and stained ceiling tiles. This was evident for 1 of 8 residents (Resident #388) and 2 of 12 Resident units (Unit #4 and #5) reviewed for the Environment. The findings are: The facility did not have a policy and procedure related to maintaining resident's equipment in good condition. On 07/15/21 at 12:13 PM, Resident #388 was interviewed and stated Resident #388 received a wide wheelchair approximately two weeks ago, and the left wheel brake is broken and does not lock. Resident #388 requested repair several times, but no repair was done. The wheelchair was observed, and there was no plastic covering on the left wheel brake. The surveyor attempted to push down the break, but it did not work. The surveyor was able to lock the left wheel brake, but once the wheelchair was moved, the brake released unintentionally. On 7/20/21 at 4:03 PM, Resident #388 was interviewed and stated Resident #388 refused to be transferred to the wheelchair (w/c) because it is unsafe. Resident #388 made several complaints and requests for repair to the Nursing and Maintenance Departments. The w/c was still in disrepair. Maintenance Department Repair Log Sheets documented Resident #388 requested wheelchair brake repairs on 4/28/21, 7/09/21, and 7/20/21. The log sheet documented the brakes were fixed on 4/28/21. There was no documented evidence the resident's wheelchair was repaired on 7/09/21 or 7/20/21. An interview was conducted with Certified Nursing Assistant (CNA) #8, Unit Clerk for Resident #388's unit, on 07/20/21 at 04:09 PM. CNA #8 stated Resident #388 received a new wheelchair from the Rehab Department in April 2021. Resident #388 constantly complains the wheelchair brakes do not work. The unit staff communicates any requests for repairs to the Maintenance Department by filling in the Maintenance Department Repair Log Sheets. The Maintenance Worker (MW) is then responsible for following through with repairing the item. The MW then signs the log to document the repair has been completed. An interview was conducted with the MW assigned to Resident #388's unit on 07/23/21 at 10:13 AM. The MW stated the logbook is checked every morning. The MW did not recall a repair request made for Resident #388 on 7/9/21, and MW was unaware the resident had any issue with wheelchair brakes until the log entry on 7/20/21. The MW was unable to repair the brakes and informed another Maintenance Worker who specializes in wheelchair repair. The MW did not follow-up after referring the repair to another staff member to ensure that it was addressed. The wheelchair repair person sometimes has many equipment repairs to manage and may not address the concern immediately. MW did not communicate this to the Director of Maintenance (DM). The MW did not personally observe the hand brakes on Resident #388's wheelchair. An interview was conducted with the Director of Maintenance (DM) on 07/20/21 at 04:21 PM. The DM stated any issue with a resident's equipment, such as faulty hand brakes, are repaired immediately and the equipment is returned to the resident in the same day. If the MW is unable to take part in the repair, the MW should communicate this to the DM, and the DM will ensure that either another MW or the DM repairs the item immediately. The logbooks are checked every morning. The DM was unaware Resident #388 had a wheelchair with faulty brakes. Upon observation of the brakes on Resident #388's wheelchair, the DM confirmed the left-hand brake was non-functional and the right-hand brake was faulty. The DM stated this needed to be repaired immediately. The Maintenance Department does not have a policy and procedure regarding resident care equipment repair. 2) The following observations were conducted on the 4th floor during environmental rounds. On 07/15/2021 at 10:39 AM, 7/20/21 at 10:36 AM, and 7/21/21 at 9:25 AM, Room #406 was observed. There were brown splatter stains on the wall to the right of the door and on the right side of the A Bed headboard. The wall to the left of the door had 6 plastered areas on the wallpaper and 5 areas with nail holes measuring 1/2 to 2 inches in diameter. The wallpaper on the left side of the window had a missing section measuring 10 feet (ft) by 5 ft, exposing the drywall. The closet doors had gouges in the the wood. The shower in the bathroom had dust and hair inside and no shower curtain. The drywall was cracked to the right of the door where the doorknob hit the wall. The paint on the top of the radiator cover was scratched on top. On 07/15/2021 at 11:28 AM and 07/20/2021 at 09:17 AM, Room #418 was observed. The wall to the left of the door had 7 holes patched with plaster on the gray wallpaper. The bathroom shower faucet was missing a knob, and there was no shower curtain. The radiator cover was dusty. On 07/20/2021 at 10:28 AM and 07/21/2021 at 09:32 AM, Room #408 was observed. The wall to the left of the AC unit had cracked drywall. The window frame and radiator cover were painted gray, but the radiator cover had areas on the top that were missed with the original cream paint showing. The bathroom shower had yellow stains on the bottom. On 07/20/2021 at 10:31 AM and 07/21/2021 at 09:36AM, Room # 410 was observed. The baseboard to the left of the door was coming off the wall, exposing 4 nails. The bathroom shower had no shower curtain, and there were brown stains around the rim of the drain and to the left of the drain on the shower floor. On 07/16/2021 at 12:41PM and 07/21/2021 at 09:28 AM, the 4th floor shower room was observed. The vents above the sink and bath tub were dusty. The shower directly in front of the shower room entrance did not have a shower curtain, and there was no privacy curtain by the door to prevent people from seeing into the shower room when the door is opened. The floor tiles by the entrance had brown dirt buildup. On 07/21/2021 at 10:10 AM, the 4th floor day room was observed. The grates on top of the AC unit were rusted and dusty, and the right side of the grate over the controller were caved in. The walls on the left and right sides of the dining room had chipped paint in many areas. There was a hole in the drywall underneath the wall-mounted computer kiosk. 3) The following observations were conducted on the 5th floor during environmental rounds. On 07/19/2021 at 12:13 PM, Room # 526 was observed. The privacy curtain for the bed by the window did not provide full privacy. There was a 12 inch gap between the curtain and the wall. On 07/15/2021 at 12:42 PM and 07/20/2021 at 12:26 PM, Room #519 was observed . The bathroom shower faucet leaked around the knob when turned on. No water came out of the shower head, and there was hair in the bathroom drain. On 07/20/2021 at 10:10 AM. LPN #1 was interviewed and stated LPN #1 conducts rounds of the unit which include resident rooms and bathrooms. LPN #1 was shown the areas of concern in Rooms #408, #410, and #406. LPN #1 stated the AC units are old and sometimes staff have to play with them to get them to work. LPN #1 stated the building needs help, and the work needs to start on the 3rd floor. LPN #1 did not notice the stains on the wall. LPN #1 stated the unit showers, works, and decorations need work, and the unit is not homelike. On 07/20/2021 at 10:28 AM and 11:47 AM, an interview was conducted with the Housekeeper/Porter who stated that the cleaning of the vents is a side project scheduled for various housekeeping department staff as a weekend project. The Housekeeper cleans staff and resident bathrooms daily. The tile on the floor is old and would need to be replaced. On 07/21/2021 at 11:22 AM, an interview was conducted with the Director of Nursing (DON) who stated the building is hold, and they have hired a nurse manager to focus on improving the Dementia units. Paintings and other items have been purchased for the 4th and 5th floors. On 07/21/2021 at 11:41 AM, an interview was conducted with the Director of Housekeeping (DOHS) who stated the DOHS tours the units Monday to Friday to check for cleanliness. Housekeeping staff follow a cleaning checklist and were in-service on the correct way to clean the rooms. Staff clean tubs, showers, toilets, handrails, vents, walls, mirrors and lights above the sink. The DOHS went to the 4th and 5th floor on Monday to look at the resident rooms and bathrooms. The DOHS checks the condition of privacy curtains, and curtain rods are checked quarterly. Nursing informs Housekeeping of any issues. Housekeeping cleans and reports drainage problems to Maintenance. The DOHS noticed the discoloration of the showers and ordered a product to help with issues like rust. The DOHS stated they have back up curtains in stock (ordered in January 2021). On 07/21/2021 at 03:20 PM, an interview was conducted with the Director of Environmental (DOE) who stated they are in the process of doing in house cleaning and painting. The air conditioning (AC) units in the day room are cleaned every 3 to 6 months. The coil is cleaned, and the top is changed if needed. Maintenance is called to the 4th floor to service the AC units more frequently due to issue with resident use (resident my urinate on or throw food and drinks on them). 415.5(h)(2)

Based on observations and interviews conducted during the recertification survey, the facility did not ensure a resident is free from physical restraint. Specifically, a resident was observed with a lap buddy that had not been identified as a restraint. This was evident for 1 of 3 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident # 439). The findings are: The facility policy and procedures titled Restraints revised on 4/22/21 documented the following: the facility furthermore adheres to the CMS definition of a Physical Restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. The policy also documented, if a request is made for a restraint, the Comprehensive Care Planning team will assess the resident's needs and medical symptoms. Alternative solutions are tried prior to the use of a restraint. The physician, as a member of the CCP team determines the most effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . If a restraint is used it must be the least restrictive intervention that manages the medical symptoms. Rehab will be requested to give recommendations regarding necessity and what is the least restrictive device. The finding is: Resident #439 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented resident had intact cognition and required extensive assist of one staff person for bed mobility, transfers, locomotion off and on unit, toilet use, and personal hygiene and total assistance of one staff person for dressing. The MDS also documented that the resident had impairment on one side of upper and lower extremity. The MDS also documented that a restraint was not used. The Quarterly MDS dated [DATE] documented resident had intact cognition and required extensive assist of one staff person with bed mobility, transfers, locomotion off and on unit, dressing toilet use, and personal hygiene. The MDS also documented that the resident had impairment on one side of upper and lower extremity. The MDS also documented that a restraint was not used. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident able to independently release on request thus not a restraint. Occupational Therapy Note dated 1/10/19 documented that lap board edges were rubbing against resident's arm when resident was propelling wheelchair so resident was referred for evaluation. The note also documented that the resident was provided with a lap buddy to allow for full clearance when resident propelled wheelchair. There was no documented evidence that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/22/21 at 2:55 PM, Certified Nursing Assistant (CNA) #3 was interviewed. CNA #3 stated resident has a bar for use in the chair so they cannot slide out and resident is not able to remove bar. CNA #3 also stated that the resident has had the device since they were assigned to the floor in 2016. CNA#3 further stated that it is a struggle for the CNAs to place the lap buddy so the resident would not be able to remove it as they have weakness on one side of the body. CNA#3 also stated that the resident has had different devices over the years and has not removed any of the devices on their own. On 7/22/21 at 3:00 PM, Resident # 439 was interviewed. Through use of a communication board, resident typed that they are not able to remove the lap buddy and staff has to take it out. On 7/22/21 at 3:05 PM, Registered Nurse (RN) #2 was interviewed. RN #2 stated resident wears lap buddy for support in chair, always uses it when out of bed and the resident needs help to remove device. RN #2 also stated the device is not a restraint because it is removed and only used for support while resident is in wheelchair. Resident has weakness to one side and also uses lap buddy as a surface for the communication device. RN #2 further stated that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/22/21 at 4:04 PM, the Occupational Therapist (OT) was interviewed. The OT stated that currently resident is provided with a lap buddy and the order previously documented a lap tray. The OT also stated they provided resident with the lap buddy. The OT further stated that usually the resident can remove it and may have had some changes. The OT stated that the resident was just discharged from OT and on last evaluation resident was able to remove it. If resident is not able to remove, then it would be considered a restraint. On 7/23/21 at 12:49 PM, the Director of Nursing (DON) was interviewed. The DON stated we do an interdisciplinary team (IDT) meeting to determine if a restraint is required or not. The DON also stated that if the resident is not able to freely remove the device or it restricts their body movements then it is considered a restraint. The DON further stated that the resident had a partial tray before that the resident would use to rest the communication board and the DON had not been informed when this had been replaced with a lap buddy. The DON stated that the use of devices with this resident had been questioned in the past, but OT informed Nursing that it was not a restraint as the resident was able to remove it. The DON further stated that staff has received in-service on what constitutes a restraint and should have known that if resident was not able to remove the device it would now be considered a restraint. 415.4 (a)(2-7)

Based on staff interviews and record review conducted during a Recertification survey, the facility did not ensure that a portion of the Minimum Data Set (MDS) Assessment accurately reflected the resident's status. Specifically, 1). a lap buddy was not coded as a restraint and 2). discharge and admission MDS did not accurately document resident's admission and discharge status. This was evident for 1 of 3 residents reviewed for Position, Mobility and 1 of 1 residents reviewed for hospitalization out of sample of 38 residents. (Resident # 439 & Resident #451) The findings are: The policy and procedure titled Minimum Data Set (MDS) -Version 3.0 reviewed on 7/23/2021 documented the results of the assessment, which must accurately reflect the resident's status and needs, will be used to develop, review, and revise each resident's comprehensive plan of care. The policy also documented different sections of the form are completed accurately and signed by staff members from various professions including nursing, social services, therapeutic recreation activities, dietary, occupational therapy, MDS coordinator and other staff members. 1. Resident #439 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident able to independently release on request thus not a restraint. The Annual Minimum Data Set (MDS) dated [DATE] documented resident with intact cognition and required extensive assist of one staff person for bed mobility, transfers, locomotion off and on unit, toilet use, and personal hygiene and total assistance of one staff person for dressing. The MDS also documented that resident had impairment on one side of upper and lower extremity. Section P of the MDS also documented that a restraint was not used. The Quarterly MDS dated [DATE] documented resident with intact cognition and required extensive assist of one staff person with bed mobility, transfers, locomotion off and on unit, dressing toilet use, and personal hygiene. The MDS also documented that resident had impairment on one side of upper and lower extremity. Section P of the MDS also documented that a restraint was not used. On 7/22/21 at 2:55 PM, Certified Nursing Assistant (CNA) #4 was interviewed. CNA #4 stated resident has a bar for use in the chair so they cannot slide out and the resident is not able to remove the bar. CNA #4 also stated that the resident has had the device since they were assigned to the floor in 2016. CNA#4 further stated that it is struggle for the CNAs to place the lap buddy so the resident would not be able to remove it as they have weakness on one side of the body. CNA#4 also stated that the resident has had different devices over the years and has not removed any of the devices on their own. On 7/22/21 at 3:00 PM, Resident # 439 was interviewed. Through use of a communication board, resident typed that they are not able to remove the lap buddy and staff has to take it out. The MDS Assessor who completed the MDS assessments was no longer employed at the facility and not available for interview. On 7/23/21 at 10:48 AM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated that the MDS Assessor must do a visualization of the resident when doing the assessment and code a restraint if the resident is unable to remove it or if it restricts their movement. If a resident has a restraint the assessor would be expected to confirm there is an order and ensure that the resident is able to self-release the device because they are the one coding the MDS. The MDSC also stated that if the assessor determined the resident could not self-release the device, the team should be alerted to determine if the use is still appropriate. 2. Resident #451 was admitted to the facility with Altered Mental Status and Possible [CONDITION(S)]. Nursing Progress note dated 4/29/21 documented resident was admitted to the facilty from an acute hospital on 4/1/21 and that the resident will be discharged to home on 4/30/21. Social Service progress note dated 4/30/21 documented resident was discharged from the facility today at 11 am and was picked by family members via car. The Discharge Assessment-Return not Anticipated MDS dated [DATE] documented that resident was discharged to the community on 3/19/18. The Admission MDS dated [DATE] coded resident as a re-entry to the facility from an acute hospital on 4/1/21 with an admitted [DATE]. The MDS did not accurately capture the resident's status as an admission on 4/1/21 and not as a re-entry to the facility. The Discharge assessment dated [DATE] documented that the resident was discharged to an acute hospital on 4/30/21. The MDS did not accurately capture that the resident had been discharged to the community on 4/30/21. On 7/23/21 at 10:37 AM, the MDS Assessor was interviewed. The MDS Assessor stated resident was discharged in 2018 and admitted in April 2021 and upon return should have been considered an admission. The MDS Assessor also stated that if the resident was discharged home, when they return to the facility, this would be considered a new admission. If the resident had been discharged to the hospital and returned within 30 days, this would have been considered a reentry. The MDS Assessor further stated that the resident was discharged home with her son on 4/30/21 and the Discharge MDS should have been coded as a discharge to the community. The MDS Assessor stated that they do check the sections of the MDS that they complete but must have missed those areas. On 7/23/21 at 10:46 AM, the MDS Director was interviewed. The MDS Director stated in this case, the resident should have been coded as an admission, not a reentry on 4/1/21. The MDS Director also stated that since the resident went home on 4/30/21, MDS should have been coded discharge to community. The MDS Director further stated that they check to ensure that the MDS is completed on time. In addition, if they notice inaccurate coding, they prompt the particular department. The MDS Director stated that the person who completes a specific section is responsible for accuracy of that section. 415.11(b)

Based on interviews and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was developed. Specifically, 1). care plans were not developed to address the use of a splint device and restraint and, 2). a care plan was not developed to address a resident's vision concerns. This was evident for 1 of 3 residents reviewed for Position, Mobility and 1 of 3 residents reviewed for Communication-Sensory out of sample of 38 residents (Resident # 439 & Resident # 334). The findings are: The policy and procedure titled Comprehensive Care Plan reviewed on 12/15/20 documented the CCP is to include resident's problems, strengths and needs. An individual CCP will be developed for each problem, strength or need. The policy further documented that each discipline is responsible for reviewing, evaluating, and revising care plans prior to the CCP completion date as outlined on the schedule. 1. Resident #439 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Left-hand roll daily, remove during nursing care, range of motion (ROM), and skin checks, Non-ambulatory right forearm stockinette sleeve during wheelchair mobility for safety and skin protection, Soft cervical collar to be worn daily when out of bed (OOB) and removed every 2 hours, including during feeding, hygiene care, ROM, and skin integrity checks and, Right upper extremity (R UE)- elbow protector to be worn OOB. Remove for skin checks and nursing care. On 07/15/21 at 03:19 PM, Resident #439 was observed seated in a wheelchair with contracture of the left hand. There was no hand roll observed in resident's left hand. Resident indicated they have a left hand roll but it was not applied. A lap buddy was observed in place. On 07/19/21 at 09:05 AM, Resident was observed lying in bed with no hand roll in left hand. A hand roll was observed on a table in the room. On 07/19/21 at 02:00 PM and at 3:24 PM, Resident was observed seated in a wheel chair with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed in position across the wheelchair. On 07/21/21 at 10:41 AM, Resident was observed seated in a wheel chair in room with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed positioned across the wheelchair. On 07/22/21 at 10:25 AM, Resident was observed seated in wheel chair in their room with no hand roll in left hand. Right forearm elbow protector and cervical collar were both in place. A lap buddy was observed positioned across the wheelchair. The Certified Nursing Aide (CNA) Accountability record contained no field in which the CNA could document placement or removal of the hand roll, elbow protector, or cervical collar. There was no documented evidence that a Comprehensive Care Plan with measurable goals and device specific interventions had been developed to address the use of splint devices and a restraint. On 7/22/21 at 2:37 PM, CNA #3 was interviewed. CNA #3 stated resident needs two staff to assist with transfers and is a one person assist for turning and positioning in bed. CNA #3 stated when resident gets out of bed, they put on the neck brace, elbow protector and something to keep fingers open. CNA #3 also stated that sometimes they are unable to find the devices that have been removed by the previous shift. CNA #3 further stated the instructions for devices are in the kiosk. On 7/23/21 at 9:54 AM, Registered Nurse (RN) #2 was interviewed. RN #2 stated that the RN and MDS staff are responsible for care plans and a care plan is created when issues or potential issues are identified. If there is a consult we update with recommendations and review every 90 days. RN #2 also stated that a new care plan is added when there is a change or a new issue develops for a resident. RN #2 further stated the resident has a hand roll, elbow protector, soft neck brace and lap buddy and the care plan for the lap buddy was created on 7/22/21. RN #2 also stated they were not able to locate a care plan with interventions for the brace or elbow protector. 2. Resident # 334 was admitted to facility on 07/30/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition and adequate vision with no glasses. The Optometry Consult dated 2/3/21 documented the resident has [CONDITION(S)] NS (Nuclear Sclerotic) and decreased BCVA (Best Corrected Visual Acuity) and mild Hypertension retinopathy-monitor for progression. Recommendation was for follow-up in 6 months and to continue Artificial Tears eye drops 1 drop to each eye two times per day for dry eyes. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No recommendation was noted. There was no documented evidence that a care plan with measurable objectives, time frames and appropriate interventions were developed to address the care of the resident with vision deficit. On 07/23/21 at 11:19 AM, an interview was conducted with the RN Nurse Manager (RN #2). RN # 2 stated they are responsible for updating and initiating care plans on the unit. RN #2 stated they noticed no care plan for vision had been created since resident's admission and so they initiated a vision care plan on 07/16/2021 after the survey had begun. On 7/23/21 at 12:49 PM, the Director of Nursing (DON) interviewed. The DON stated the Nurse Manager (NM) updates care plan daily. The DON also stated that the MDS nurses do the quarterly and annual care plans and the Nurse Managers are responsible for updates when issues arise between care plans. The DON further stated that the MDS staff will review prior to completing MDS to make sure the care plans are there. The DON stated that here should be a care plan for all devices which includes interventions and goals. The DON stated that the orders may not have been entered in the right way and so did not trigger the creation of a care plan. The DON also stated the CCP for vision deficit should have been in place upon admission for Resident # 334. The DON further stated that an in-service will be given to make sure all CCP's are in place on admission. 415.11(c)(1)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that services and treatments were provided to prevent further decrease in ROM or mobility. Specifically, hand rolls, elbow splints, and cervical collar were not provided to residents as ordered. This was evident for 2 out of 3 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident # 439 and Resident #180). The findings are: The facility's policy Adaptive Device Policy reviewed August 2020 documented the responsibility of the Clinical Nurse supervisor or Supervising Nurse is to ensure that all shifts of nursing are in-serviced as to the proper use and wearing schedule of the device. 1. Resident #439 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Left-hand roll daily, remove during nursing care, range of motion (ROM), and skin checks, Non-ambulatory right forearm stockinette sleeve during wheelchair mobility for safety and skin protection, Soft cervical collar to be worn daily when out of bed (OOB) and removed every 2 hours, including during feeding, hygiene care, ROM, and skin integrity checks and, Right upper extremity (R UE)- elbow protector to be worn OOB, Remove for skin checks and nursing care. On 07/15/21 at 03:19 PM, Resident #439 was observed seated in a wheelchair with contracture of the left hand. There was no hand roll observed in resident's left hand. Resident indicated they have a left hand roll but it was not applied. A lap buddy was observed in place. On 07/19/21 at 09:05 AM, Resident was observed lying in bed with no hand roll in left hand. A hand roll was observed on a table in the room. On 07/19/21 at 02:00 PM and at 3:24 PM, Resident was observed seated in a wheel chair with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed positioned across the wheelchair. On 07/21/21 at 10:41 AM, Resident was observed seated in a wheel chair in room with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed in position across the wheelchair. On 07/22/21 at 10:25 AM, Resident was observed seated in wheel chair in their room with no hand roll in left hand. Right forearm elbow protector and cervical collar were both in place. A lap buddy was observed positioned across the wheelchair. The Certified Nursing Aide (CNA) Accountability record contained no field in which the CNA could document placement or removal of the hand roll, elbow protector, or cervical collar. On 7/22/21 at 2:37 PM, CNA #3 was interviewed. CNA #3 stated when resident gets out of bed, they put on the neck brace, elbow protector and something to keep the fingers open. CNA #3 also stated that sometimes they are unable to find the devices that have been removed by the previous shift. CNA #3 further stated the instructions for devices are in the kiosk. CNA #3 stated that if they are unable to locate the resident's devices, they inform the Nurse Manager. 2. Resident #180 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/16/21 at 9:55 AM and at 1:19 PM, resident was observed seated in a wheelchair in their room. No device was observed on resident's left hand. On 7/19/21 at 9:08 AM and at 12:45 PM and on 7/20/21 at 9:20 AM and at 3:06 PM, resident was observed seated in a wheelchair in the dayroom. No device was observed on resident's left hand. On 7/21/21 at 9:05 AM, resident was observed seated in wheelchair in the day room with WHFO applied in a twisted position on the resident's left hand. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Annual Minimum Data Set (MDS) dated [DATE] and Annual MDS dated [DATE] documented splint or brace assistance 7 days in the last 7 calendar days. A Comprehensive Care Plan (CCP) titled Contractures/At risk/Actual effective 10/30/15 and updated 5/28/21 documented a goal of: Resident will remain free from further contractures x 90 days to L hand/digits. Interventions included resident to use left hand splint as per MD order. Currently only able to tolerate 30 minutes duration. Splint/braces: See wearing schedule. On 7/22/21 at 2:18 PM, CNA #5 was interviewed. CNA #5 stated resident has a hand roll and special boot for left leg and also has a hand rest for left arm. CNA #5 also stated they put devices on and document them in the general area on the kiosk. CNA #5 further stated they may have forgotten to put the device on. CNA#5 also stated the device gets placed on in the morning and is removed at bedtime. On 7/23/21 at 9:54 AM, Registered Nurse (RN) #2 interviewed. RN #2 stated they make sure the residents have the devices and monitor to ensure that it is always on the resident. If I see a device is not in place, I will ask the aide to put the device on or I put the device on myself. RN #2 also stated that if the resident is out of bed, the expectation is that the device should be in place and aides should be documenting on the CNAAR. RN #2 further stated that there was never a time that the CNAs reported to them that they could not find devices and they actually did an audit recently to determine which residents had devices and any missing devices were replaced by Rehab. On 7/23/21 at 12:49 PM, the Director of Nursing (DON) was interviewed. The DON stated that the expectation is that CNAs make sure the devices are in place and they should alert nurse immediately if a device is missing. The Nurse Manager is expected to follow up to get device located or replaced as soon as possible. The DON also stated that in addition, the Nurse Manager makes sure the devices are on the care plan and on the CNA accountability record. The DON further stated that the Nurse Manager is responsible for monitoring the CNAs and ensuring that they are completing all assigned tasks. 415.12(e)(2)

Based on observations, interviews and record reviews conducted during an abbreviated survey, (NY 543, NY 406 and NY 912), the facility did not ensure that residents were free from physical abuse. Specifically, (1) Resident #2, a resident with a history of wandering and combative behavior when redirected, was not adequately monitored and wandered into the room of Resident #1. A physical altercation ensued, and Resident #2 sustained serious injuries and expired in the hospital. (2) Resident #4, a resident with a history of wandering, aggressive, and impulsive behavior, was not adequately monitored and wandered into the room of Resident #3. Resident #4 assaulted Resident #3, and Resident #3 sustained a fractured nose. (3) Resident #6, a resident with a history of aggressive behavior, was not adequately monitored and assaulted their roommate, Resident #5. Resident #5 sustained a Left Anterior Frontal and periorbital Subcutaneous Contusion and Left Parietal Laceration. This resulted in actual harm to Residents #2, #3 and #5 that was not immediate jeopardy. The findings are: The facility's Policy and Procedure for Abuse with dated ,d+[DATE] documented all residents are assured the right to be free from abuse, neglect, and mistreatment. The Residents will not be subjected to abuse from anyone, including but not limited to facility staff, other Residents, volunteers, and staff from other agencies. The facility's undated Policy and Procedure titled: Behavioral Protocol for Resident to Resident Altercations documented: 'Residents with behavioral issues are known to have a tendency to lose their tempers over everyday issues. As a result of this knowledge, we have a behavioral identification program in place that stars at the resident's admission into the facility and continues throughout their stay at the facility.' The policy instructs staff to assess residents after resident to resident altercations and develop a plan to address the behaviors. This program is limited to incidents of resident to resident altercations and does not address aggressive or abusive behaviors towards staff. The facility submitted a report to NYS DOH in the Health Commerce System on [DATE] at 9:04 PM regarding an incident that occurred on [DATE] at 7:00 PM. Staff responded to a commotion in Resident #1's room and observed Resident #2 on the floor with Resident #1 standing over them. Resident #2 sustained an injury to the head and was unresponsive. The facility called 911. The facility investigation was ongoing, and the investigation at the time determined that Resident #2 wandered into Resident #1's room and engaged Resident #1 in a physical altercation that resulted in injury. 1) Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition with short and long-term memory problems. Resident #1 required supervision and set up to limited assistance for most activities of daily living, and they had no range of motion limitations. Resident #1 was able to stand with no assistance and did not require any ambulation devices. Resident #1 was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] The Comprehensive Care Plan (CCP), initiated on [DATE] and updated on [DATE], was reviewed. The CCP documented Resident #1 had Cognitive Loss with Dementia. The interventions included staff to use low and soft voices and not to approach the resident from behind. The CCP also identified the resident with behavioral symptoms directed toward others such as irritation and agitation. The interventions included non-pharmacological approaches such as analyzing triggers for behaviors, 30- minute monitoring and placing a Stop sign across their room door. A social work note dated [DATE] documented Resident #1 was observed the prior evening with agitation and exit seeking behavior. Resident #1 verbally expressed a desire to go home. Resident #1 was redirected, but not with ease. The medical progress notes dated [DATE] documented Resident #1 was seen by the physician for aggressive behavior and agitation. The resident expressed that they wanted to go home and did not know why they were in the facility. The physician ordered a psychiatrist consultation and continued behavioral monitoring. The physician also ordered an increase of Lorazepam 0.5mg to twice a day. There was no evidence that the resident's CCP was reviewed or updated to document increased monitoring for wandering or the new pharmacological interventions to address verbal aggression or agitation. The psychiatrist consultation note dated [DATE] documented Resident #1 denied depression and expressed some feelings of anxiety. There was no evidence of suicidal or homicidal ideation or delusions. The psychiatrist noted that there was a gradual dose reduction of Trazadone between [DATE] and [DATE] until the resident became agitated and aggressive, wanting to go home. The recommendation was made to restart Trazadone and add Lorazepam. A medical note dated [DATE] documented Resident #1 had no signs or symptoms of anxiety, and the physician ordered Lorazepam to be discontinued. A review of the behavioral notes documented between [DATE] through [DATE] documented Resident #1 was exhibiting wandering behavior, with exit seek behavior. A wander guard was placed on the resident on [DATE]. Resident #1 was also exhibiting rejection of care and verbal aggression toward staff. On [DATE] the nurse documented that the resident was having delusions with episode of wandering. Interventions continued to be tactile redirection and verbal comfort. The medical record documented there was an annual interdisciplinary team (IDT) care plan meeting on [DATE], with the guardian participation. The resident was stable with no significant decline noted in either mood or behavior. No new interventions or goals were documented. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in the medical notes or nursing notes as to why Resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The medical note dated [DATE] documented Resident #1 had an episode of confusion and behavioral monitoring should be continued and the resident would have Psychiatry follow-up as needed. The Certified Nursing assistant Accountability Record (CNAAR) from [DATE] to [DATE] documented Resident #1 required supervision for ambulation in the room and on the unit. Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #2 had severely impaired cognition. Resident #2 required limited assistance of one (1) person for most activities of daily living including bed mobility, walking, transfer, locomotion on the unit, eating and personal hygiene. Resident #2 was unsteady during transitions and walking; they did not use any walking devices. The Comprehensive Care Plan (CCP) for Behavior dated [DATE] documented the resident exhibited behavioral symptoms directed towards others. The interventions included assess distress triggers, nonpharmacological approaches, analyze time/place/circumstances and triggers to see what de-escalates behaviors, escort to a less stimulating area, intervene before agitation escalates, psychiatric services, Q (every) 30 minute monitoring (initiated [DATE]), and Stop sign across the room door (initiated [DATE]). Care plan notes do not describe any episodes of aggressive behavior until [DATE]. The note dated [DATE] documented the resident had territorial behavior and was aggressive towards other residents. A note dated [DATE] documented the resident was agitated and aggressive towards staff. The resident stated he wanted to go home and exhibited exit seeking behavior. Stat [MEDICATION(S)] was administered, and staff plan was to continue to monitor and place the resident in a high-visibility area. There were no new interventions initiated on the behavior CCP despite the resident's increasing aggression. The last new intervention was initiated [DATE]. The CCP did not describe the types of aggressive behaviors the resident exhibited per the notes and staff interviews. The Comprehensive Care Plan for Potential for Abuse/Neglect effective [DATE] documented Resident #2 was at risk for abuse/neglect secondary to Dementia. The CCP interventions included maintain a safe environment, observe for unusual skin marks/discoloration/ecchymosis, provide emotional support, inform MD and family of occurrence, investigate accidents as needed, and in-service staff on abuse/neglect. The care plan note written by the Social Worker on [DATE] documented the resident was severely impaired and unable to participate in the assessment. The resident had moderate depression and no behaviors noted or reported at that time. Social Work will monitor adjustment to the facility, mood/behavior, and any increased signs/symptoms of worsening mood/depression. The last CCP note dated [DATE] documented no s/s of abuse were noted. The last time the CCP goal was reviewed was [DATE]. There was no documented evidence the CCP for Abuse/Neglect was reviewed and revised with interventions to address Resident #2's increased risk for abuse related to wandering and aggressive behavior. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of weekly behavioral notes from [DATE] through [DATE] documented incidents of Resident #2 exhibiting physical aggression towards staff, and peers during episodes of wandering and attempts at redirection. Review of the Certified Nursing Assistant Accountability Record (CNAAR) dated from [DATE] to [DATE] documented Resident #2 exhibited behavioral symptoms of wandering, verbal abuse, resisting care, and refusing to wear hearing aid. The intervention was to report behavior to the nurse. Review of the Visual Observation /Monitoring Sheets for Resident #2 for the time period preceding the incident on [DATE] documented Resident #2 was being monitored every (q) 30 minutes on all shifts. The last observation of the resident was on [DATE] at 6:30 PM. During an interview conducted on [DATE] at 11:00AM the Attending Physician (MD) stated Resident #1 was always quiet and stayed in their room. Resident #1 was able to hold an intellectual conversation, the MD did not recall any behavioral issues or altercations. Staff reported that Resident #1 wanders around the unit, but the MD did not recall reports of aggressive behavior. During an interview on [DATE] at 2:52 PM, CNA #4 (Certified Nurse Assistant) stated that they worked on the unit but did not witness the incident. The dinner meal was completed by 6:00 PM. The residents were being walked to their rooms and toileted. CNA #4 stated that between 6:30 PM and 7:00 PM they were providing care to other residents and did not hear any commotion. At 7:00 PM, CNA #4 was alerted by the nurse to come to the room of Resident #1. Other staff were in the room. They observed Resident #2 on the floor lying in a pool of blood. Resident #1 stated, I was defending myself. CNA #4 described Resident #2 as a wanderer who entered the rooms of other residents. They also stated that Resident#2 displayed aggressive behavior, including spitting, and hitting staff. CNA #4 stated all residents on the unit are on a 30-minute monitoring schedule. There are 4 CNAs assigned to the unit during the 3:30 PM to 11:30 PM shift. During an interview on [DATE] at 3:06 PM, CNA #3 stated that they usually work on the unit during the 7:30 AM to 3:30 PM shift. On the day of the incident, they worked an extra shift during the evening. Resident #2 was assigned to them for care. CNA #3 stated that all residents on the unit, including Resident #2, were on 30-minute monitoring. On [DATE], they toileted Resident #2 after dinner. At 6:20 PM, they saw Resident #2 in the hallway. They told Resident #2 to come to the dining room, but Resident #2 did not acknowledge them. Resident #2 walked towards their room, and CNA #3 followed Resident #2. Resident #2 laid on their bed, pulled up the sheet. However, CNA #3 stated Resident #2 refused to remove their shoes as requested, and they did not remove the shoes because they did not want Resident #2 to become agitated. Between 6:30 PM and 7:00 PM, they were toileting another resident in the main bathroom with the assistance of CNA #4. At 7:00 PM, the nurse called for CNA #4 to come immediately. CNA #4 responded, and CNA #3 remained in the bathroom and continued to perform care. CNA #3 stated that they did not hear any noise, yelling, or commotion. CNA #3 stated that they were later informed of the incident. CNA #3 stated Resident #2 was a wanderer who would walk around and go into the rooms of other residents even with the stop signs. They stated that Resident #2 was able to remove the Velcro stop signs from the doors and then enter rooms. CNA #3 stated Resident #1 was quiet and a little territorial. Resident #1 did not want anyone entering the room without their consent and required staff to introduce themselves prior to entering. During the interview conducted on [DATE] at 3:32 PM, CNA #1 stated that Resident #1 was assigned to them for care during the 3:30PM to 11:30 PM shift. Dinner was over by 6:00 PM and staff were walking residents back to their rooms. They described Resident #1 as quiet. Resident #1 spent time in their room doing puzzles. CNA #1 did not recall Resident #1 being in any physical or verbal altercations with other residents. CNA #1 stated that they left the resident in their room at 6:00 PM. They went on a break and came back at 7:00 PM. They responded to one of the CNA's calls and went to Resident #1's room. During an interview on [DATE] at 3:41 PM, CNA #2 stated that they work the evening shift on the unit. At the time of the incident they were performing care for a resident in the main bathroom with the assistance of CNA #4. At around 7:00 PM the nurse called their name and told them to come to Resident #1's room quickly. Once they entered the room, they observed Resident #1 standing and Resident #2 on the floor with blood. During an interview conducted on [DATE] at 3:52 PM, LPN #2 (Licensed Practical Nurse) stated that normally they work on the 7th floor, but on the day of the incident they were assigned to the Dementia Unit. At the time of the incident, they were standing in the hallway, outside a resident's room, about to administer medication, when they heard a voice repeatedly say, I was just defending myself. They followed the voice to Resident #1's room. The door was slightly ajar, and when they opened the door, they saw Resident #1 standing near the door with blood on their hands and shirt. Resident #2 was on the floor with a lot of blood. LPN #2 stated that they immediately called for help, and all staff on the unit came. During an interview on [DATE] at 11:30 AM, the Assistant Director of Social Services (SW #1) stated Resident #1 was quiet. Resident #1 kept to themself and participated in more independent activities, like watching TV and doing puzzles. The facility had limited knowledge of Resident #1's mental health history. There were no known incidents of any altercations with any residents. Resident #1 previously resided in a two-bed room, but they expressed that they were not comfortable sharing a room with someone of the same identified gender. SW #1 stated that they identified this as a cultural issue, so the decision was made to give them a private room. SW #1 stated that there were no precipitating behaviors that would predict the incident. SW #1 stated Resident #2 had no history of aggressive behavior despite nursing staff's behavioral notes documenting verbal and physical aggressive behavior towards staff. During the interview conducted on [DATE] at 11:26AM, RNS #1(Registered Nurse Supervisor) did not clarify why monitoring schedules were generalized to every 30 minutes and not individualized according to behavior patterns. During the telephone interview conducted on [DATE] at 12:00 PM, the Psychiatrist stated Resident #1 as quiet and always in their room. Earlier this year, they discontinued Trazadone, but the resident's anxiety level increased so they re-ordered the medication. It was working. Resident #1 was able to hold a conversation, and there was no suicidal or homicidal ideation. They were calm and cooperative with no depression and no agitation. During a telephone interview conducted on [DATE] at 3:00 PM, the Psychiatric Nurse Practitioner (NP) stated that they provided services for Resident #2. Despite behavioral notes documented by the nursing staff, they said that they were not aware of aggressive behaviors. They stated that Resident #2 had wandering behavior but was easily redirected by staff. They stated that episodes of the Resident #2's aggressive behaviors were not reported to them. 2) Review of the Facility's Incident/Event Intake Form and Investigation Findings (for Resident #3 and Resident #4) dated [DATE], revealed that on [DATE] at 7:45 PM, a nurse heard Resident #3 screamed from their private room. Resident #4 was observed walking around in Resident #3's room. Resident #3 was observed lying in bed with minimal nosebleed and slight swelling on the left side of the nose. Facility staff immediately intervened and redirected Resident #4 out from Resident #3's room. a Cold compress was applied to Resident #3's affected area. Tylenol 325mg 2 tables every 8 hours ordered and vital signs monitoring every shift for 3 days. A STAT x-ray was also ordered but was not done. Resident #3 was transferred to the hospital and returned to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 was placed on 30-minute monitoring. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set, a resident assessment tool) dated [DATE], documented that Resident #3 had long/short-term memory impairment. Resident #3 required one-person for transfer and walking. A Comprehensive Care Plan (CCP) related to potential for abuse dated [DATE], documented interventions to provide emotional support and visual observation. Review of the Visual Observation Monitoring Sheet dated [DATE], documented that Resident #3 was being monitored every 30-minute and was in their room at 7:30 PM and 8:00 PM. A Nursing Progress note dated [DATE] at 10:55 PM, documented that Resident #3 was transferred to the emergency room (ER) after the incident on [DATE]. The hospital papers documented that a CT-SCAN of Resident #3's head was completed and revealed no evidence of acute intercranial hemorrhage. The CT-SCAN revealed a minimally displaced fracture of the left frontal process of the maxilla. No facial bone fracture and no surgical intervention indicated. Orders include [MEDICATION(S)] 875mg twice a daytime seven days, [MEDICATION(S)] 2 sprays two times a day and Saline spray as needed. Resident #3 was placed on 15-minute monitoring. Resident #3's Hospital Discharge Summary dated [DATE], documented that Resident #3 was evaluated due to questionable assault by another nursing home resident. The CT-SCAN showed minimally displaced fracture of the left frontal process of the maxilla. No surgical intervention indicated. The recommendations include Antibiotic for prophylactic treatment, pain management, soft, mild diet, [MEDICATION(S)] precaution and dental consult. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented that Resident #4 had long/short-term memory impairment. Resident #4 required extensive assistant with walking in the room and on the unit. Review of the Hospital and Community Patient Review Instrument (PRI), for Resident #4 dated [DATE], revealed that while Resident #4 was in the hospital, Resident #4 became acutely agitated. Resident #4 required sedation and was restrained while in the hospital. Review of the Facility's Admission Abuse Assessment tool dated ,d+[DATE], revealed that Resident #4 had Dementia, unable to tolerate frustration, acted out impulsively and exhibited threatening or intimidating behavior. Resident #4 expressed anger and physically-strikes out. Resident #4 hits, throw or breaks things. A CCP related to Dementia and wandering dated [DATE], revealed that Resident #4 was at risk for abuse and victimization. Interventions documented to maintain a safe environment and monitor Resident #4 every 30-minutes. Staff were to provide redirections during wandering and provide diversional activity as needed. They were to remove Resident #4 from potentially dangerous situations and observed Resident #4 for signs of abuse. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4 had orders for [MEDICATION(S)] 10mg at night for Alzheimer disease, [MEDICATION(S)] 375mg two times a day for Dementia with behavior disturbance, [MEDICATION(S)] and [MEDICATION(S)] 10mg daily for depressive disorder. A CCP related to Behavior dated [DATE], revealed that Resident #4 exhibited wandering behavior. Resident #4 exhibited physical behavioral symptoms directed towards other such as hitting, kicking, and grabbing. Resident #4 verbally threatened and cursed others. Review of the Visual Observation Monitoring Sheet dated [DATE], revealed that Resident #4 was being monitored every 30-minutes and was in their room at 7:30 PM and 8:00 PM. Review of a nurse's note dated [DATE] at 1:15 AM, documented that Resident #4 was last seen in the hallway moments prior to the questionable incident. At around 7:45 PM, a nurse heard Resident #3 screaming from their room. Staff members went to check Resident #3's room and observed Resident #4 walking around the room. Resident #3 was observed with slight swelling on the left side of the nose and a minimal nosebleed. The staff immediately intervened and redirected Resident #4 out of the room. The nursing supervisor was notified. The residents were not able to give an account. Resident #4 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:00 PM, Assistant Director of Social Service (ADSS) stated that Resident #4 was assessed, upon admission, for being at risk for abuse. The ADSS stated that they obtained information about Resident #4 from the Hospital Patient Review Instrument, from a prior nursing home that Resident #4 had resided in and from a family member. The ADSS stated that the information collected revealed that Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADSS stated that Resident #4 did not have any history of aggression towards other residents. The ADSS reported that Resident #4 did not exhibit any inappropriate behavior, in the facility, prior to [DATE]. During an interview on [DATE] at 3:30 PM, CNA #2, who worked on [DATE], ,d+[DATE] shift, stated that they were conducting 30-minute rounds when they heard a nurse called out for help. CNA #2 stated that they entered Resident #3's room and observed Resident #4 pacing back and forth, from the door to the window, in Resident #3's room. CNA #2 stated that Resident #4 was removed from Resident #3's room. During an interview on [DATE] at 3:30 PM, CNA #3 stated that they were assigned to Resident #4 on [DATE] on the ,d+[DATE] shift. CNA #3 stated that Resident #4 usually walks around on the unit and that Resident #4 responded to name only. CNA #3 asserted that Resident #4 was not aggressive. CNA #3 reported at the time of incident, they were walking in the hallway and heard Resident #3 screaming. CNA #3 stated that they immediately went to check on Resident #3 and observed the charge nurse and another CNA entering Resident #3's room. CNA #3 stated that they observed Resident #3 covered up in bed with a sheet. CNA #3 stated that when they arrived in the room, Resident #3 was quiet. CNA #3 further stated, Resident #4 was standing near the window away from Resident #3's bed and they removed Resident #4 from Resident #3's room. CNA #3 stated, prior to the incident, they saw Resident #4 in their room at 7:20 PM with their face turned towards the window. During an interview on [DATE] at 3:50 PM, Registered Nurse #1 (RN #1), who worked on [DATE] on the ,d+[DATE] shift, stated that they were passing medication at around 7:45 PM and heard screaming coming from Resident #3's room. RN #1 stated that they called out to staff for help and went to Resident #3's room. RN #1 stated that they observed Resident #4 confused and was walking around in Resident #3's room. Resident #3 was lying in bed with a little blood coming from the nose and some swelling. Resident #3 was not able to verbalize what happened but pointed their finger at Resident #4. RN #1 stated that Resident #3's facial expression showed that Resident #3 was mad at Resident #4. Resident #4 was removed immediately from the room and the nursing supervisor was called. RN #1 stated that they called the Medical Doctor and Tylenol was ordered and administered to Resident #3. During an interview on [DATE] at 4:15 PM, Registered Nurse Supervisor #2 (RNS #2), who worked on [DATE] on the ,d+[DATE] shift, stated that they observed Resident #3, who was confused, with swelling and bleeding. A small amount of blood was coming from Resident #3's nose. Resident #3 was transferred to the hospital for evaluation. RNS #2 stated that Resident #3 returned to the facility from the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RNS #2 also stated that they cannot assumed that Resident #4 hit Resident #3 because there were no witnesses. RNS #2 stated that Resident #4 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . RNS #2 stated that Resident #4 was not aggressive prior to the incident and that Resident #4 had no history of wandering. Resident #4 was being monitored every 30-minute prior the incident. During an interview on [DATE] at 4:15 PM, the Attending Physician (AP) stated, in their professional judgment, there was no reason to increase supervision for Resident #4 because there was no aggressive behavior prior to the incident. The AP also stated that there were no witnesses to corroborate Resident #4 was aggressive towards Resident #3. The AP stated that there was no need to transfer Resident #4 to the hospital. Resident #4 did not display aggressive behavior before or after the incident. The AP stated that staff were able to manage Resident #4's behavior and Resident #4 was being monitored closely. During an interview on [DATE] at 12:10 PM, the Risk Manager (RM) stated that they are responsible for reporting to New York State Department of Health (NYS DOH) and to local law enforcement. The RM stated that the incidents were reported to NYS DOH withing 24 hours because there was no evidence of a criminal act. The RM stated if there was evidence of serious bodily injury and a criminal act, the Police would have been notified. Resident #4 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility's Incident/Event Intake Form and Investigation Findings (for Resident #5 and Resident #6), dated [DATE], documented that on [DATE] at 9:30 PM, Resident #5 was observed with multiple bruises and lumps on their head and facial area. Multiple red marks were also observed on Resident #5's upper chest and back. Resident #6 was observed standing at the foot of Resident #5's bed. Resident #6 had a detached call bell cord in their hand. Resident #6 was observed with increased agitation and aggression. Resident #5 and Resident #6 were unable to give an account of the event. The facility concluded that it was most likely that Resident #5 and Resident #6 had a physical altercation resulting in injury. Resident #5 and Resident #6 were roommates at the time of the incident. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The MDS dated [DATE] identified that Resident #5 had long and short -term memory impairment. A CCP related to risk for abuse updated [DATE], documented interventions were to maintain a safe environment at all time, provide emotional support, observe the resident for unusual skin marks, discoloration etc. and report promptly. Review of a Visual Observation Monitoring Sheet dated [DATE], documented that Resident #5 and Resident #6 were being monitored every 30-minutes. Resident #5 and Resident #6 were both in their room at 9:00 PM and at 9:30 PM. Review of a nursing note dated [DATE] at 11:00 PM, revealed that Resident #5 was observed with multiple bruises and lumps on their head and facial area. Resident #5's left eye and lip were grossly swollen. Resident #5 had an abrasion to the left side of the head. Multiple red marks were observed on Resident #5's upper chest and back. Per assigned staff member, Resident #6 was observed standing at the foot of Resident #5's bed. Resident #6 was holding a detached call bell in their hand. The Residents were separated for safety and the Nurse Practitioner (NP) was notified. Resident #5 was medicated for pain and the abrasion was cleansed and covered. Resident #5 was transferred to the hospital. Resident #5's Emergency Department Summary dated [DATE], documented: Left Anterior Frontal and Periorbital Subcutaneous Contusion. Left Parietal Laceration repaired with Dermabond. Resident #5 also received a [CONDITION(S)] shot and a CT-SCAN was performed with negative finding for fracture. Review of a nursing note dated [DATE], revealed that Resident #5 returned to the facility after an altercation with their roommate (Resident #6). Resident #5 was in stable condition. Resident #5 left eye was grossly swollen. The hospital discharge documented: Laceration was repaired with Dermabond, a [CONDITION(S)] shot was given, and a CT-SCAN was performed, and the results revealed no fracture. There were no other acute findings. The NP reviewed the hospital discharge and ordered to start Tylenol 500 mg every 8 hours. An order also given for an Ophthalmology consult, warm compress to the affected eye as tolerated, neurological checks for 72 hours, and staff were to closely monitor for changes. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #5's affected eye every shift until swelling goes down. Tylenol 500 mg 2 tabs every 8 hours for pain. [MEDICATION(S)]-[MEDICATION(S)] eye ointment to apply by ophthalmic route every 4 hours for 7 days to the left eye. Ophthalmology Consult for swollen left eye. An order dated

Based on record review and staff interviews, the facility did not ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs. Specifically, a resident's wheelchair leg rests were removed by CNA (Certified Nurse Assistant) #2 and three days later, while being pushed by CNA 31, the resident fell out of the wheelchair without leg rests in place. Subsequently, the resident was hospitalized for [REDACTED]. This was evident for 1 of 30 sampled residents (Resident #6). This resulted in actual harm that is not immediate jeopardy. This is a repeat deficiency. The finding is: Resident #6's Minimum Data Set 3.0 Assessments ((MDS) dated [DATE] and 1/3/11 documented that the resident has severe cognitive impairment, and is totally dependent on staff for eating, dressing, transfers, personal hygiene, and bathing. The resident occurrence report dated 12/21/10 documented "...Nurse was in the process of Medication pass when nurse heard a loud thud coming from the elevators. Upon writers' observation, resident was noted lying on the floor in front of the wheelchair with his face down on the floor. Nurse also observed minimal bleeding to the forehead with superficial cut. As per CNA I was wheeling resident to the dayroom when he fell forward..." The following statements were attached to the resident occurrence report dated 12/21/10: 1) The CNA Statement dated 12/21/10, written by CNA #1, documented "Resident was sitting in w/c (wheelchair) in the hallway. I took resident from the hallway and was wheeling him to the dayroom when he fell forward out of the chair". 2) A Statement Form dated 12/24/10, written by CNA #2, documented that CNA #2 was assigned to the resident on 12/21/10. CNA #2 wrote that she noticed a few days prior that the resident's pant leg got caught in the foot rest of the w/c while he was doing his "foot dance." The statement further documented that the Resident always put his feet on the floor, and she notified the nurse. 3) An addendum to the statement written by CNA #2, dated 12/21/10, was written by the Registered Nurse (RN) Risk Manager and documented: "I removed his leg rest because he was moving his legs around and it banged against the leg rest. His feet was resting on the metal of footrest so I removed them. I saw the therapist on the unit and was going to show him, but (resident) fell before I could do it". The Radiology Report, from the hospital, dated 12/21/10 documented "CT Head Without Contrast ...Impression: Large mixed right subdural, small left acute posterior and tentorial subdural. Possible trapped left lateral ventricle". There was no documented evidence in the medical record that any rehab consult was requested to assess the resident's equipment needs in the wheelchair prior to the incident on 12/21/10. The Nursing Supervisor's Review of Accident/Incident dated 12/24/10 documented: "...Upon investigation, resident has behavior of placing his feet on the ground off the leg rest. Staff removed leg rest upon noticing that resident legs were resting on the metal base of same to avoid injury. Resident was due for evaluation by rehab on same day. Staff was unable to prevent fall. Resident does not keep his feet on the leg rest and would often be seen dancing his legs around ...Corrective Action: Transferred to hospital for evaluation; Rehab evaluation; 72hr bed mobility evaluation; Stop drop to footrest of wheelchair". There is no documented evidence of any corrective action/inservice implemented for the CNAs involved in this accident/incident as of 2/10/11 (51 days after the resident's fall). The resident is an [AGE] year-old readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/8/11 at 12:26pm, CNA #1 was interviewed and stated that she was in the process of wheeling the resident from the hallway to the day room when he fell forward. She further stated that she could not remember how it happened or whether the resident moved in any way. She also stated that she was not assigned to the resident, and the resident did not have any legs rests on his wheelchair at the time. On 2/8/11 at 12:43pm, the Occupational Therapist (OT) was interviewed and stated that the resident is supposed to have leg rests on the wheelchair, and the leg rests do prevent the resident from falling forward. She further stated that she went to the unit immediately after the fall and found the leg rests in the resident's room. The OT also stated that she was not informed of any problems with the resident's leg rests prior to the incident, and she is on the unit at least four times per week. In addition, she stated that she had never seen the resident have problems with keeping is feet on the foot rests and leg rests. On 2/9/11 at 9:50am, CNA #2 was interviewed and stated that she removed the resident's leg rests when she noticed that his pants were getting caught in them a few days prior to the incident. She further stated that she believed that she removed them on a Friday and the incident happened the following week. She also stated that she told the Licensed Practical Nurse (LPN) that the resident may not need the leg rests because he could hurt himself and received no response or instruction. The CNA stated that she then took the leg rests off the wheelchair. On 2/9/11 at 9:57am, the LPN was interviewed and stated that she did not remember being informed of any problem with the resident's leg rests. She further stated that rehab should be called for an assessment prior to removing or discontinuing any equipment. She also stated that the CNAs should not stop using equipment on their own. On 2/10/11 at 3:30pm, the Director of Nursing was interviewed and stated that she realizes that the CNAs should be in-serviced. She further stated that she was preparing an in-service with the Rehab Director on positioning because she was aware that it was a problem, but it has not been completed yet. 415.26(c)(1)(iv)

Based on observation, record review, and resident and staff interviews, the facility did not ensure that each resident was free from abuse. Specifically, resident #36 was not free from repeated incidents of inappropriate sexual behavior by resident #13, and the resident tearfully expressed that she was scared of resident #13. This was evident for 1 out of 30 sampled residents (Resident #36). This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #36 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented that the resident has intact cognition. The resident was interviewed on 2/16/11 at 10:25am. The resident stated that in late October, 2010 at approximately 3:00am, Resident #13 came into her room naked, holding his genitalia, and said "look at this." The resident said she was startled and screamed at him to get out of her room, and the night nurse came to her and tried to calm her down. The resident stated that she was nervous for the next 1 to 2 weeks because she worried that Resident #13 would try to come into her room again in the middle of the night. She would wake up and check the room during the night because Resident #13 was not on 1:1 observation. The resident further stated that about 2 weeks later, Resident #13 came into her room naked and holding his genitalia in the morning around 7:45 during her nebulizer treatment. She said she told the Licensed Practical Nurse (LPN) on duty what the resident had done. The next morning, Resident #13 attempted to enter her room again, dressed in a gown, but he got startled and left. The resident began crying as she told this information to this surveyor. She said the staff did not do anything about the incidents until she threatened to report it to the Department of Health on the day of the 3rd attempt. The resident stated that she told her brother what happened and he came to the facility and demanded to speak to the Administrator, which he did. The resident said that the staff told her they would move the resident closer to the nursing station as a resolution, but they did not ask her how she was doing or whether she felt safe. The resident said she was scared ever since the incidents occurred. When the surveyor asked the resident why she was crying, the resident stated that the incidents scared her, and she still has flashbacks about them. A Nursing Note from Resident #13's medical record dated 10/27/10 at 2:45am documented "Resident was observed in Rm (room) (room # of Resident #36) wearing night gown and holding his private part in hands towards resident in Rm (room # of Resident #36). Staff assisted resident to his room and staff members provided 1:1 supervision. Continue to monitor." There was no documented evidence of the 10/27/10 incident in resident #36's medical record and/or documented evidence of interventions for resident #36 to prevent further incidents with resident #13. A Licensed Practical Nurse note dated 11/6/10 at 8:15am in resident #13 record documented that "the resident in Room (resident #36 room) told me that the resident come into her room and exposed his private part..." A Licensed Practical Nurse note dated 11/6/10 at 3pm in resident #36 record documented that the resident complained that Resident #13 came into her room, exposing his private parts. There was no documented evidence in resident #36's medical record of efforts made to protect resident #36 from resident #13. A Nursing Note dated 11/7/10 at 8:15am in resident #36 record documented that the resident told the LPN (Licensed Practical Nurse) that Resident #13 came to her door and knocked at 8:05am, and she recognized his voice and told him to leave her alone. She stated the resident left after she told him to leave her alone. There was no documented evidence in resident #36 record of interventions to address the repeated episodes with resident #13. On 2/16/11 at 9:45am and 11:35am, the Registered Nurse (RN) Manager was interviewed and stated that she was not aware of Resident #13 exposing his genitalia to Resident #36 on two occasions. She stated that Resident #36 told the staff and her brother about the attempt to come into her room, and the resident was reassured that Resident #13 would be moved closer to the nursing station. On 2/16/11 at 11:25am, the Social Worker was interviewed and stated that the resident was very disturbed by what happened, and she spoke to the resident and provided support. She further stated that she was only aware of one incident where Resident #13 came to her room and was redirected. She also stated that she was not aware that Resident #13 had ever exposed his genitalia to Resident #36. The resident's brother spoke to the Administrator about the matter, and Resident #13 was moved. The SW stated that the resident was never tearful, and she had no idea that she was fearful or continued to be upset by the incidents. She further stated that if she had known, the resident would have been referred to the psychologist so she could talk about what happened and her feelings. The RN Risk Manager was interviewed on 2/16/11 at 1:12pm and stated that she was not informed of any incidents where Resident #13 exposed himself to Resident #36, but she recalled the incident where Resident #13 attempted to come into Resident #36's room but did not enter. She further stated that incidents reports and investigations are done for actual physical contact but not for exposing genitalia unless the resident is cognitively impaired and there is uncertainty about what occurred. She also stated that if the resident is cognitively intact, they can say whether they were touched and no report or investigation is needed. The RN Risk Manager stated that she did speak to the resident about the last incident and she did not seem upset or distraught at the time, and she said she was okay. When asked about whether acts could be abusive even if there was no touching involved, she stated that abuse could be verbal or mental. 415.4(b)(1)(i)

Based on record review, resident and staff interviews, the facility did not implement the abuse protocol policy and procedures. Specifically, the facility did not investigate, protect and prevent incidents of inappropriate sexual behavior by resident #13 toward resident #36 and several unidentified female residents. Additionally, the facility did not protect resident #13 from potential physical abuse by another resident. This was evident for 1 of 30 sampled residents (Resident #13) and 1 out-of-sample resident (Resident #36) and several unidentified female residents. This resulted in actual harm for resident #36. This resulted in no actual harm with potential for more than minimal harm for resident #13 and for several unidentified female residents. The findings include but are not limited to: 1) Resident #13 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented that the resident had severely impaired cognition and displayed physical behaviors and other behaviors that intruded on the privacy of others. The Behavior CCP (Comprehensive Care Plan) was updated on 4/26/10 with the following: "Hx (history) of going to peers room @ (at) times (with) open gown & (and) exposed genitalia ...Interventions: Provide direction in positive manner & redirect as needed ...Psych (Psychiatric) consult as per MD (physician) order ...Medications. " On 4/26/10 a second Behavior CCP for "Resident to Resident Altercation (Aggressor) " was implemented. The CCP documented: " On 4/25/10 @ 11:30am - as per statement of ...son, resident ...went to his mother's room (with) exposed genitalia. Charge nurse redirected him to his room ." The CCP also documented the following interventions: "Remove resident from situation utilizing calm approach ...Provide 1:1 supervision until calm ...Asses for injury ...Psychiatric consult as per MD ...Assess for causes of behavior ...Engage in diversional activities i.e.: music, ambulation ...Room change/unit change ...Continuous 1:1 supervision ...Keep resident apart from other resident ...1:1 observation. " The Patient Activity Log printed on 2/14/11 documented that the resident was moved to the 4th floor on 4/26/10. There is no documented evidence that the facility implemented their abuse protocol. There was no incident report or investigation for this occurrence for the resident or the victim of his sexual behavior. The Patient Activity Log printed on 2/14/11 documented that the resident was moved from the 4th floor to the 10th floor on 5/15/10. There is no documented evidence that the facility implemented their abuse protocol. The Patient Activity Log printed on 2/14/11 documented that the resident was moved from the 10th floor to the 7th floor on 6/14/10. There is no documented evidence that the facility implemented their abuse protocol. A Social Services Note dated 6/14/10 documented: " On this date (resident) was transferred from room ...to ...(secondary) to him being inappropriate to another resident." There was no documented evidence of the nature of the incident that occurred that led to a room change for this resident. There was no documented evidence that an investigation was done regarding any incident around 6/14/10 for the resident or the victim. There was no documented evidence that the victim was counseled or protected to ensure that no abuse occurred. A Social Services Note dated 6/15/10 documented " ...phoned resident's wife and made her aware resident has exposed himself to several women on the unit. This date resident was placed on one to one for extra support from staff." The Behavior CCP was updated on 6/15/10 with the following note " Resident alert and verbally responsive. Inappropriate behavior towards 3 residents on the unit. Supervisor made aware. Staff watched resident, and he is on one to one with a CNA (Certified Nursing Assistant)." There was no documented evidence that there were any investigations for the 3 unidentified residents. There was no documented evidence that the abuse protocol was implemented for the 3 unidentified residents. A Social Services Note dated 6/16/10 documented "Res (resident) has been wandering and touching staff (Females) and other residents (Female). Res (resident) has jump suit and has not been able to disrobe; Res presents as being at risk of harm from other male resident who become angry that res touches women. Res was pushed into a chair by other male res. Room change to be done to protect res from harm." The "Resident Occurrence Report" dated 6/16/10 documented "Resident Continues to inappropriately touch female Resident/Staff when Resident (resident initials) intervene putting his hand around resident #13 neck stating " You never do that again" Resident separated. Closely Monitor. Continue on 1:1 observation." The Accident and Incident Investigation dated 6/18/10 documented "...Resident was chocked by another resident after he touched a female staff/resident. Resident (resident initials) was present and yelled at him, "you never do that again" after putting his hand around residents neck. Residents were immediately separated. Resident on 1:1 observation. Residents were in a supervised, but staff was unable to prevent incident...Remained on 1:1 until such time. No evidence of abuse/neglect." The Behavior CCP was updated on 6/16/10 with the following note: " Continue to walk & touch female resident & staff inappropriately. On 1:1 monitoring due to behavior. Another resident attempted to choke him. No visible injuries noted." A Social Services Note dated 6/17/10 documented that the resident was transferred to an inpatient psychiatric unit because of his inappropriate sexual behavior. On 2/16/11 at 12:35pm, the CNA that provided 1:1 supervision on 6/16/10 was interviewed and stated that she did not witness the incident because she went to lunch. She further stated that it is common practice that if there is not enough staff to cover the 1:1, the CNA providing the 1:1 can leave the resident in the day room during lunch in order to take a lunch break. The CNA also stated that she left the resident in the day room for lunch, but the CNAs in the day room are familiar with the resident's behaviors. A Social Services Note dated 7/6/10 documented that the resident was readmitted and would be monitored. The Patient Activity Log printed on 2/14/11 documented that the resident was readmitted to the same room on the 7th floor where the 6/16/10 incident occurred. There was no documented evidence that the facility implemented the abuse protocol to protect resident #13, a cognitively impaired resident, from physical abuse. A Social Services Note dated 7/12/10 documented that the resident was attempting to touch a female resident while stating sexual advances towards her. The note further documented that the resident was separated from the female and placed on monitoring. There was no documented evidence that an investigation was done for this unidentified female resident who was touched on 7/12/10 by resident #13. There was no documented evidence of nursing notes, physicians' notes/orders from April, 2010 to September, 2010 in resident #13 medical record. The Assistant Director of Nursing was interviewed on 2/14/11 at 5:20pm stated that the resident's entire medical record could not be found from April 2010 to September 2010 in resident #13 medical record. A Nurses' Note dated 10/9/10 at 11am documented "Touch the resident on her bottom. Behavior discourage by resident." There was no documented evidence that an investigation was done for the unidentified female resident or that the abuse protocol was implemented. A Nursing Note dated 10/27/10 at 2:45am documented "Resident was observed in Rm (resident #36 room) wearing night gown and holding his private part in hands towards resident in Rm ...Staff assisted resident to his room and staff members provided 1:1 supervision. Continue to monitor " . There was no documented evidence that an investigation was conducted and that the abuse protocol implemented for resident #36 concerning the 10/27/10 incident. The Nursing Notes dated 11/6/10 at 8:15am documented: "The resident in room (resident #36 room) ...told me that the resident #13 came into her room and exposed his private part ...Resident was walking in the hallway and I took him into the day room." There was no documented evidence that an investigation or the abuse protocol was implemented for resident #36 concerning the 11/6/10 incident. The Nursing Notes dated 11/7/10 documented: " 7:35am Resident was asleep during walk through round ...7:50am ...observed resident ambulating in hallway and I took him into the dayroom ...8:15am The resident in Room ...told me that the resident in Room ... came to her door and knocked at 8:05am. She said that she recognized his voice and told him to leave her alone " . There was no documented evidence that an investigation and the abuse protocol implemented for resident #36 concerning the 11/7/10 incident. On 2/10/11 at 6:50pm the Registered Nurse (RN) Risk Manager (abuse protocol coordinator) was interviewed and stated that she could not find any other incident reports for the resident #13 or for any of the other residents involved in the incidents. She further stated that the documentation regarding touching another resident in the 6/16/10 incident report must be an error, and she was not aware that the resident was exposing his genitalia to other residents or touching other residents. She also stated that if he touched other residents, there should be an incident report and investigation. The RN Risk Manager was interviewed on 2/16/11 at 1:12pm and stated that she was not informed of any incidents where Resident #13 exposed himself to Resident #36, but she recalled the incident where Resident #13 attempted to come into Resident #36 ' s room but did not enter. She further stated that incidents reports and investigations are done for actual physical contact but not for exposing genitalia unless the resident is cognitively impaired and there is uncertainty about what occurred. She also stated that if the resident is cognitively intact, they can say whether they were touched and no report or investigation is needed. The RN Risk Manager stated that she did speak to the resident about the last incident and she did not seem upset or distraught at the time, and she said she was okay. On 2/11/11 at 3:20pm, the Social Worker (SW) that was assigned to the resident from 6/14/10 to 1/11/11 was interviewed and stated that she was informed from the previous Social Worker that the resident had an incident with another resident on his previous floor. She was not aware of the nature of the incident. She further stated that the resident touched a cognitively impaired female resident on her knee on 6/16/10 and she provided support, but the female resident is unable to remember. The SW also stated that she was only aware of the resident exposing himself to staff. On 2/16/11 at 9:45am, the RN Manager was interviewed and stated that the resident usually touched the sexual parts of females and expressed what he wanted to do to them sexually. She further stated that occurrence reports and investigations are done when someone has been touched, but I do not think the resident touched anyone because he was always prevented from doing so. 2) Resident #36 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented that the resident had intact cognition. The resident was interviewed on 2/16/11 at 10:25am. The resident stated that in late October 2010 at approximately 3:00am, Resident #13 came into her room naked, holding his genitalia, and said " look at this " . The resident said she was startled and screamed at him to get out of her room, and the night nurse came to her and tried to calm her down. The resident stated that she was nervous for the next 1 to 2 weeks because she worried that Resident #13 would try to come into her room again in the middle of the night. She would wake up and check the room during the night because Resident #13 was not on 1:1 observation. The resident further stated that about 2 weeks later, Resident #13 came into her room naked and holding his genitalia in the morning around 7:45 during her nebulizer treatment. She said she told the Licensed Practical Nurse (LPN) on duty what the resident had done. The next morning, Resident#13 attempted to enter her room again, dressed in a gown, but he got startled and left. The resident began crying as she told this information to this surveyor. She said the staff did not do anything about the incidents until she threatened to report it to the Department of Health on the day of the 3rd attempt. The resident stated that she told her brother what happened and he came to the facility and demanded to speak to the Administrator, which he did. The resident said that the staff told her they would move the resident closer to the nursing station as a resolution, but they did not ask her how she was doing or whether she felt safe. The resident said she was scared ever since the incidents occurred. When this surveyor asked the resident why she was crying, the resident stated that the incidents scared her, and she still has flashbacks about them. There was no documentation in the resident's medical record of any incident in October 2010. A Nursing Note from Resident #13 ' s medical record dated 10/27/10 at 2:45am documented: : " Resident was observed in Rm (room) (room # of Resident #36) wearing night gown and holding his private part in hands towards resident in Rm (room # of Resident #36). Staff assisted resident to his room and staff members provided 1:1 supervision. Continue to monitor " . There was no documented evidence that an investigation was done or that attempts were made to protect the resident. There is no documented evidence that the abuse protocol was implemented. A Nursing Note dated 11/6/10 at 3pm documented that the resident complained that Resident #13 came into her room, exposing his private parts. There was no documented evidence that an investigation was done and efforts were made to protect the resident. There is no documented evidence that the abuse protocol was implemented. A Nursing Note dated 11/7/10 at 8:15am documented that the resident told the LPN that Resident #13 came to her door and knocked at 8:05am, and she recognized his voice and told him to leave her alone. There was no documented evidence that an investigation was done and efforts were made to protect the resident. There is no documented evidence that the abuse protocol was implemented. On 2/16/11 at 9:45am and 11:35am, the Registered Nurse (RN) Manager was interviewed and stated that she was not aware of Resident #13 exposing his genitalia to Resident #36 on two occasions. She stated that Resident #36 told the staff and her brother about the attempt to come into her room, and the resident was reassured that Resident #13 would be moved closer to the nursing station. On 2/16/11 at 11:25am, the Social Worker was interviewed and stated that the resident was very disturbed by what happened, and she spoke to the resident and provided support. She further stated that she was only aware of one incident where Resident #13 came to her room and was redirected. She also stated that she was not aware that Resident #13 had ever exposed his genitalia to Resident #36. The resident ' s brother spoke to the Administrator about the matter, and Resident #13 was moved. The SW stated that the resident was never tearful, and she had no idea that she was fearful or continued to be upset by the incidents. She further stated that if she had known, the resident would have been referred to the psychologist so she could talk about what happened and her feelings. The RN Risk Manager was interviewed on 2/16/11 at 1:12pm and stated that she was not informed of any incidents where Resident #13 exposed himself to Resident #36, but she recalled the incident where Resident #13 attempted to come into Resident #36's room but did not enter. She further stated that incidents reports and investigations are done for actual physical contact but not for exposing genitalia unless the resident is cognitively impaired and there is uncertainty about what occurred. She also stated that if the resident is cognitively intact, they can say whether they were touched and no report or investigation is needed. The RN Risk Manager stated that she did speak to the resident about the last incident and she did not seem upset or distraught at the time, and she said she was okay. When asked about whether acts could be abusive even if there was no touching involved, she stated that abuse could be verbal or mental. 3) Resident #17 is a [AGE] year old female with the [DIAGNOSES REDACTED]. The MDS 3.0 dated 12/8/10 documented moderately impaired cognition with short term memory problem. Observed resident's room on initial tour on 2/4/11. Resident had full side rails on her bed. Again observed resident's room on 2/8/11 around 10 am and resident had full side rails. Observed resident on 2/8/11 at 12 PM finishing physical therapy. The nurses' notes dated on 2/15/10 at 11:20 PM documented "resident came to nurses station upset says that there is a man in her room who wants to touch her. Brought to dayroom comforted resident. Afraid, crying reassured allowed to ventilate. Brought back to bedroom. Reassured and put back to bed. No further episode. To be follow up." On nurses' notes dated on 2/15/10 at 10 AM documented "CNA reports that resident states " A man came in my room last night and pushed his finger in my panties; trying to have sex with me." Resident interviewed by the nurse manager and reported the same. Manager, Social Worker, the CNA'S of the evening tour for previous day - they reported that there was no visitors to resident and that resident has been saying "I want sex" for sometime now. Manager placed resident for a psychiatric evaluation for further follow up. On nurses' notes dated on 2/17/10 at 6 PM documented "Resident in dayroom had supper was calm conversing with all at table during supper. Medicated went to bed. Noted teary eye saying "the man touched me in my private area." Agitated, crying and talking loudly. Calmed continued to ventilate becoming more and more agitated. Asked to go to the dayroom, agreed brought resident to dayroom informed staff and monitored until 10PM calmed escorted back to room no further period of agitation or talks of a man. There is no documented evidence that these incidents were investigated. There is no documented evidence that the abuse protocol was implemented. An interview with the Charge Nurse that works the shift 3:30 PM to 11:30 PM was conducted by phone on 2/9/11 at 12:15 PM. The nurse stated that the resident came out of her room and was crying. The nurse went into her room and consoled the resident. The nurse calmed her down and reassured the resident that there was no stranger there. When these incidents reoccurred staff would have the resident sit near the nursing station or dayroom and would monitor the resident. The nurse stated she would document the incidents in the chart and would make the supervisor aware. The process is that you inform the supervisor and the supervisor would follow up and Accident and Incident Report would be initiated by the nursing office. The Nurse stated that the resident was never sexually preoccupied, that is not the type of person she is. The resident never stated she wanted sex. An interview with the Nurse Consultant who was the Director of Nursing when these incidents occurred was interviewed on 2/9/11 at 1:20 PM. She stated that she recalls that the nurse manager at the time who no longer works in the facility verbally stated that she interviewed all the evening staff. The Nurse consultant continued to state "that the resident stated that a man came in her room and pushed his finger in her panties." She continued to state that the evening supervisor passed the report to the day supervisor who did the investigation. There is no documented evidence this was done. An interview with the DNS was conducted on 2/9/11 at 11:25 am. The DNS stated there was no investigation done for the sexual abuse in February 2010. A family interview was conducted with the daughter on 2/11/11 at 10 AM. The daughter stated that when the incident occurred the mother described the situation that you believed it really happened. The mother still speaks about the situation, the last time she spoke about it was three weeks ago. 415.4(b)

Based on observations, record review and staff interviews, the facility did not ensure that (1) each resident received adequate supervision and assistance devices to prevent accidents and (2) the resident environment remained free from accident hazards. Specifically, (1) a resident was not provided with adequate supervision and wheelchair leg rests which resulted in the resident sustaining a subdural hematoma; (2) protruding metal screws were observed in handrails provided in resident unit corridors; and (3) sharp edges were observed in radiators lacking proper covers. This was evident for 1 of 30 sampled residents (Resident #6) and 2 of 12 resident units (units 6 and 7). This resulted in actual harm for resident #6 that is not immediate jeopardy and no actual harm with potential for more minimal harm for residents on units 6 and 7. This is a repeat deficiency. The findings are: 1) Resident #6 is an [AGE] year-old readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident has severe cognitive impairment, and is totally dependent on staff for eating, dressing, transfers, personal hygiene, and bathing. The nurses note dated 3/10/10 at 3:30pm documented "...verbally responsive s/p (status [REDACTED]. No signs of pain when site is touched. No c/o (complaints of) pain or signs of discomfort noted. Neurochecks in progress. Seen by ...NP (Nurse Practitioner) ...PT/OT (Physical Therapy/Occupational Therapy) evaluation s/p fall; cold compress for forehead hematoma TID (three times per day) x (for) 2 days; Bacitracin to Rt Knee abrasion daily x 3 days; fall precautions, neurochecks x 24 hours, low bed, floor mattress ...bed alert. No low bed or floor mattress available. Request made through housekeeping and PT department. Bed alarm will be applied when in bed". The Comprehensive Care Plan for Accidents dated 10/19/09 was updated on 3/10/10 with the interventions of low bed ordered, mattress at bedside, PT/OT evaluation, and bed alarm. The Accident/Incident Report (A/I) dated 3/10/10 documented a defined parameter mattress among the interventions. There was no documented evidence that the plan for a defined parameter mattress was implemented. The Certified Nursing Assistant Resident Care Plan Directives dated August 2010 documented that as of 10/5/10 the resident required the use of a Hoyer lift and 2 persons to transfer from bed to wheelchair. It also documented that the resident had a bed and chair alarm. The Daily Bed/Chair Alarm Check Sheet dated 11/6/10 did not contain resident's name for having alarms that needed to be checked. Nursing Notes on 11/7/10 at 6:43 am documented: " Resident observed on floor in room lying on his (R) (right) side on (L) (left) side of bed. (No) visual injuries, denies pain. Able to move ...extremities. Alert, confused ...Monitor closely by staff". A Nursing Note on 11/7/10 at 7am documented: "Son called back to request side rails". The Comprehensive Care Plan for Accidents was updated on 11/7/10 with the following new intervention: "Keep bed in lowest position". The A/I dated 11/7/10 contained a CNA (Certified Nursing Assistant) statement that was blank for all questions regarding alarms use and if they were in place, bed in lowest position, and whether mats were used and in place. The corrective action documented was low bed. There was no documented evidence that the bed alarm, floor mattress, defined parameter mattress, and low bed recommended on 3/10/10 were implemented. The Daily Bed/Chair Alarm Check Sheet dated 11/7/10 did not contain resident's name for having alarms that needed to be checked. Nursing Notes dated 11/8/10 at 2:20am documented: "Resident observed on (L) side of bed on his (L) side. (No) Visible injuries ...denied pain. No distress noted ...to be monitored closely by staff ...Resident tends to lean to (L) side of bed ...Instruct staff to make sure Resident is positioned to middle of bed". A Nursing Note dated 11/8/10 at 6:30am documented: "Bed alarm functioning and in place on bed". A Nursing Note dated 11/8/10 at 6:40am documented: "son notified of incident. Wants a mat placed on floor and 1 side rail. Will f/u (follow-up)." The A/I dated 11/8/10 documented corrective actions of bed alarm and 72 hour side rail assessment. The CNA Statement attached was blank for questions regarding the use of a bed alarm and floor mats. The CCP for Accidents was updated on 11/8/10 with the intervention of side rail assessment. There was no documented evidence that the interventions of bed alarm, floor mattress, and defined parameter mattress, recommended on 3/10/10 were implemented. A Rehabilitation Consult Form containing an OT consult dated 11/8/10 documented: "Asked to see Res (Resident) (secondary to) fall 11/7/10 ...He will benefit from perimeter mattress and bed should be placed in lowest position. Nursing made aware". Nursing Notes dated 12/21/10 at 11:40am documented: "While in the process of medication pass, writer heard a loud thud coming from the elevator. Upon my investigation writer observed resident lying on the floor in front of wheelchair. Nurse also observed a superficial cut (2cm) to forehead with minimal bleeding... NP...notified ordered to transfer resident to hosp (hospital) ...for CT (CAT Scan) of the head". The Radiology Report, from the hospital, dated 12/21/10 documented: "CT Head Without Contrast ...Impression: Large mixed right subdural, small left acute posterior and tentorial subdural. Possible trapped left lateral ventricle". The following statements were attached to the A/I dated 12/21/10: 1) The CNA Statement dated 12/21/10, written by CNA #1, documented: "Resident was sitting in w/c in the hallway. I took resident from the hallway and was wheeling him to the dayroom when he fell forward out of the chair". 2) A Statement Form dated 12/24/10, written by CNA #2, documented that CNA #2 was assigned to the resident on 12/21/10. CNA #2 wrote that she noticed a few days prior that the resident's pant leg got caught in the foot rest of the w/c while he was doing his "foot dance". The statement further documented that the Resident always put his feet on the floor, and she notified the nurse. 3) An addendum to the statement written by CNA #2, dated 12/21/10, was written by the Registered Nurse (RN) Risk Manager and documented: "I removed his leg rest because he was moving his legs around and it banged against the leg rest. His feet was resting on the metal of footrest so I removed them. I saw the therapist on the unit and was going to show him, but (resident) fell before I could do it". The Nursing Supervisor's Review of Accident/Incident dated 12/24/10 documented: "...Upon investigation, resident has behavior of placing his feet on the ground off the leg rest. Staff removed leg rest upon noticing that resident legs were resting on the metal base of same to avoid injury. Resident was due for evaluation by rehab on same day. Staff was unable to prevent fall. Resident does not keep his feet on the leg rest and would often be seen dancing his legs around ...Corrective Action: Transferred to hospital for evaluation; Rehab evaluation; 72hr (hour) bed mobility evaluation; Stop drop to footrest of wheelchair". The Nurse Practitioner note dated 12/29/10 documented that the resident was readmitted from the hospital on [DATE]. There was no documented evidence in the medical record that any rehab consult was requested to assess the resident's equipment needs in the wheelchair prior to the incident on 12/21/10. On 2/8/11 at 12:26pm, CNA #1 was interviewed and stated that she was in the process of wheeling the resident from the hallway to the day room when he fell forward. She further stated that she could not remember how it happened or whether the resident moved in any way. She also stated that she was not assigned to the resident, and the resident did not have any legs rests on his wheelchair at the time. On 2/8/11 at 12:43pm, the Occupational Therapist (OT) was interviewed and stated that the resident is supposed to have leg rests on the wheelchair, and the leg rests do prevent the resident from falling forward. She further stated that she went to the unit immediately after the fall and found the leg rests in the resident's room. The OT also stated that she was not informed of any problems with the resident's leg rests prior to the incident, and she is on the unit at least four times per week. In addition, she stated that she had never seen the resident have problems with keeping his feet on the foot rests and leg rests. On 2/9/11 at 9:50am, CNA #2 was interviewed and stated that she removed the resident's leg rests when she noticed that his pants were getting caught in them a few days prior to the incident. She further stated that she believed that she removed them on a Friday and the incident happened the following week. She also stated that she told the Licensed Practical Nurse that the resident may not need the leg rests because he could hurt himself and received no response or instruction. The CNA stated that she then took the leg rests off the wheelchair. On 2/9/11 at 9:57am, the LPN was interviewed and stated that she did not remember being informed of any problem with the resident's leg rests. She further stated that rehab should be called for an assessment prior to removing or discontinuing any equipment. She also stated that the CNAs should not stop using equipment on their own. On 2/9/11 at 1:30pm, the Registered Nurse (RN) Manager was interviewed and stated that the resident has always had a low bed and bed alarm to her knowledge. She further stated that she does check to see that alarms are checked on the sheets, but she did not remember any issue with resident not being on the list or not having an alarm. She also stated that she does rounds herself to check that alarms are in place. On 2/10/11 at 3:30pm, the Director of Nursing was interviewed and stated that she realizes that the CNAs should be in-serviced. She further stated that she was preparing an in-service with the Rehab Director on positioning because she was aware that it was a problem, but it has not been completed yet. 2) During the annual environmental tour conducted on 02/04/11 to 02/09/11 between 9:00am and 3:30pm, the following was observed: 1) Protruding metal screws in sections of handrails provided in resident unit corridors. For example on the 6th floor, it was observed in the corridor by the linen chute, at the corner of the elevator lobby, by room 605, by the 6th floor nurse ' s station and at the corner of the elevator lobby opposite the day room. Examples not all inclusive. 2) Radiators lacked proper covers there by exposing some sharp edges of the radiator. Radiators with exposed sharp edges were observed in rooms 626, 722, 716 (examples not all inclusive). In an interview with the Assistant Administrator on 02/08/11 at approximately 11:50am, he stated that these issues noted would be addressed. 415.12(h)(1) 415.12(h)(2) Based on interviews and record review during an abbreviated survey, the facility did not ensure that residents were provided with adequate supervision to prevent elopement. This was evidenced by 2 of 6 sampled residents (Resident # 1 and #2). Resident #1 and #2, identified as at risk for elopement and on 30 minute visual monitoring, eloped from the facility unnoticed for approximately 2 hours. The residents eloped during two separate incidents. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint ID#s NY 137 and NY 246 The findings are: Resident #1 is a [AGE] year old admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set Assessment 3.0 ((MDS) dated [DATE] documented that the resident has severely impaired cognition. The resident is independent in ambulation and bed mobility and requires supervision with all other Activities of Daily Living (ADLs). The Elopement Assessment Guide documented that the resident was evaluated on 8/10/10 and 10/25/10 as at risk for elopement with a score of 5. The evaluation on 8/10/10 included that the resident refused wander guard placement. A Comprehensive Care Plan (CCP) implemented on 7/15/10 documented that the resident is at risk for elopement related to confusion and independent ambulation. Interventions included monitoring behaviors, redirecting away from exit doors, 30 minute visual checks and a wander guard to the left wrist. An update to the CCP dated 8/10/10 and 8/31/10 documented that the resident removed the wander guard and refused to have it placed. The resident is on 30 min visual checks and "monitored closely for safety." An update on 11/25/10 documented that security reported that the resident was observed pacing around the main lobby door. He was redirected back to the unit and refused attempts to place a wander guard. Visual checks every 30 minutes were continued. Visual Observation Monitoring Sheet dated 12/13/10 documented that the Certified Nursing Assistants (CNA) signed the 30 monitoring sheet indicating that the resident was in his room at 6:00 PM, 6:30 PM and 7:00 PM. A Nurse's Notes dated 12/14/10 as late entry for 12/13/10 documented that at 3:40 PM the resident was in his room. At approximately 4:15 PM the resident was given his medication and then took a shower. He was served his dinner in his room and then returned the tray to the cart. At approximately 8:10 PM - 8:20 PM the resident did not respond when the nurse called out his name to give his medication. The nursed continued with the medication pass intending to come back to the resident later. At 8:40 PM the CNA informed the nurse that the resident was missing. Security and the Nursing Supervisor were notified and Code Butterfly was activated immediately. 911 was called and the family was notified. At 11:30 PM the resident was still missing. A Nurse's Notes dated 12/14/10 at 8:00 PM documented that the resident returned at 5:45 PM with his family. When the resident was interviewed he was able to state that he left the facility by climbing the fence. He then walked to the hospital, where he went inside for warmth and shelter. The Police took him to his mother's house. The resident returned in stable condition. With the family's encouragement a wander guard was applied to his right ankle and he was as placed on one to one observation. The Facility Investigation dated 12/21/10, completed by the Director of Nursing (DON), documented that the resident has a history of removing his wander guard and refused have it reapplied. His refusal was respected and he was maintained on 30 minute visual checks. On 11/25/10 the resident started walking out the front door. He never left the lobby but security felt that he was ready to exit. He was redirected to the unit where the nurse attempted to place a wander guard on him. He refused and again remained on 30 minute visual checks. On 12/13/10 the resident eloped from the facility by climbing over a six foot fence. According to the 30 minute visual check sheet the resident was last seen at 7:00 PM. However, after reviewing the video surveillance, it was learned that the resident left the facility at 6:15 PM. It was determined that the CNAs initialed the 30 minute visual check sheet without actually seeing the resident at 6:30 and 7:00 PM. The CNAs responsible were terminated and staff were educated on the importance of 30 minute visual checks. CNA # 5 was interviewed on 12/15/10 11:00 AM via telephone. She stated she worked the 3:30-11PM shift on Monday 12/13/10. She stated that the resident walks around independently and is supposed to wear a wander guard but he refuses. The resident is on 30 minute visual checks and is always in his room. CNA #5 stated that CNAs take turns doing the 30 minute checks. She was on break from 6:30-7:30PM and the resident was on the floor when she left. When she returned she took care of other residents. She then knocked on his door but he wasn't there. She did not inform anyone that she did not observe the resident at the 8:00 PM visual check. She handed over the 30 minute check sheets at 8:30PM to another CNA and also informed her that she did not see the resident at 8:00 PM. The Director of Building Operations was interviewed on 12/15/10 at 11:30AM. He stated that the resident was found at his mother's house and was then returned to the facility. The Director of Building Services that the resident stated that he "jumped the fence like Superman." The Director of Social Work (DSS) was interviewed at 12:10PM on 12/15/10. The DSS stated that the resident told her he left because "he was bored." He mixed people meeting on the first floor in the Adult Day Care area, went out to the patio and jumped the fence. The 3-11:00 PM Licensed Practical Charge Nurse was interviewed on 12/15/10 at 2:50 PM. The LPN stated that she saw the resident at 6:30PM when he put his dinner tray on the cart. She was never informed that the resident was not observed at 7:30 or 8:00 PM. She was informed that he was not seen at the 8:30PM check and was missing. The DON was interviewed on 1/3/11 at 3:15PM via telephone. She stated that CNAs involved did not see the resident at the times they signed for on the 30 minute visual check sheet. They were terminated by the facility. Resident #2 is an [AGE] year old admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Minimum Data Set Assessment (MDS) 3.0 dated 12/05/2010 documented that the resident has moderately impairment cognition and uses a walker for mobility. The Elopement Assessment documented that the resident was evaluated on 09/01/2010, 10/02/2010, and 12/10/2010, as at risk for elopement with a score of 10. The evaluation on 10/02/2010 included that the resident removed the wander guard and refused to have a new one applied. The resident remained on 30 minute checks. The evaluation on 12/10/2010 included that the resident is risk for elopement and is monitored closely every 30 minutes. A Comprehensive Care Plan (CCP) implemented on 09/03/2010 documented that the resident is at risk for elopement. The interventions included providing a calm structured environment, encourage participation in recreation therapy programs, monitor behavior, provide 30 minute checks, and redirect from exit doors as needed. Certified Nursing Assistant (CNA) Resident Care Plan Directives for January 2011 documented that at high risk for elopement and is on every 30 minute visual checks. Elopement List dated 01/08/2011 documented that the resident was included on the list, has wander guard in place and is monitored on 30 minute visual checks. Visual Observation Monitoring Sheet dated 01/08/2011 documented that the CNAs signed the 30 monitoring sheet indicating that the resident was in her room at 1:30 PM, 2:00 PM, 2:30 PM, and 3:00 PM. A Nurse's Note dated 01/08/2011 11:45 PM documented that 30 minute monitoring was done by CNA and resident was not on the unit. The charge nurse was notified. A search for the resident was immediately started on the unit and other floors through out the building. Security and the Nursing supervisor were notified. Code butterfly was initiated. An officer from the Police Department called at 6:58 PM stating that the resident will be transferred to the hospital for evaluation for change in mental status. The family member was notified of the situation and the resident's hospitalization . The Facility's Investigation and Occurrence Report dated 01/08/2011 documented that the resident was missing from the unit. Code butterfly was initiated and thorough search of the building and external grounds were done, but the resident was not located. A call was received from the police department stating that the resident was found and was being transferred to the hospital for evaluation. As per staff interviews conducted by the Assistant Director of Nursing (ADON) the resident was last seen by CNA #1 at 1:30 PM when she delivered the resident's lunch tray. CNA #1 stated that the resident was sleeping at that time and she woke her up to eat lunch. CNA #2, the assigned CNA, went to the resident's room at 2:00 PM and heard "laughing and man's voice." CNA #2 stated that she did not actually see the resident. CNA #2 stated that she signed the 30 minute observation sheet for 2:30 PM and 3:00 PM but she did not physically see the resident. Security Officer #1 was on duty during the day shift on 01/08/2011. He stated that once the code butterfly was initiated, he looked at the resident's picture and realized that he may have mistaken her for a visitor as she exited the building around 2:00 PM. Video surveillance was reviewed and the resident was seen exiting thru the front door at 2:16 PM. The facility concluded that CNA #2 failed to follow facility policy on performing and documenting 30 minute observation resulting in the resident eloping from the facility unnoticed. On 01/25/2011 at 2:30 PM, review of the video surveillance was done. It showed that the resident was able to get out of the building thru the front door by walking past the Security Officer. An interview with the Director of Nursing (DON) was conducted on 01/25/2011 at 10:00 AM. She stated that on 1/8/2011, CNA # 2 did not physically see the resident between 2:00 PM and 3:00 PM. At 3:40 PM CNA #3 checked for the resident in her room PM but she was not there and reported to the nurse. The DON stated that the resident was able to get out of the building by exiting thru the front door. She stated that if residents refuse to wear wander guard then the security officer cannot identify if the resident is an elopement risk. After the incident the policy was reviewed and found to be sufficient. The cause of this incident was "human error." An interview was conducted with Security Officer #1 (SO #1) on 01/25/2011 at 11:30 AM. He stated that that on 1/8/2011, he received a phone call from the resident's floor between 5:00 PM to 5:30 PM. The staff asked him if he saw the resident downstairs and he stated "No." Code butterfly was announced and search of the entire building was conducted. SO #1 stated that at about 6:05 PM, he received a phone call from the Police Department stating that they found the resident. SO # 1 stated that the video surveillance revealed that the resident walked past him. He stated that the resident looked like a visitor that he was familiar with and she was surrounded by other visitors. The resident ' s arm band was not visible and the resident was dressed up for winter. An interview was conducted with the Administrator on 01/25/2011 at 1:50 PM. The Administrator stated that he "looked at the whole picture" and felt that SO #1 was not neglectful in his job duties. He was standing at his post as required. 415.12(h)(2)

Based on observation, record review and staff interviews, the facility did not ensure that acceptable parameters of nutritional status were maintained. Specifically, the facility did not administer supplements as planned for residents with nutritional deficits, significant weight loss and a decrease in their [MEDICATION NAME] levels (Residents #4, and #6). Additional Resident #6 was identified as being a high risk for pressure ulcers and developed 4 new pressure ulcers. This was evident for 2 of 30 sampled residents. (Resident #4 and #6) This resulted in actual harm that is not immediate jeopardy. This is a repeat deficiency. The finding is: 1) Resident #6 is an [AGE] year-old readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident has severe cognitive impairment, and is totally dependent on staff for eating, dressing, transfers, personal hygiene, and bathing. On 2/7/11 at 12:11 pm the resident was observed in the day room during lunch. The resident consumed all of his food. He was fed by a Licensed Practical Nurse (LPN). The food was blenderized. There was no supplement on the tray. On 2/7/11 at 2:40 pm the resident was observed receiving an 8oz. (ounce) can of Two Cal HN supplement. The resident consumed the entire supplement. The Monthly/Weekly Weight Record for 2010 documented a weight of 139.12 lbs (pounds) on 12/28/10. An Interim physician's orders [REDACTED]. A Dietary Order Form dated 12/29/10 documented "Start Diet: NAS (No Added Salt) Blenderized; Start Supplement: Health Shake 6oz. TID (3 times per day) and LPS 15/30 30cc TID". LPS 15/30 is a protein supplement. A Nutrition Assessment (for Readmission) dated 12/29/10 documented the following: "DBW (Desired Body Weight) 142 +/- 10%...Health Shake ...for weight maintenance. (No) s/s (sign and symptoms) p/u's (pressure ulcers) at this time ...7# (pounds) (4.7%) (lost) during hosp (hospital) stay. Will continue weekly weights". The desired body weight range is 156.2 - 127.8 lbs. A laboratory report dated 1/4/11, for a specimen collected 12/30/10, documented an [MEDICATION NAME] level of 2.9 g/dL (grams per deciliter) - a low level (reference range 3.2 - 4.7). A review of the Medication Administration Record dated 12/30/10 documented no administration of LPS 15/30 and Health Shake from 12/31/10 to 1/15/11. A Nurse Practitioner (NP) Progress Note dated 1/10/11 documented: "Noted around 1x1 cm (centimeter) redness on L (left) lateral foot near the small toe. Site clean. No s/s of infection ...Continue to monitor". A Dietary Progress Note dated 1/11/11 documented: "As of 1/11/11 new p/u on (L) lat (lateral) foot stage II 1x1 cm. Currently on LPS and Health Shake Suppl. (supplement) for nutritional support". The Physician's Monthly Order dated 1/13/11 did not contain orders for supplements. A review of the MAR dated 1/14/11 revealed that no LPS 15/30 or Health Shake was administered from 1/15/11 to 2/6/11. The Daily Accountability of Assignment records for December 2010, January 2011, and February 2011 were reviewed. There was no documented evidence that any nourishments were given to the resident. A Dietary Progress Note dated 1/26/11 documented: "Wt 137# as of 1/23/11. 1# (loss) x 1wk. Will provide 2x Super Cereal @ (at) B (breakfast) meal for (increased) calories to deter wt loss. Shake provided 3x day along (with) LPS Suppl. for nutritional support. As of 1/21/11 (L) lateral foot remains Stg II 1x1 cm." The Weight Sheet for 2011 documented the following weights: ? 1/3/11 - 138 lbs ? 1/20/11 - 137.5 lbs ? 1/23/11 - 137 lbs ? 1/28/11 - 137 lbs ? 2/3/11 - 134.8 lbs ? 2/8/11 - 130.12 lbs (The resident experienced a significant weight loss of 5.7% from 1/3/11 to 2/7/11.) A Nurse Practitioner Progress Note dated 2/3/11 documented: "L (left)buttock skin opening-noted with slough in the middle of the wound (with) pinkish red skin at the edges. No drainage ...Cleanse (with) NS (normal saline) & (and) apply Collagenese daily. Monitor." The Weekly Pressure Ulcer Progress Assessment Update, initiated 2/4/11, documented a stage 2 left buttock ulcer measuring 2x4 cm. A Nurse Practitioner Progress Note dated 2/7/11 at 10:15 am documented: "Resident noted to have pressure ulcers on L hip & R (right) buttock. Resident evaluated (with) wound nurse ...R buttock - stage II pressure ulcer has pink skin 2x1cm. No drainage, no foul odor. L hip - stage II pressure ulcer. Has pink skin 5x1 cm - (no) drainage, (no) foul odor. L buttock - unstageable - Has slough in wound bed. L lateral foot drying blister - stage II ...Supplements Vit (vitamin) C & Zinc ordered". An addendum to the NP Progress note dated 2/7/11 at 10:25am documented: "D/C (Discontinue) Vit C & Zinc. Resident is on LPS as per dietician". A Dietary Progress Note dated 2/7/11 documented: "New p/u on (L) Buttock Stg II 2x4 cm as of 2/4/11. (L) Lat foot stg II 0.5x0.5 as of 2/4/11. New (L) Hip Stg II 5x1cm and (R) Buttock II 2x1 cm as of today. Presently on LPS 15/30 ...(changed) to LPS Critical Care TID ...Health Shake D/c'd (discontinued) (changed) to 2 Cal HN 8 oz TID ...for (increased) cal (calories) / Pro (protein) to assist (with) wound healing and deter weight loss. Wt as of 2/3/11 135#...Reweigh pending. Calorie Count pending". An Interim physician's orders [REDACTED]. A Dietary Order Form dated 2/7/11 documented: "Discontinue: LPS 15/30 and Health Shake ...Start Supplement: LPS Critical Care 30cc TID and 2 Cal HN 8oz TID". A Laboratory Report dated 2/9/11 documented an [MEDICATION NAME] level of 2.7 g/dL (reference range 3.2 - 4.7) and a [MEDICATION NAME] level of 16.30 mg/dl (milligrams per deciliter) (reference range 20.00 - 40.00 mg/dl). (The [MEDICATION NAME] level decreased by 0.2 g/dL from 12/30/10 to 2/8/11.) On 2/8/11 at 2:45pm the Registered Dietician (RD) was interviewed and stated that the resident was supposed to be on LPS 15/30 and Health Shake prior to her supplement changes on 2/7/11. She further stated that she reviews the physician's orders [REDACTED]. She also stated that the LPS is supposed to help with wound healing. On 2/8/11 at 3:07pm the Physician was interviewed and stated that if there was no order to discontinue the supplements then they should have been carried over on the monthly orders. He further stated that he must have missed it when reviewing the monthly orders. On 2/10/11 at 10:55am the Licensed Practical Nurse (LPN) who was the second nurse to review the 1/13/11 monthly orders, was interviewed and stated that the monthly orders are checked against the interim orders and MAR to see if anything was missed. She further stated that the supplements should have been added to the orders or the nurse should have called the Physician to order them. She also stated that the LPS and Health Shake are documented on the MAR when given. On 2/10/11 at 11:05pm the NP was interviewed and stated that she did assess the resident on 2/7/11. She was not aware that the resident was not receiving the supplements ordered. The lack of supplements could possibly contribute to the skin breakdown, but the resident has been declining. 2) Resident #4 is a [AGE] year old female with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) 3.0 dated 12/27/10 documents that the resident's cognition is moderately impaired with long term memory problems. This MDS documented the resident's weight as 101# (pounds). The weight sheet documented the following monthly weights for 2010: August - 105#; September - 102.8#; October - 102.8#; November - 102#; and December - 101#. The weight sheet documented the following for 2011: January 4 - 100.04#; January 12 - 98#; January 17 - 91#; January 21 - 91.9#; February 1 - 97#; and February 7 - 96.04# The "Nutritional Assessment" dated 1/5/11 documented that the resident is 56 inches (4 feet 7 inches), Weight 100.04#, DBW (desirable body weight) 95-114 # BMI (Body Mass Index) 22.5 (Normal Weight). " Greater than or equal to 7.5 %change in 3 months: No...Greater than or equal to 10% Change in 6 months: No....Assessment: Po intake (By mouth) is 25 -50 % breakfast/lunch and 50 - 75% dinner. Resident just started on LPS 15/30 30 ml (milliters) BID ( twice a day) to address low [MEDICATION NAME] 2.5 and low total protein 5.9. Weight is 100.04 lbs. (pounds). No significant change in weight over the past six months. Resident started on weekly weights times 4 weeks. Ensure plus provided once daily. Continue to monitor." The "Dietary Interim Notes" dated 1/21/11 documented that the resident loss 9.1 lbs. from December 2010 to January 2011. Weight loss is significant at 9%. Dietitian will start resident on Booster diet and start three day calorie count on Monday 1/24/11. Resident will continue with weekly weights and be started on Weight Loss Monitoring Report. The "Dietary Interim Notes" dated 1/31/11 documented calorie count as follows: Day 1: 624 calories and 24 grams of protein consumed. Day 2: 1722 calories and 47 grams of protein. Day 3: 978 calories and 29 grams of protein. Dietitian will increase supplement to TID (three times a day). Continue to monitor. The "Dietary Interim Notes" dated 2/4/11 Diet upgraded to mechanical soft. New Diet reads: Mechanical Soft, NAS (No Added Salt), booster diet. Resident was not eating the puree food except for the mashed potatoes. Appetite expected to increase with new diet. Continue to Monitor. Resident has right lower extremity (LE) swelling, which may cause fluctuations in weight. Right LE [MEDICAL CONDITIONS] as well. Continue to monitor. There was no documented evidence that the Ensure Plus 8 oz (ounces) TID was ordered. There was no documented evidence in the Nursing notes from August 2010 to February 2011 regarding the resident's weight loss. There was no documented evidence in the Physician notes that the physician addressed or was aware of the weight loss from August 2010 to February 2011. On 2/7/11 at 4 PM the resident was interviewed with the RN manager present. The surveyor asked the resident how she likes her supplement. The resident responded by saying that she likes the supplement and today is the first day she received it twice. On 2/8/11 at 4:10 PM the Certified Nursing Assistant (CNA) was interviewed. The CNA stated that this resident eats okay and when you see her not eating the CNA's give her encouragement to eat her meal. The resident will tell the CNA's based on her mood if she will eat. The CNA's offer the resident an alternative, like Peanut Butter and Jelly sandwich which the resident may take. An interview was conducted with the dietitian on 2/7/11 at 12:15 PM. The dietitian stated that she put in the order for Ensure 1 can po TID on 1/31/11 and assumed the resident was getting it three times a day, she was not aware that the resident was only receiving the Ensure once a day. The dietitian stated that she usually reviews the physician's orders [REDACTED]. Another interview was conducted with the dietitian on 2/7/11 at 3pm. The dietitian stated that in the end of August the resident was in her desirable body weight which is her Ideal Body weight range. Since the resident was in her Ideal Body Weight range and she did not have a significant weight loss, she did not put the resident on WLMR (Weight Loss Monitoring Report). The dietitian continued by saying the resident was meeting her estimated needs with her diet and supplement. The dietitian stated that she did not follow up on the [MEDICATION NAME] level of 2.5. The Dietitian stated that when resident was 91 pounds she started the resident on Ensure Plus 8 ounces TID, Booster Diet, and LPS 15/30 30 ml BID. There is no documented evidence that resident received Ensure Plus three times a day or the LPS 15/30 (protein Supplement). An interview with the physician was conducted on 2/8/10 at 4:05 PM, and stated that he wrote the order for Ensure once a day based on the recommendation of the transfer papers from the hospital on [DATE]. 415.12(i)(1)