Every finding on record at Queens Nassau Rehabilitation And Nursing Center

Based on record review and interviews conducted during the Recertification and Complaint- survey, the facility did not ensure that residents are informed and provided information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This was evident for 1 (Resident # 84) of 3 residents reviewed for Advance Directives out of a total sample of 38 residents. Specifically, the facility failed to discuss the resident's right and option to formulate an advance directive for Resident # 84. The findings are: The facility policy titled Advance Directives with effective date 01/17/2020 and last updated 06/04/2025 documented the interdisciplinary team will review annually with the residents for their advance directives to ensure that such directives are still the wishes of the residents. The policy also documented such reviews will be recorded on the medical record. Resident #84 was admitted to the facility with diagnoses that included Cerebral infarction, Hemiplegia and Hemiparesis. The Quarterly Minimum Data Set 3.0 dated 05/19/2025 documented Resident #84 had moderate cognitive impairment and had no rejection of care. The Minimum Data Set also documented only Resident #84 participated in the assessment.On 07/01/2025 at 11:02 AM, Resident #84 was interviewed and stated they did not recall having discussion of advance directives with the facility staff.The Medical Order documented Full Code since 01/27/2022 and was last renewed on 05/14/2025.The Comprehensive Care Plan related to Advance Directives initiated 01/25/2022 and last updated 05/31/2025 documented the interventions included to review with resident and their designated representative for advance directives annually. The Social Services notes dated 01/12/2024 to 07/01/2025 contained no documented evidence that advance directives were discussed with Resident #84 and/or their designated representative. On 07/07/2025 at 10:55 AM, Certified Nursing Assistant #4 was interviewed and stated Resident #84 was alert and oriented x3 and able to make decision themselves. On 07/07/2025 at 11:57 AM, Social Worker #1 was interviewed and stated they discussed advance directives with residents and/or their designated representative at least every 3 months during care plan meetings. Social Worker #1 also stated they documented the advance directives discussion in the Social Services progress note. Social Worker #1 further stated they entered the order of advance directives for the Attending Physician to sign when there was any change to the advance directives. Social Worker #1 reviewed the Social Service notes from 01/01/2024 to 07/07/2025 and Resident # 84's medical record, and stated they were not able to locate documented evidence that they discussed the advance directives with Resident # 84. Social Worker #1 also stated they discussed the advance directives with Resident # 84 and might have forgotten to document the discussion in the medical record. On 07/07/2025 at 12:11 PM, the Director of Social Service was interviewed and stated the Social Worker should review the advance directives at least annually with residents and/or their designated representative to check if there was any change to advance directives. The Director of Social Service also stated the Social Worker should document the advance directives discussion in Social Services progress note as evidence that the advance directives were discussed with residents and/or their designated representatives.On 07/07/2025 at 02:27 PM, the Administrator was interviewed and stated advance directives should be discussed every quarter during the care plan meeting. The Administrator also stated the Social Worker should document the advance directives discussion in the Social Services note even though a resident and/or their representative refused to discuss the advance directives. 10 NYCRR 415.3(e)(1)(ii)

Based on interviews and record review conducted during the Recertification and survey, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 1 (Resident #159) out of 2 residents reviewed for Accident. Specifically, the facility did not report Resident #159 was found with injuries of an unknown source to the New York State Department of Health (NYSDOH) within 2 hours. The findings are:The facility policy titled Abuse Prevention with no effective date and last review date 2/2025 was reviewed. The policy did not document allegation of injuries of unknown and what to do for injuries of unknown. Resident #159 was admitted to the facility with diagnoses which included Hemiplegia, Cerebral infarction, and Seizures.The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #159 was severely impaired in cognition. On 07/01/2025 at 11:37 AM, review of the Matrix for Providers revealed Resident #159 had a fall with injury. The Nursing progress note dated 04/08/2025 documented the nurse heard a bang sound and went to check what happened. The Nursing progress note also documented Resident #159 was observed sitting on the floor at the entrance of their room. The Nursing progress note further documented Resident #159 had a superficial cut with bleeding over the left eyebrow.The Medical note dated 04/08/2025 documented Resident #159 was noted to have abrasion to the left eye and slight swelling in the orbital region. The Medical note also documented computed tomography scan of head done at the emergency room for Resident #159 was negative for any injury. The Nurse Supervisor Communication Book documented Resident #159 had a fall incident with left eyebrow injury and was transferred to emergency room for computed tomography scan.The Facility Occurrence Report dated 4/9/2025 documented Resident #159 was observed on the floor of their room entrance. The Occurrence Report also documented Resident #159 was confused and unable to say what happened. The Occurrence Report did not document any witnesses to the incident. The Occurrence Report documented Resident #159 had a one-centimeter-long skin cut to left eyebrow with bleeding. The Occurrence Report also documented Resident #159 was transferred to hospital emergency room for computed tomography scan of head to rule out head injury. The Facility Summary of Investigation documented Resident #159 was found sitting on the floor and assessed having about 1 cm (centimeter) skin cut to left eyebrow with bleeding. It also documented Resident #159 was unable to give account of the occurrence due to impaired cognition.On 07/07/2025 at 05:27 PM, Registered Nurse # 2 was interviewed and stated they were the night shift nurse supervisor when the incident happened on 04/07/2025. Registered Nurse #2 also stated they heard a bang sound and found Resident #159 sitting on the floor at the entrance to their room. Registered Nurse #2 further stated no one witnessed the incident and Resident #159 was unable to tell what happened due to severe cognitive impairment. Registered Nurse #2 stated they assumed Resident #159 had a fall incident, and the assessment revealed Resident # 159 had about 1 cm (centimeter) skin break at left eyebrow with bleeding. Registered Nurse #2 also stated they notified the Associate Director of Nursing Services, Director of Nursing Services, Administrator, other nurse supervisors, attending doctors, and Medical Director of the incident through the clinical chat group. Registered Nurse #2 further stated they did not recall if they called and reported the incident to the Associate Director of Nursing Services or Director of Nursing Services. Registered Nurse #2 stated they documented the incident in the communication book for nurse supervisors. Registered Nurse #2 also stated all the nurse supervisors, Associate Director of Nursing Services, and Director of Nursing Services had access to the book. On 07/08/2025 at 10:45 AM, the Associate Director of Nursing Services was interviewed and stated they have a clinical chat group to communicate among the clinical staff and Administrator. The Associate Director of Nursing Services also stated they read the text messages the next morning if they fall asleep as the text message was sent out late. The Associate Director of Nursing Services further stated they did not recall if the nurse supervisor called them or not immediately after the incident. The Associate Director of Nursing Services stated the Director of Nursing Services was responsible to report allegation to Department of Health. On 07/08/2025 at 11:02 AM, the Director of Nursing Services was interviewed and stated the Associate Director of Nursing Services, Administrator, and themselves had access to Health Commerce System to report incidents to the Department of Health. The Director of Nursing Services also stated they were the primary person to report incidents to the Department of Health. The Director of Nursing Services also stated they were able to check the text messages immediately. The Director of Nursing Services stated they discussed the incident during morning meeting to decide if the incident was reportable or not. The Director of Nursing Services also stated Resident #159 had no major injury and they thought the incident was not reportable to the Department of Health. On 07/08/2025 at 11:35 AM, the Administrator was interviewed and stated they remembered receiving a call to discuss the incident about Resident #159 on the night the incident happened. The Administrator also stated they did not recall the details of the incident. The Administrator stated the incident for Resident # 159 was considered as an unwitnessed injury for a cognitively impaired resident. The Administrator also stated the facility had to report the incident of injuries of an unknown source to Department of Health within 2 hours of awareness of the allegation. The Administrator had no explanation why the incident was not reported to Department of Health. 10 NYCRR 415.4(b)(2)

Based on record review and interview during the Recertification survey, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for 1 (Residents #96) of 8 residents investigated for Pressure Ulcer/Injury out of 38 total sampled residents. Specifically, there was no comprehensive care plan developed to address at risk for skin breakdown and potential to develop pressure ulcers for Resident #96. The findings are:The facility policy and procedure titled Comprehensive Care Plan dated 02/2025 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs are developed for each resident. The policy also stated that the Care Planning Interdisciplinary team is responsible for reviewing and updating the care plan during admission, every quarterly, annual or readmission.Resident #96 had diagnoses that included Seizure Disorder or Epilepsy, Traumatic Brain Injury, and Malnutrition.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #96 had severely impaired cognition. The Minimum Data Set assessment also documented Resident #96 was dependent on two people to complete Activities of Daily Living. The Quarterly Minimum Data Set further documented Resident #96 was at risk of pressure ulcers/injuries. The Braden Scale assessment dated [DATE] documented Resident #96 was cognitively impaired, chairfast, had limited mobility, and had a potential for friction problem. The Braden Scale assessment also documented Resident #96 was high risk for skin breakdown. On 07/02/2025 at 11:36 AM, Resident #96 was observed in the Geri chair, alert and awake. Resident #96 was confused, and unable to answer questions.On 07/03/2025 at 03:00 PM, Resident #96 was observed in bed, alert and awake, and was unable to follow commands. There was no documented evidence that a comprehensive care plan to address the risk for skin breakdown and the potential to develop pressure ulcers had been developed for Resident #96. On 07/07/2025 at 12:55 PM, an interview was conducted with Certified Nurse Assistant #3 who stated that they have provided care to Resident #96 for about a year. Certified Nurse Assistant #3 also stated Resident #96 used to have a wound at the buttock in the past, but their skin is intact right now. On 07/07/2025 at 01:12 PM, an interview was conducted with Licensed Practical Nurse #1 who stated that they do assist in development and updating care plan at times and the Registered Nurse would then review them and sign off on them. Licensed Practical Nurse #1 also stated Resident #96 is at risk for skin breakdown and the Registered Nurse supervisor will be able answer those questions further. On 07/07/2025 at 01:11 PM, an interview was conducted with Registered Nurse #1, a supervisor, who stated the registered nurse on the unit is responsible to develop admission, readmission, quarterly and episodic care plans. Registered Nurse #1 also stated that the Minimum Data Set Assessors also help the in the development of initial and quarterly care plans. Registered Nurse #1 concluded that the facility had not had any concerns with timely completion or revision of care planning, and this was an omission on their part. On 07/09/2025 at 11:49 AM, an interview was conducted with the Director of Nursing who stated the Unit Nurse managers are responsible to ensure care plans are updated accordingly. The Director of Nursing also stated the Licensed Practical Nurses are also responsible for completion of care plans however, the Registered Nurse will ensure the accuracy of it. The Director of Nursing further stated the Minimum Data Set staff are responsible for admission and readmission care plans and concluded that the missing care plan for Resident #96 was an oversight. 10 NYCRR 415.11(c)1

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that resident's Comprehensive Care Plans were reviewed and revised. This was evident for 1 (Resident #63) of 8 residents reviewed for Pressure Ulcer out of 38 sampled residents. Specifically, there was no documented evidence that the Comprehensive Care Plans for Skin Integrity and Pressure Ulcer were reviewed and revised after the last quarterly Minimum Data Set assessment was completed, or after Resident #63's Stage 3 pressure ulcer re-opened. The finding is: The facility policy and procedure titled Comprehensive Care Plan dated 2/2025 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs are developed for each resident. The policy also stated that the Care Planning Interdisciplinary team is responsible for reviewing and updating the care plan during admission, every quarterly, annual or readmission. Resident #63 had diagnoses which included Seizure Disorder, Traumatic Brain Injury, and Anxiety Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #63 had severely impaired cognition and was dependent on two staff to complete Activities of Daily Living. On 07/02/2025 at 10:03 AM, Resident #63 was observed in the hallway, lying on the Geri-Chair. Resident #63 appeared confused and could not talk or make facial gestures. The Nursing Progress note dated 06/22/2025, documented a new open wound was noted to the left inner buttock, physician was notified, orders carried out to cleanse wound with normal saline, pat dry apply Bacitracin cover with dry dressing daily and as needed. The Physician wound note dated 06/26/2025 documented the following: Wound #2 Left Buttock is a Stage 3 Pressure Injury Pressure Ulcer. The Physician order dated 06/27/2025 documented Medi Honey 100 % topical paste once daily and as needed cleanse left inner buttock with normal saline, pat dry, apply Medi honey, cover with dry dressing daily and as needed. There was no documented evidence that the Comprehensive Care Plans for Skin Integrity and Pressure Ulcer were reviewed and revised after the last quarterly Minimum Data Set assessment on 06/09/2025, or after Resident #63's Stage 3 pressure ulcer re-opened. On 07/03/2025 at 12:23 PM, an interview was conducted with Certified Nursing Assistant #1 who stated Resident #63 is confused, and nonverbal. Certified Nursing Assistant #1 also stated that Resident #63 had a wound at the buttock about two to three weeks ago and the wound appeared to be a reopened wound. On 07/03/2025 at 12:44 PM, an interview was conducted with Licensed Practical Nurse #1 who stated Resident #63 used to have some wounds that were resolved and later had a wound that reopened recently. Licensed Practical Nurse #1 also stated that they performed the wound care today, and the wound is still open and receives daily treatment. On 07/07/2025 at 01:11 PM, an interview was conducted with Registered Nurse #1, a supervisor, who stated the registered nurse on the unit is responsible to develop admission, readmission, quarterly and episodic care plans. Registered Nurse #1 also stated the Minimum Data Set Assessors also help in the development of initial and quarterly care plans. Registered Nurse #1 concluded that the facility had not had any concerns with timely completion or revision of care planning, and this was an omission on their part.On 07/09/2025 at 11:49 AM, an interview was conducted with the Director of Nursing who stated that the Unit Nurse managers are responsible to ensure care plans are updated accordingly. The Director of Nursing also stated that the Licensed Practical Nurses are also responsible for completion of care planning however, the Registered Nurse will ensure the accuracy of it. The Director of Nursing further stated the Minimum Data Set staff are responsible for admission and readmission care plans and concluded that the missing care plan for Resident #63 was an oversight. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that drugs and biologicals were stored in accordance with professional standards. This was evident in 1 Unit (2 South Unit) of 3 units observed for Medication Storage. Specifically, the 2 South Unit medication refrigerator was observed to contain one opened multi-dose insulin vial that was undated and three opened, dated multi-dose insulin vials that had not been discarded within 30 days. The findings are:The facility policy titled Medication- Label/Store Drugs & Biologicals, with a revision date of 02/2025, documented drugs and biologicals used in the facility must be stored and labeled in accordance with currently accepted professional standards, and include cautionary instructions, special storage instructions, and the expiration date when applicable. Medications are to be stored per pharmacy/manufacturer instructions. Multi-use insulin vials will be dated and discarded 30 days later. Nursing staff are responsible to ensure the proper storage and handling of medications. It is the responsibility of the Medication/Charge Nurse to check medication rooms and medication carts for expired medications. The Nurse Supervisor/Designee will audit the medication rooms and medication carts for the presence of expired medications. The facility policy titled Medication Storage, with a review date of January 2025, 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.On 07/01/2025 at 11:36 AM, an observation of the 2 South Unit Medication Storage Room was performed with Registered Nurse #3. The medication refrigerator was observed to contain one opened, undated 10 milliliter vial of Lispro Insulin (U100) 100 Unit/milliliter prescribed for Resident #133, one 10 milliliter vial of Lispro Insulin (U100) 100 Unit/milliliter prescribed for Resident #25 with an open date of 05/22/2025, one 10 milliliter vial of Lantus Insulin 100 unit/milliliter prescribed for Resident #154 with an open date of 05/23/2025, and one 10 milliliter vial of Lispro Insulin (U100) 100 Unit/milliliter prescribed for Resident #70 with an open date of 05/29/2025.The facility did not ensure that multidose vials were dated upon opening and discarded within 28 days of opening.On 07/01/2025 at 11:55 AM, Registered Nurse #3, was interviewed and stated all medications should be labeled with the opened date by the nurse. Registered Nurse #3 also stated the charge nurse is to check the medication storage areas every morning and discard expired medications and vaccines. Registered Nurse #3 further stated insulin multi-dose vials should be discarded within 30 days after the opened date.On 07/02/25 at 9:10AM, the Associate Director of Nursing was interviewed and stated opened insulin vials are to be discarded within 28-30 days after the opened date. The Associate Director of Nursing further also stated the nurse who administers the insulin is to ensure that medications are discarded within the correct time frames. On 07/02/25 at 10:19 AM, the Director of Nursing was interviewed and stated they were made aware of the insulin vials that were not discarded within 30 days of being opened. The Director of Nursing also stated that insulin multi- dose vials should be dated when opened and discarded within 30 days. The Director of Nursing also stated that the charge nurse should check the medication storage rooms and medication carts daily to ensure medications are dated and not expired. The Director of Nursing further stated that there is no audit tool that the nurses complete that documents the medication storage rounds that are performed. 10 NYCRR 415.18(e) (1-4)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. This was evident for 1 (Resident #22) of 8 residents observed for Pressure Ulcer/Injury out of 38 sampled residents. Specifically, Registered Nurse #5 failed to follow Enhanced Barrier Precautions by not donning a gown while performing a wound care dressing change.The findings are: The facility policy titled Enhanced Barrier Precautions reviewed/revised 03/2025, documented that Enhanced Barrier Precautions, in addition to standard and Contact Precautions will be implemented during high contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism such as residents with wounds, indwelling medical devices or residents with infection or colonization with a multidrug-resistant organism. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted multidrug-resistant organism or any resident with a wound or indwelling medical device, regardless of multidrug-resistant organism infection or colonization. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of multidrug-resistant organisms to employee's hands and clothing during care, beyond situations in which staff anticipate exposure to blood or body fluids. High contact Resident Care Activities include dressing, bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care of any skin opening requiring a dressing. Resident #22 was admitted to the facility with diagnoses that include Cerebral Vascular Accident and Diabetes Mellitus Type 2.The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #22 had severely impaired cognition, required maximum assistance for care and mobility, and required wound care and treatments for 1 unhealed Stage 3 pressure ulcer injury.A Wound Assessment Note and Care plan Activity Report dated 06/13/2025, documented Resident #22 was seen by the wound care team for treatment of a Stage 3 left Lateral Malleolus wound.A Physician Treatment Order dated 6/26/2025, documented the ordered treatment as, apply by topical route once daily and as needed Silvadene 1% topical cream to ankle, cover with a dry protective dressing daily and as needed. A Physician Order dated 6/26/2025, documented Enhanced Barrier Precautions due to the presence of a Stage 3 Left Lateral Malleolus wound.On 07/09/25 at 9:39 AM, during a wound care observation for Resident #22, Registered Nurse #5 was observed performing a wound care treatment to the Stage 3 left lateral malleolus pressure ulcer that included normal saline irrigation, an application of Silvadene 1% topical cream, and application of a dry protective gauze dressing. Registered Nurse #5 did not don a gown when they performed the treatment. Enhanced Barrier Precautions signage was observed posted on Resident 22's room door. On 07/09/25 at 9:49AM, an interview was conducted with Registered Nurse #5 who stated enhanced barrier precautions were put in place and the signage was posted on the door for the resident in the B bed, Resident #22's roommate, who has a gastrostomy tube. Registered Nurse #5 also stated that they did not don a gown to perform Resident #22's wound care treatment because the Stage 3 Left Lateral Malleolus wound has minimal drainage. Registered Nurse #5 further stated that they now realize they should have worn a gown to follow the enhanced barrier precautions guidelines for any resident with an open wound. On 07/09/25 at 09:58AM, an interview was performed with Registered Nurse #1, the Nursing Supervisor who stated, that they perform treatment observations during rounds periodically. Registered Nurse #1 also stated that observation for wound treatment was performed with Registered Nurse #5 previously at hire in March but obviously more in-services and reminders are needed.On 07/09/25 at 10:06 AM, an interview was performed with the Infection Control Preventionist/Inservice Coordinator who stated enhanced barrier precautions were implemented to prevent the transmission of multidrug-resistant organisms and staff has been in serviced to wear personal protective equipment for close contact during personal care, and activities involving care of the residents. The Infection Control Preventionist/Inservice Coordinator also stated that personal protective equipment including gowns must be worn for care of any residents with indwelling tubes, medical devices, and wounds where medications are administered or treatment applied. The Infection Control Preventionist/Inservice Coordinator further stated that there are yearly and constant in-services performed on enhanced barrier precautions during morning rounds for infection control, but they have not performed any wound observations to determine compliance with enhanced barrier precautions. On 07/09/25 at 10:40 AM, an interview was performed with the Director of Nursing who stated enhanced barrier precautions are implemented anytime a resident has a skin opening, a tube or drain, which makes them susceptible to multidrug-resistant organisms, so all staff is to wear personal protective equipment, including gown and gloves, when performing any treatment and/or bedside care. The Director of Nursing also stated that staff is educated, and supervisors are to observe wound treatments when rounding and report any compliance issues that were found. The Director of Nursing further stated that they should have been notified in morning meetings if there were any issues and competencies for nurses and supervisors will be reimplemented. 10 NYCRR 415.19 (a) (1-3)

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure resident's Minimum Data Set assessments accurately reflect the resident's status. This was evident for 1 (Resident #63) of 8 residents investigated for Pressure Sores, 1 (Resident #79) of 5 residents investigated for Mood and Behavioral Symptoms, and 1 (Resident #93) of 2 residents investigated for Activities of Daily Living out of 38 total sampled residents. Specifically, 1. The Minimum Data Set assessment did not document Resident #63's use of hand mittens. 2. There was no documentation of Resident #79 use of Wander Guard Device on the Minimum Data Set assessment. 3.) The Minimum Data Set assessment did not capture that Resident #93 had a Stage 3 pressure ulcer. The findings are: The facility did not provide a policy and procedure related to Minimum Data Set assessment accuracy. 1. Resident #63 had diagnoses, which include Seizure Disorder, Traumatic Brain Injury, and Anxiety Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #63 had severely impaired cognition and was dependent on two staff to complete Activities of Daily Living. The Quarterly Minimum Data Set assessment also documented Resident #63 had a Feeding tube. On 07/07/2025 at 11:00 AM, Resident #63 was observed on the Geri Chair with a mitten in place on the right hand. On 07/09/25 at 11:41 AM, Resident #63 was also observed in the day room, alert and awake with a mitten in place on their right hand. Resident #63 was confused, and unable to follow instructions. The Physician Order dated 04/02/2024, revised on 05/20/2025 documented the following: Right hand mittens to wear at all times to prevent pulling Gastronomy Tube and injury. Release every 2 hours x 15 minutes and as needed for Activities of Daily Living and for skin check. A review of Comprehensive Care plans for Physical Restraints secondary to use of right-hand mitten, dated 10/29/2020, last revised on 03/20/2025 documented Resident #63 had a right-hand mitten to wear at all times to prevent pulling Gastronomy Tube and injury. Release every 2 hours x 15 minutes and as needed for Activities of Daily Living and for skin check. There was no documented evidence that the Minimum Data Set assessment for Resident #63 captured the use of a mitten on their right hand. 2.) Resident #79 had diagnoses which included Schizoaffective disorder, Seizure Disorder or Epilepsy, and Traumatic Brain Injury. The Physician order dated 01/15/2025, last revised 06/01/2025 documented Wander guard Device to apply to left lower leg at all times. Check wander guard for functioning daily by nursing staff on 11 PM-7AM shift. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #79 had severely impaired cognition. The Minimum Data Set assessment did not document Resident #79's use of a Wander Alert Device. On 07/02/2025 at 09:16 AM, Resident #79 was observed in the hallway, walking towards the elevator. Resident #79 had a wander guard device to left ankle. An alarm sounded as Resident #79 approached the elevator. On 07/09/2025 at 11:51 AM, an interview was conducted with the Minimum Data Set Coordinator who stated they were responsible for overseeing the Minimum Data Set Department. The Minimum Data Set Coordinator also stated that each assessor is responsible for the accuracy of their assessment. The Minimum Data Set Coordinator further stated the Minimum Data Set assessor is supposed to physically assess the resident and indicate if the resident uses equipment and document appropriately. The Director of Minimum Data Set stated the hand mitten is a restraint and should be coded on the Minimum Data Set assessment, however the wander guard device was not a restraint and should be coded on the Minimum Data Set assessment as well. The Minimum Data Set Coordinator also stated it was a mistake that this information had not been included on the assessments. 3. Resident #93 was admitted with diagnoses that included Anoxic Brain Damage, Traumatic Brain Injury, and Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #93 had severely impaired cognition and was completely dependent on staff with all Activities of Daily Living including turning and positioning and transfers. The Quarterly Minimum Data Set did not document in Section M Skin and Pressure Ulcers Resident #93 had multiple pressure ulcers. The Physician's order dated 03/24/2025 and last revised on 05/07/2025 documented treatments for the different wounds which included left Hip cleanse with Dakins solution 0.25% daily and cover with moistened 4 x 4 bordered gauze. On 07/08/2025 at 3:00PM, the Minimum Data Set Coordinator was interviewed and stated during the assessment, they go to see and assess the resident, speak with the staff and review the medical record. The Minimum Data Set Coordinator also stated they were not the individual who completed the assessment, and Resident #93 does have multiple pressure ulcers which should have been coded on the assessment. 10 NYCRR 415.11 (b)

Based on observation, interviews and record review conducted during an Abbreviated Survey (NY00323188), the facility failed to protect the resident's right to be free from physical abuse by nursing home staff. This was evident for one out of five residents (Resident #1) sampled for abuse. Specifically, on 09/02/23, Resident #1 was hit on the right side of the forehead during incontinent care, on the 3:00pm to 11:00pm shift, by Certified Nursing Assistant (CNA) #1. The physical abuse was witnessed by CNA #2. Resident #1 was assessed by Registered Nurse Supervisor (RNS) #3 with discoloration and swelling to the right side of the forehead. Resident #1 was transferred to emergency room (ER) for evaluation. Resident #1 returned to the facility on [DATE]. The findings are: The facility Policy and Procedure for Abuse Prevention was updated 11/11/2022. The policy states that all employees will be trained and be knowledgeable about the facility's abuse prevention policies. The policy also states that all staff members responsibility regarding mandatory state and federal reporting requirements. Training will include care of the residents with dementia including appropriate behavioral interventions. The policy includes reporting and the Elder Justice Act (1150B of the Social Security Act). Resident #1 was admitted to the facility with diagnoses that include Unspecified Dementia, mild with agitation. The Minimum Data Set (MDS, a resident assessment tool) with an assessment reference date of 09/02/23 documented that Resident #1 had severely impaired cognition. Resident #1 requires extensive assistance of one person with dressing, personal hygiene, and total assistance of one with toileting use. An Abuse Care Plan for Resident #1 was implemented on 08/31/23. The interventions include: the seven elements of abuse prevention will be enforced as per facility policy. Distract, guide with physical assist, reassure, breakdown steps, gentle touch, allow time, smile, listen, and report any suspicion of abuse to supervisor or social worker. A Behavior Care Plan was initiated on 08/31/23 documented Resident #1, though calm is unpredictable, impulsive, aggressive, combative, hits, scratches, kicks, and bites. The interventions include providing a calm relaxing environment, staff to speak with Resident #1 during care and allow Resident #1 to respond. The care plan was updated on 09/06/23 to reflect on the incident. A Resident CNA Documentation History Detailed dated 08/30/23 to 08/31/23 documented, under behavior, that Resident #1 was resistive to care and wanders. The Resident Nursing Instruction was updated 09/07/23 (under behavior) with information that Resident #1 yells, screams, kicks, and hits. There were no instructions on the Resident Nursing Instructions as to what staff should do if Resident #1 should become aggressive or combative. The facility's conclusion of the investigation dated 09/04/23, documented that Resident #1 was observed with a raised area to the right forehead and discoloration. The investigation also documented that CNA #2 reported that Resident #1 kicked CNA #1 and scratched CNA #2 and CNA #1 hit Resident #1. CNA #1 was immediately removed from schedule and the police were notified. The facility concluded that the abuse was witnessed. A Progress Note dated 09/03/23 at 3:43am, written by Registered Nurse Supervisor (RNS) #3, documented that Resident #1 was soiled and while staff was taking care of Resident #1, Resident #1 became physically aggressive and kicked assigned CNA (CNA #1). Resident #1 was later observed with a slight swelling and discoloration to the right forehead. A full body check was not done because Resident #1 was aggressive. The Medical Doctor (MD #1) was notified and ordered a transfer to the hospital. A Progress Note dated 09/04/23 at 6:36am documented that Resident #1 returned to the facility via stretcher with two Emergency Medical Service (EMS) attendants at approximately 2:55am. A CT scan (Computerized Tomography) was done with no acute intracranial pathology and no acute osseous (no bone abnormalities) of face. Body assessment revealed ecchymosis to the right orbital area with no complaints of pain. Neurological check done and monitoring. Progress Notes dated from 09/04/23 to 09/07/23 documented that Resident #1 exhibits aggressive behavior, and wanders and is not easily redirected. Resident #1 observed on the unit (2nd floor) in bed on 09/13/23 at 10:30am lying on their back asleep. Resident #1's was observed with a fading yellow discoloration below the right eye and around the right side of the forehead (temporal area). LPN #1 provided a statement to the facility dated 09/02/23. The statement states that LPN #1 heard Resident #1 yelling for help and screaming ouch, stop. LPN #1 stated that they went to Resident #1's room, but only saw the CNA holding Resident #1's arms and legs while cleaning Resident #1. LPN #1's statement also documented that LPN #1 was later told that CNA #1 hit Resident #1. CNA #1 was interviewed via telephone on 09/14/23 at 10:41am and stated that on 09/02/23 (does not know time) they went into Resident #1's room to provide incontinent care and Resident #1 kicked at them and was combative. CNA #1 said that they called out for help and asked CNA #2 to assist them with Resident #1. CNA #1 said that CNA #2 held Resident #1's legs so CNA #1 would be able to provide incontinent care. CNA #1 said that Resident #1 scratched CNA #2 and kicked CNA #1 in the abdomen. CNA #1 said just as Resident #1 kicked them Licensed Practical Nurse (LPN) #1 walked into the room. CNA #1 said that they (CNA #1) completed incontinent care and all three (CNA #1, CNA #2, and LPN #1) left Resident #1 in bed. CNA #1 said they saw the discoloration on Resident #1's forehead when RNS #1 showed it to them at around 10:00pm (not sure of time) on 09/02/23. CNA #1 said between 3:00pm and 3:30pm, CNA #2 told them that Resident #1 wanders. CNA #1 said that they did not receive a report about Resident #1 from the nurse. CNA #1 said that they did not hit Resident #1. CNA #2 was interviewed on 09/13/23 at 1:00pm and said that they came off the elevator at around 8:15pm (not sure of time) and heard CNA #1's voice calling for help. CNA #1 was saying stop and stay still. CNA #2 said they went into Resident #1's room and assisted CNA #1 with Resident #1. CNA #2 said they held Resident #1's legs so that CNA #1 would be able to clean Resident #1, who had a lot of bowel movement. CNA #2 said that Resident #1 scratched them and kicked CNA #1 in the abdomen and CNA #1 turned and hit Resident #1 with a closed fist to the right side of the forehead. CNA #2 stated that Resident #1 did not make any sound after being hit. CNA #2 said that they told CNA #1 to stop and don't hit Resident #1. CNA #2 said that Resident #1 allowed CNA #1 to complete cleaning Resident #1, and CNA #2 left the room. CNA #2 said that they did not see any discoloration or swelling on Resident #1's forehead at the time. CNA #2 stated that between 09:45pm and 10:00pm (not sure of the time) they saw Resident #1 standing at their room door. CNA #2 stated that they observed a bump and discoloration on the right side of Resident #1's forehead. CNA #2 stated that CNA #1 did not go back into Resident #1's room after incontinent care was completed. CNA #2 stated that they called RNS #1 to come immediately. CNA #2 stated that when RNS #1 came to the unit, CNA #2 did not tell RNS #1 that CNA #1 hit Resident #1. CNA #2 stated that they were afraid of CNA #1 and that they (CNA #2) had a past issue with CNA #1. CNA #2 stated they did not want CNA #1 to know that they (CNA #2) reported them, so they wrote about the hitting in their statement. CNA #2 said at around 3:15pm before CNA #1 started their assignment, CNA #2 told CNA #1 to approach Resident #1 and talk in a calm voice, and advised that Resident #1 hits, kicks, and spits. During a telephone interview on 09/27/23 at 4:44pm, RNS #1 stated that they were called to the unit at approximately 9:40pm (not sure of the time and does not recall who called them to the unit). RNS #1 said that they went to the unit and Resident #1 was sitting on a chair at their room door. RNS #1 said that they checked Resident #1 and Resident #1's right cheek had three little scratch marks and one thin long one. RNS #1 stated that a nurse and a CNA were sitting at the nursing station (does not recall who the staff were) and RNS #1 told the nurse to clean Resident #1's face because one of the scratch marks had a little redness on it. RNS #1 said that they left the unit and went downstairs notify supervisor (RNS #2). RNS #1 said they did not ask the staff what happened, and staff did not notify RNS #1 that Resident #1 was abused. RNS #2 was interviewed on 09/13/23 at 2:00pm and stated that at about 10:15pm they saw Resident #1 with a mild swelling around the right forehead. RNS #2 stated that they were not immediately told that Resident #1 was hit. RNS #2 said that the staff gave them the statements at approximately 10:45pm. RNS #2 stated when they reviewed the statements, they found a statement written by CNA #2 and it mentioned that CNA #1 hit Resident #1 after Resident #1 kicked CNA #1. RNS #2 said it was then about 11:00pm and CNA #1 had already left the unit. RNS #2 stated that staff are told if Resident #1 becomes combative, to stop care and report it to the nurse. RNS #2 said that RNS #3 came in early about (10:30pm) and assisted with the investigation. RNS #3 was interviewed on 09/13/23 at 2:30pm and stated that they reviewed CNA #2's statement and saw that it mentioned CNA #1 hit Resident #1. RNS #3 spoke with CNA #2 who stated that Resident #1 kicked CNA #1 and scratched CNA #2 and CNA #1 hit Resident #1 on the right side of the forehead. RNS #3 said that they called the Director of Nursing and the police. CNA #1 was immediately removed from the schedule. RNS #3 said that staff are to stop care and report to the nurse when Resident #1 is combative. RNS #3 stated that they were not aware that instructions for CNAs were not on the Resident Nursing Instructions for CNAs. During an interview on 09/13/23 at 5:05pm, the Director of Nursing (DON) said that they were notified of the incident on 09/13/23 at 11:00pm, and they came to the facility at approximately 12:00am. The DON said that they reviewed the statements from the staff and questioned the witness (CNA #2), who provided the same version of having observed CNA #1 hit Resident #1 after Resident #1 kicked CNA #1 in the abdomen. The DON said that they interviewed CNA #1 and CNA #1 said that they did not hit Resident #1. The DON explained that the investigation concluded that abuse had occurred because Resident #1 had injury and the incident was witnessed by CNA #2. The DON said that to protect the residents CNA #1 was immediately suspended and subsequently terminated. The DON said that the police and Resident #1's family member were notified. The DON said that staff are instructed to immediately stop rendering care and notify the nurse. The DON stated that the interventions on the care plan should have been reflected on Resident #1's CNA Nursing Instruction, indicating what staff should do when Resident #1 becomes aggressive or combative. The DON advised that the Registered Nurses or LPNs can update the care plan and the Resident Nursing Instructions. During a telephone interview on 09/27/23 at 5:30pm, Resident #1's primary physician (PP) said that they were notified that Resident #1 sustained an injury. The PP stated that they examined Resident #1 on 09/04/23 when Resident #1 returned from the emergency room (ER). Resident #1 had a bruise, some swelling to the right side of forehead and that Resident #1's eyes were [NAME]. The PP also said that they examined the rest of Resident #1's body and there were no other injuries. The PP said that they forgot to write a note in Resident #1's medical record. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews, and record review during an abbreviated and partial extended survey (NY00322953), the facility failed to ensure a resident, identified as an elopement risk and had a history of previous elopement, received adequate supervision to prevent elopement from facility. This was evident in 1 of 5 residents sampled (Resident #1). Specifically, on 08/29/2023, Resident #1, who was cognitively impaired and had a wander alert device in place, left the building undetected. Resident #1 returned to the facility from a clinic appointment on 08/29/2023 at 3:42 PM. There was no documented evidence that Resident #1 was monitored by staff every 15 minutes, as an intervention to prevent elopement, after 3:45 PM on 08/29/2023. Subsequently, Resident #1 was identified missing at 5:40 PM. This resulted in no actual harm with likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care to resident health and safety. The findings are: The facility policy titled Elopement of Resident with review date of 10/2020 stated that it is the policy of the facility to prevent and manage elopement attempts that may occur with residents. All residents are assessed for elopement risk on admission, quarterly, and as needed. The facility policy titled Missing Residents with review date of 02/2018 stated that it is the policy of the facility to ensure the safety and security of residents, staff, and visitors. The process for locating and recovering a lost or missing resident from the facility will include but not be limited to coordination with law enforcement agencies. The procedure states that staff will record the time that the resident becomes missing, including when and where they were last seen. Staff will verify that the resident has not signed out with family. A Code C (code for elopement) will be announced. Resident #1 was admitted to the facility with diagnoses of Traumatic Brain Injury (a serious condition that affects brain's function due to a sudden impact) and Mood Disorder (a mental health condition with long periods of extreme happiness, extreme sadness, or both). The Minimum Data Set (MDS, a resident assessment tool) dated 07/17/2023 documented that Resident #1 is severely cognitively impaired. The MDS documented that Resident #1 had a history of wandering. A Wandering /Elopement Risk assessment dated [DATE] documented that Resident #1 was at risk for elopement. A Comprehensive Care Plan (CCP) on elopement risk was initiated for Resident #1 on 02/13/2023. The facility interventions included ongoing assessment with 15-minute monitoring to Resident #1's location and a wander alert device. The care plan notes documented on 03/07/2023, at risk for elopement, seeking out first floor exits, wander alert device was applied to left ankle. On 04/22/2023, Resident pushed through back door attempted to elope through the ambulance door, was returned by nurse. On 05/19/2023, status post elopement from the clinic. And on 08/29/2023, around 4:00 PM, Resident left the facility unescorted. A Resident Nursing Instruction (a care plan instruction for Certified Nursing Assistants) dated 03/07/2023 documented safety precaution: Elopement; wander alert device to the left ankle; check placement of wander alert device to left ankle every shift; and every 15-minute monitoring. The Door Alarm and Wander Guard Weekly Inspection Form documented the 3rd floor stairways, A, B and C exit doors, and elevators were properly tested , and the wander alert system was working properly on the 4th week of August. There was no indication as to what date the inspection was performed. A Visual Monitoring Sheet dated 08/29/2023 3-11 shift documented that Resident #1 was on 15-minute monitoring and documented Out on Pass (OOP) from 3:15 PM to 3:30 PM. The last entry on the monitoring sheet at 3:45 PM documented that Resident #1 was at the nursing station. There was no documented evidence of Resident #1's location or activities after 3:45 PM. A Resident Half Hour Observation Sheet dated 08/29/2023 documented from 3:00 PM to 4:30 PM that Resident #1 was OOP. There was no further documentation after 4:30 PM. A nursing note dated 08/29/2023 at 11:05 PM by Licensed Practical Nurse #1 (LPN #1), documented Resident #1 returned to the nursing unit at 3:45 PM from their clinic appointment. A nursing note dated 08/30/2023 at 12:36 AM by Registered Nurse Supervisor #1 (RNS #1), documented Resident #1 left the facility unescorted on 08/29/2023 around 4:00 PM and did not notify the staff prior to departure. On 09/06/2023 at 10:30 AM, the facility surveillance camera was reviewed with the Director of Nursing (DON) and the Administrator. The camera time is 10 minutes behind actual time. The surveillance camera showed on 08/29/2023 at 3:37 PM (actual time 3:47 PM), Resident #1 came to the lobby from the elevator area (the elevators were not in camera view). The Attending Physician #1 (AP #1) walked behind Resident #1. There were no other people in the lobby. Resident #1 passed by the security desk and walked towards the main entrance (the main entrance door was not visible on camera). AP #1 stopped by the security desk, threw an item in the garbage bin, and walked towards the main entrance behind Resident #1. At 3:38 PM (actual time 3:48 PM), Resident #1 exited through the main entrance with AP #1 behind them (only the corner of the door was visible). Resident #1 made a right turn on the sidewalk and disappeared from the camera view. The facility's investigation summary form dated 09/04/2023 by the DON, documented Resident #1 exited the facility on 08/29/2023 at approximately 4:00 PM. Resident #1 returned from their clinic appointment at 3:45 PM accompanied by CNA #4 and was escorted to the unit nurse. The nurse did not inform the staff that Resident #1 returned to the facility. 15-minute monitoring was done only up to 3:45 PM by the nurse. The investigation summary documented that facility acknowledged that Resident #1 left the facility through the front door. The wander alert system was operational based on the last check. The facility concluded the wander alert bracelet worn by Resident #1 was faulty because the security guard stated that they did not get up to reset the system. Resident #1 returned to the facility on [DATE] at 5:15 PM accompanied by the family. A review of the Security Record Book dated 08/29/2023 documented Code C (facility's code for resident elopement) was called for Resident #1 at 6:00 PM. During an interview on 09/06/2023 at 2:00 PM, CNA #4 stated they escorted Resident #1 to their clinic appointment on 08/29/2023 and left the unit at approximately 2:58 PM. They returned to the facility at approximately 3:45 PM. They brought Resident #1 to their room and told LPN #1 that Resident #1 was back. CNA #4 stated they left the unit after speaking with LPN #1. They stated that they did not hear any alarm go off while they were on the unit. During an interview on 09/05/2023 at 2:41 PM, LPN #1 stated that Resident #1 was an elopement risk, had a wander alert device, and to be monitored every 15 minutes. LPN #1 stated that Resident #1 went to a clinic appointment on 08/29/2023 at 3:00 PM and returned to the unit at 3:45 PM. LPN #1 stated they documented in the 15-minute monitoring sheet that Resident #1 was on the unit. LPN #1 stated they told Resident #1 to go to their room but did not make sure Resident #1 followed the instruction. LPN #1 stated they did not inform the CNAs on the unit that Resident #1 had returned. LPN #1 stated it was their responsibility to inform the assigned CNA that Resident #1 was back and give them instructions. LPN #1 stated they did not monitor Resident #1 every 15-minutes upon return from the clinic because it was the CNA's responsibility. LPN #1 stated at approximately 5:40 PM, they were passing by Resident #1's room and noticed Resident #1's supper tray was not touched. The roommate told them they had not seen Resident #1. LPN #1 stated they did a head count and started a search on the unit, went to every floor, and the basement. LPN #1 stated when they did not find Resident #1, they called RNS #1 but does not recall the time. RNS #1 told them to continue the search and a Code C was called. LPN #1 stated during a subsequent interview on 09/07/2023 at 10:03 AM, that they did not hear any alarm go off during their shift on 08/29/2023. During an interview on 09/05/2023 at 1:20 PM, CNA #1 stated they arrived in the unit on 08/29/2023 at 3:00 PM and did not see Resident #1 during monitoring. CNA #1 stated they asked LPN #1 where Resident #1 was, and LPN #1 told them Resident #1 was out on a clinic appointment. CNA #1 stated while serving supper at approximately 4:45 PM, they asked LPN #1 again where Resident #1 was. LPN #1 stated Resident #1 had returned to the unit earlier. CNA #1 stated they did a head count of residents and started to search for Resident #1. CNA #1 stated that RNS #1 and Security were notified, and a Code C was announced. Staff went to different locations, to nearby buildings, and the hospital, but they were not able to locate Resident #1. CNA #1 stated they did not hear any alarm go off. During an interview on 09/05/2023 at 3:40 PM, CNA #2 stated they were not aware that Resident #1 came back to the unit from their clinic appointment on 08/29/2023. CNA #2 stated the nurse is supposed to let them know when a resident is back from clinic appointments. CNA #2 stated they did not find Resident #1 while serving supper at approximately 5:50 PM. LPN #1 told CNA #1 Resident #1 had been back earlier. CNA #1 stated they immediately searched for Resident #1. CNA #2 stated that they did not hear any alarm go off. During an interview on 09/07/2023 at 10:40 AM, CNA #3 stated they did resident monitoring at 3:00 PM on 08/29/2023 and was told by LPN #1 that Resident #1 was out on appointment. CNA #3 knew Resident #1 was at risk for elopement, had a wander alert device, and was on 15-minute monitoring. CNA #3 stated they were not aware Resident #1 was back in the unit and they did not hear any alarm go off during their shift. During an interview on 09/06/2023 at 4:22 PM, RNS #1 stated on 08/29/2023 at approximately 3:45 PM, CNA #4 informed them Resident #1 returned to the unit from a clinic appointment and gave them the clinic paper. RNS #1 stated after 6:00 PM, LPN #1 notified them Resident #1 was not in the unit. RNS #1 immediately went to the unit, did a search on the unit, and then called Code C. During an interview on 09/05/2023 at 12:51 PM, Security Guard #1 (SG #1) stated they worked on 08/29/2023 from 9:00 AM to 5:00 PM. SG #1 stated they did not see when or how Resident #1 left the facility because they were on the phone. SG #1 stated there was a shift change between 3:00 PM and 4:00 PM and there was a lot of staff traffic. SG #1 stated they did not hear an alarm sound. SG #1 stated, Maybe because the door was open otherwise the door would be locked if a person with a wander alert device approach the exit. SG #1 stated no alarm was activated, and they did not reset the wander alert system. SG #1 was aware Resident #1 was at high risk for elopement and Resident #1 had a picture at the front desk. During a subsequent interview with SG #1 on 09/07/2023 at 10:17 am, they stated they did not hear the alarm when Resident #1 left for a clinic appointment on 08/29/2023 at 3:00 PM and did not hear an alarm when Resident #1 returned from their clinic appointment. SG #1 did not hear an alarm when Resident #1 exited the building. SG #1 stated they do not recall resetting the alarm. SG #1 stated they do other tasks such as answering phones, distributing employee paystubs, distributing COVID-19 test kits and explain to visitors how to use the test kits. SG #1 stated the main entrance door will automatically lock when a resident with a wander alert device approached the main entrance and an alarm would go off if they tried to open the door. SG #1 stated they must physically reset the alarm on the panel at the main entrance if the wander alert alarm is triggered. SG #1 stated it is hard to hear the alarm if the phone was ringing. During an interview on 09/06/2023 at 11:40 AM, AP #1 stated that they do not recall Resident #1 walking near them when they were exiting the facility. They do not recall if the elevator was blocked and did not hear an alarm when they exited the facility on 08/29/2023. During an interview on 09/06/2023 at 6:12 PM, the Director of Maintenance (DOM) stated they conducted a daily inspection of the wander alert system for proper functioning. The DOM stated they check the wander alert system every week on Monday to make sure the wander alert system worked properly when generator turns on. The DOM stated the last time they checked the wander alert system on 08/29/2023 during morning rounds and it was functioning. During an interview on 09/05/2023 at 2:35 PM, the DON stated RNS #1 informed them on 08/29/2023 at around 6:20 PM that Resident #1 was missing. The DON stated according to their investigation, Resident #1 came back from a clinic appointment with CNA #4. CNA #4 returned Resident #1 to the nursing unit and told LPN #1. LPN #1 did not tell the assigned CNA or any other CNAs on the unit that Resident #1 was back and needed to be monitored every 15-minutes. The DON stated LPN #1 told them when LPN #1 passed by Resident #1's room at 5:40 PM, LPN #1 noticed Resident #1's meal tray was not touched, and Resident #1's roommate stated they had not seen Resident #1. LPN #1 started a search on the unit and notified RNS #1. A Code C was called at around 6:00 PM. The DON stated it was unknown how Resident #1, who was wearing a wander alert device, was able to use the elevator and exit through the main entrance door. The DON stated the staff did not hear any alarm go off in the lobby. During an interview on 09/05/2023 at 5:10 PM, the Administrator stated they were notified by the DON that Resident #1 was missing. They called SG #1 and requested they go to the facility and review the camera to find out how Resident #1 exited the building. The Administrator stated the investigation revealed LPN #1 did not notify the staff on the unit that Resident #1 returned from their appointment. They stated it is the security guard's responsibility to prevent residents from leaving the facility unescorted. The Administrator stated that the security guard should pay attention to who is leaving the facility, stop the resident from leaving, and to notify nursing if a resident is leaving without an escort. The Administrator stated they did not know what happened on the day Resident #1 exited the facility. Resident #1 was able to ride the elevator to the first floor and exit through the main entrance and no one, not even SG #1, heard the alarm. The Administrator stated that Resident #1 was smart and may have manipulated the wander alert bracelet. Immediate Jeopardy (IJ) was identified, and the DON was notified on 09/07/2023 at 6:00 PM. An acceptable immediate corrective action plan from the facility was received on 09/08/2023 at 1:18 AM. Immediate Jeopardy was removed prior to survey exit on 09/12/2023 based on the following corrective actions taken by the facility: 1. Resident #1's care plan for elopement was reviewed and interventions were updated to include 1:1 monitoring. 2. A wander alert antenna was installed closer to the security desk that will trigger before a resident with a wander alert device reaches the main entrance. A siren and flashing light were also installed in the lobby which will get the attention of the security guard and other employees in the area. Sirens were installed on each elevator. 3. The facility implemented a policy and procedure on Wander Guard / Code Alert on 09/08/2023. The policy stated the 11:00 PM -7:00 AM nursing supervisor will be responsible for checking the functionality of the wander alert device. The unit nurse will check for placement every shift and document in the treatment administration record. 4. The security guard duties and responsibilities were modified. Clerical duties such as distributing payroll checks and COVID-19 kits were removed from their job responsibility. This allows for consistent monitoring of front door and lobby area at all times. A copy of the revised General Duties of Security Guards was signed by each security guard submitted to the DON. 5. An Elopement Risk Drill was conducted by the facility on 09/09/2023 at 10:45 AM and 3:30 PM. The objective of the drill was to have staff demonstrate the rapid response to a Code C (code for elopement) and for staff to demonstrate an understanding of the updated Code Alert System. A copy of the drill documentation was submitted by the facility. 6. A Quality Assurance meeting was held on 09/11/2023 by the interdisciplinary team regarding Resident #1's elopement. 7. The facility completed staff education on Elopement Risk Prevention and Missing Resident Protocol with emphasis on informing nursing staff when a resident returns to the facility from a clinic appointment, therapeutic leave or out on pass; wander alert system; and the facility's policy and procedure on Wander Guard / Code Alert. The facility had 195 employees. 9 employees are on leave, on vacation, or are out on disability. As of 09/12/2023, a total of 188 employees received education. Staff interviews were conducted to verify they were educated. They were knowledgeable of the elopement protocol and the updates to the wander alert system. Staff who are out of work will attend education prior to reporting to their workstation. 10 NYCRR 415.12(h)(2)

Based on observation, record review and interview, during the recertification survey of [DATE] to [DATE], the facility failed to ensure food was storeed, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, multiple items were observed in the dairy and meat walk-in refrigerators without proper labeling and dating. Two expired food items were observed in the emergency storage area. An employee was observed without a hair restraint or beard restraint, with hair exposed. The findings are: A facility policy and procedure titled Food Storage review/updated [DATE], documented that old stock is always used first. Food should be dated as it is placed on the shelves if required by state regulation. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. All refrigerated and frozen foods should be covered, labeled, and dated. A facility policy and procedure titled 3-day Emergency/Disaster food supply, dated [DATE], review/updated [DATE], documented the facility will ensure that there is a 3-day emergency/disaster food supply for both staff and residents. The facility will ensure the emergency food supply is adequately stocked and rotated by completing an inventory on a routine basis. A facility policy titled Accepting Food Deliveries reviewed/revised [DATE], documented perishable foods will be properly covered, labeled, and dated and stored in the refrigerator or freezer as appropriate. A facility policy titled Dietary Uniforms, updated [DATE], documented employees are required to have hair restraints that cover all hair on the head. Beard nets are required when facial hair is visible. On [DATE] 09:21 AM an initial tour of the kitchen was conducted with the 2nd Cook, and the following was observed: Dairy walk-in refrigerator: In pans: 3-bean not dated; vanilla pudding not labeled/dated. 2 milk crates were on the floor; 4 trays portioned fruit dessert not dated. In the meat/produce walk-in refrigerator, there was a Styrofoam flip container labeled meatloaf for residents no date; a second Styrofoam flip container was without a label and date. In the dry storage day room, a package of onion soup mix, farina, and 3 bags of cream of rice cereal were not dated. A bag of diet cookies were not labeled and dated (product was out of the original box). In the walk-in freezer, there were several boxes stored on the floor, an unlabeled and undated open bag of a breaded food product was not closed so that the item was exposed. There was also an undated open bag of chicken. A second tour of the kitchen was conducted on [DATE] at 11:28 AM with the Food Service Director (FSD) and the following was observed: Dietary Aide (DA) #1 was observed in the kitchen on [DATE] at 11:48 AM wearing a surgical mask with their sideburns visible and a baseball cap with dreadlocks extending down their back without a hair covering. In the dietary storage room, a bulk sized case of thickened orange juice, expiration date [DATE], and 4 oz. portion control cups, expiration date [DATE] were observed in the emergency food supply. An interview was conducted with Dietary Aide (DA) #2 on [DATE] at 9:37 AM, who stated that today they were assigned to the storeroom as relief. When the delivery comes in, everything is dated. They rotate items, the new on the bottom, old on top or front to back. They check the expiration dates on delivery. In the refrigerator or freezer, whichever cook used the product was responsible for putting it away properly (closing the package, labeling, and dating). An interview was conducted with the DA#1 on [DATE] at 11:48 AM. DA #1 was asked about their beard and hair not being covered. They stated that the hair coverings do not fit easily to cover their hair, but when they are on the tray line, they put on the bouffant hair covering and then their hat over it. They tuck their dreadlocks into the hair covering. DA #1 stated that they were trained about keeping their hair covered when they first started working at the facility. With regard to their beard, they stated that they use the surgical mask to cover it. There are no beard nets or mesh hair nets to use that will cover the sideburns that are not covered by the face mask. On [DATE] at 11:53 AM, an interview was conducted with the FSD who stated the policy is that everyone has to wear a head covering, either a hair net or a bouffant. The FSD further stated that DA#1 is supposed to wear the hair covering, not a baseball cap. Their dread locks are supposed to be covered. The FSD said the beard is covered only through the mask. When they were asked about the sideburns, they stated they had nothing to cover it up with. On [DATE] at 10:47 AM, an interview was conducted with the FSD who stated the cooks put their left-over foods into the refrigerator, and they are responsible for labeling and dating. They further stated that when a product comes out of its original packaging the storeroom, then the storeroom person is responsible for dating the item. The FSD further stated that all staff have been in-serviced on hair restraints and will be re-in-serviced on beard restraints. As for the expired food items, the FSD said that they check the emergency food supply inventory/dates along with the storeroom person. On [DATE] at 10:10 AM, an interview was conducted with the 1st Cook who stated that a product is supposed to be wrapped, labeled, and dated with what the product is. The 1st Cook stated that the storeroom person is responsible to ensure things are wrapped and dated, as well as the person cooking who then puts something away. Everyone should be wrapping/dating whatever they are using and putting back. 415.14

Based on observations, record reviews, and interviews conducted during the Recertification survey from 03/09/23 to 03/16/23, the facility did not ensure each resident remained free from physical restraints. This was evident for 2 out of 6 residents reviewed for Physical restraints out of a sample of 35 residents. (Resident #54 and #141). Specifically, Resident #141 had a lap tray restraint in use without a medical justification, assessment, evidence of less restrictive alternatives tried, and ongoing evaluation for continued use. Resident #54 had a lap tray restraint in use without a medical justification, assessment, care plan, evidence of less restrictive alternatives tried, and ongoing re-evaluation for continued use. The findings are: The facility policy titled Restraints Reduction/Elimination dated 01/2023 documented a physical restraint is 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 and restricts freedom of movement or normal access to the Resident. The clinical team will team will consider various alternatives prior to the use of restraint. The policy also documented that the rehab and the nursing will complete restraint assessment and follow up the physician and the Interdisciplinary team. Then the social worker will complete a restraint consent form and and notify the family member. Upon request, the facility provided a list of residents currently in use of lap trays. The list consists of a total of 16 residents. 1) Resident #141 had diagnoses which include Dementia, Cerebrovascular Accident (CVA), Parkinson's Disease, and Seizure Disorder, Traumatic Brain Injury (TBI) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired . The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS also documented trunk restraints were not used. The Physician's order initiated 11/15/2022, last renewed on 03/01/23, documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. On 03/13/23 at 09:55 AM, Resident #141 was observed in their room, sitting in a wheelchair (w/c) with a lap tray in place. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. Resident #141 was confused, not interview able, and unable to follow simple directions. The resident could not remove the lap tray when asked to do so. The Certified Nurse Aide (CNA) #1 was present during the observation. On 03/15/23 at 11:30 AM, Resident #141 was observed in the day room attending recreational activities with other residents. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. A nursing rehab note dated 11/15/22 (hard copy paper documentation), documented Resident #141 was seen by the Occupational Therapist (OT) on 11/15/22 and was provided with lap tray while OOB to standard wheelchair to facilitate midline positioning. The resident was monitored and able to tolerate the use of the lap tray as a therapeutic device and not as a restraint. The resident's family member consented to the use of the lap tray, and a physician's order was obtained. The health care team agreed to the lap tray use as a positioning device. Resident #141 would benefit from using the lap tray to facilitate midline positioning with release every 2 hours for 15 minutes and as needed (PRN) for Activity of Daily Livings (ADLs) care and skin checks. The restraint consent form dated 11/15/2022 documented that in order to prevent potential injuries, every effort was made to use alternative methods to provide a safe environment for the resident. Since alternatives were unsuccessful, it was determined a physical restraint was necessary. A lap tray was provided to facilitate midline positioning and was not being used as a restraint. The consent form was completed by the social worker and documented a verbal consent was given by a family member. The Comprehensive Care Plan (CCP) for Physical Restraint Secondary to a diagnosis of Traumatic Brain Injury (TBI) initiated 11/15/2022, revised 2/10/23 documented interventions to increase judgement and safety awareness, Rehab screen for restraint reduction if condition improved, and provide resident with change in position Q (every) 2 hours by toileting, ambulation and/or ROM (Range of Motion) exercise. The CNA Accountability Records (CNAARs) from 1/1/23 to 3/13/23 contained no documentation that the lap tray was released every 2 hours for 15 minutes. There was no documented evidence in the medical record that Resident #141 was assessed for use of a physical restraint (lap tray). There was no medical justification documented with the medical symptoms the lap tray was used to treat. There was no documented evidence of less restrictive alternatives tried, monitoring of the tray, and ongoing re-evaluation for the continued use of the lap tray. During an interview on 03/13/23 at 10:23 AM, the Occupational Therapist (OT) stated Resident #141 was currently receiving rehab after having a seizure. The resident has poor awareness, and the lap tray is needed for positioning and because the resident was attempting to get up. The OT stated an assessment was not conducted for the lap tray because Resident #141 continued to receive rehab and an assessment is always conducted for this resident. The OT stated that once they inform the rehab nurse that the resident required a lap tray, they will initiate an order and then the rehab nurse would follow up. They stated that they rehab nurse wrote a note on resident #141 on 3/15/22 and then they signed off on it. During an interview on 03/13/23 at 02:11 PM, CNA #2, the assigned CNA for over 3 months, stated the resident is confused and does not have awareness of their surroundings. CNA #2 stated Resident #141 attempts to get up and sometimes has aggressive behaviors putting them at risk for falls. CNA #2 stated Resident #141 cannot remove the lap tray independently, and they remove the lap tray every 2 hours. CNA #2 could not recall if there were documentation of the lap tray on their task. The C.N.A concluded by saying I don't know. During an interview on 03/16/23 at 01:23 PM, the Rehab Registered Nurse (RN) who stated that the rehab instructed her during the IDT meeting that the resident required a device. The Rehab RN stated that the facility has a lot of residents with TBI who use lap trays. The lap tray is not considered a restraint, even if the resident is confused or unable to remove it, because it is used for positioning. The rehab nurse further stated that the CNAs are responsible for applying the lap tray and releasing it every 2 hours. The release is documented in the CNAAR. The Rehab RN was unable to explain why the lap tray documentation was not being done. They stated that the RN who entered the order and CCP was supposed to make sure the lap tray was reflected on the CNAAR under safety tasks. During an interview on 03/13/23 at 02:40 PM, the Director of Social Work (DSW) stated that if rehab and nursing determines a restraint is necessary, social work will initiate the restraint consent form and notify the family. The DSW also stated that the team meeting concluded the lap tray was a restraint. During an interview on 03/16/23 at 01:05 PM, the MDS Coordinator stated that her staff completed the MDS assessment, and she reviews them. The lap tray is used for positioning because the resident has poor balance. That is why it was not coded as a restraint on the MDS. The facility has a lot of residents that use lap trays. A lap tray is not a restraint if the resident does not have the ability to remove it. If the resident is confused and cannot remove it, the lap tray is not a restraint. During an interview on 03/16/23 01:40 PM, the Director of Nursing (DON) stated that restraints are physical devices that restrict residents' movement. They stated that some residents do not have safety awareness, and the lap tray is used for positioning, not for resident safety. The DON stated that they have tried a series of different alternatives. Even when a resident cannot remove the lap tray, if they need it, it is not a restraint. 18881 2) Resident # 54 admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Parkinson's Disease, Seizure Disorder and Traumatic Brain Injury. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired . The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS documented no restraints or alarms were used for the resident. On 03/13/23 from 11:59 AM to 1:20 PM, Resident #54 was observed seated in a wheelchair (w/c) in front of the Nursing station with a lap tray in place, attached to the w/c. At 12:30 PM, Resident #54 was wheeled to the Dining room, and the lap tray was released to enable the resident to eat. On 03/16/23 from 12:07 PM to 1:00PM , Resident #54 was observed again in front of the nursing station with a wander guard on the left ankle, chair alarm, and lap tray applied to the front of the w/c, restricting the resident's movement. The resident was not able to move or release the lap tray independently. The Physician's order dated 02/06/2023,documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. Wander alert device placement and check every shift. Review of the Comprehensive Care Plan (CCP) revealed there was no CCP developed for the use of the lap tray. There was no documented evidence in the medical record of the medical symptoms the lap tray was used to treat, a lap tray assessment, less restrictive measures tried before the lap tray, ongoing re-evaluation for continued use, or documentation regarding the release of the lap tray. On 03/14/2023 at 12:50 PM, the Occupational Therapist (OT) was interviewed and stated Resident #54 had a history of falls and standing all the time. The lap tray was applied for positioning. The OT stated no other devices were tried prior to the use of the lap tray, and a wander alert device and chair alarm are used for the resident. On 03/16/2023 at 12:16 PM, the MDS Coordinator was interviewed and stated the MDS staff do the initial, significant change, and annual CCPs and assessments. The Nursing staff complete the quarterly and episodic CCPs. The MDSC stated the lap tray is used for positioning and body trunk support, and it is not a restraint. On 03/16/2023 at 12;20PM, the Registered Nurse (RN #1) was interviewed and stated no other devices were used prior to the lap tray. RN #1 stated Resident #54 likes to get up from the chair, and they will also get out of bed and walk down the corridor. Resident #54 had a history of previous falls. Interventions implemented were a mattress on the floor, bed at lowest position, bed alarm, and chair alarm. No other alternatives were tried instead of a lap tray. RN #1 stated the lap tray prevents the resident from standing and falling. Resident #54 will get up from the chair when no one is looking and walk away from the chair. 415.4(a)(2-7)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that all alleged violations, including injuries of unknown origin, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve serious bodily injury, to the State Survey Agency. This was evident for 1 of 4 resident reviewed for Accident. (Resident #59). Specifically, the facility did not report Resident #59's left distal tibia fracture of unknown origin to New York State Department of Health (NYSDOH) within 2 hours. The finding is: The facility policy titled Accident/Incident Reporting dated 08/2022 states All accidents/incidents/episodic events will be investigated thoroughly, documented and reported to the NYS DOH as appropriate. If the event is an injury of unknown origin, statements must be obtained from all staff going back until a determination can be made as to the time of the injury, using the forms for Certified Nurses Aides and Licensed Nurse. The Risk Manager determines the need to expand scope of the investigation as necessary. Resident #59 was admitted to the facility with diagnoses which include Non-Alzheimer's Dementia, Cerebro-Vascular Accident, and Psychotic Disorder. The Minimum Data Set (MDS ) 3.0 assessment dated [DATE] documented Resident #59 cognition as severely impaired. On activities of Daily Living (ADLS) as completely dependent to staff for dressing and bed mobility, and required the total assist of two persons with a Hoyer lift for transfers. On 03/13/2023 at 11:51 AM, Resident #59 was observed in their room sitting in a Geri chair with a soft cast wrapped with ace bandage on the left lower extremity. Resident is with contractures of upper and lower extremities, non responsive verbally. A Nursing Note dated 1/9/23 at 3:17 PM documented Resident #59 was assessed after being noted with left ankle swelling. The Nursing Supervisor and Physician (MD) were notified, and an order for stat x-ray of the left ankle was given and transfer to the hospital. Resident #59 had facial grimacing and yelled ouch when the ankle was touched during the assessment. A stat Tylenol order was obtained, and the resident was monitored. The x-ray was completed with results pending. A Physician's Note dated 01/09/2023 documented Resident #59 was seen for left ankle swelling. The resident was verbal and had no report of a recent fall or injury. On exam, the left ankle was swollen and warm to touch with restricted Range of Motion. The physician discussed the possibility of left ankle injury with nursing staff. Resident #59 was very rigid during the physical exam with left ankle edema. X-Ray results dated 1/9/23 documented the resident had a non displaced butterfly fracture deformity of the distal fibula. Correlation with dedicated ankle level tibia and fibula radiographs advised. Resident was sent to the hospital on 01/09/2023 and was returned to the facility on [DATE] with a soft cast and wrapped with an ace bandage as documented in the nurses' notes. Accident/Incident investigation was initiated on 01/09/2023 with written statements and interviews taken from the staff on duty and going back 72 hours. The Director of Nursing wrote on the summary of the investigation as follows: This case has been reviewed with the Medical team and the medical Director. The facility believes there is no evidence of abuse, neglect or mistreatment. There was no investigation completion date. Further review of the medical record reveals no documented evidence that the injury of unknown origin was reported to the NYS DOH within 2 hours of the incident. On 03/13/2023 the Director of Nursing (DON) was interviewed and stated the injury of unknown origin was reported to NYSDOH on 1/11/23. The DON stated they know it should have been reported earlier, but there were a lot of things going on at the time. 415.4(b)(2)

Based on observations, record reviews, and interviews conducted during the Recertification survey from 03/09/23 to 03/16/23, the facility did not ensure that the Minimum Data Set (MDS) assessments accurately reflects the resident's status. This was evident for 2 out of 6 residents reviewed for Physical restraints and 1 out of 3 residents reviewed for close records, out of a sample of 35 residents. Specifically, 1.) the MDS assessments did not accurately document trunk restraints were used for 2 residents with a lap tray (Resident # 54 and Res #141) who were unable to release the lap trays independently due cognitive and disability impairment. 2.) Resident #179 was discharged to the community and the discharge MDS dated [DATE], documented discharge assessment return not anticipated, discharge status to acute hospital. The findings are: 1) Resident #141 had diagnoses which include Dementia, Cerebrovascular Accident (CVA), Parkinson's Disease, and Seizure Disorder, Traumatic Brain Injury (TBI) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired. The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS also documented trunk restraints were not used. The Physician's order initiated 11/15/2022, last renewed on 03/01/23, documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. On 03/13/23 at 09:55 AM, Resident #141 was observed in their room, sitting in a wheelchair (w/c) with a lap tray in place. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. Resident #141 was confused, not interview able, and unable to follow simple directions. The resident could not remove the lap tray when asked to do so. The Certified Nurse Aide (CNA) #1 was present during the observation. On 03/15/23 at 11:30 AM, Resident #141 was observed in the day room attending recreational activities with other residents. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. The restraint consent form dated 11/15/2022 documented that in order to prevent potential injuries, every effort was made to use alternative methods to provide a safe environment for the resident. Since alternatives were unsuccessful, it was determined a physical restraint was necessary. A lap tray was provided to facilitate midline positioning and was not being used as a restraint. The consent form was completed by the social worker and documented a verbal consent was given by a family member. The Comprehensive Care Plan (CCP) for Physical Restraint Secondary to a diagnosis of Traumatic Brain Injury (TBI) initiated 11/15/2022, revised 2/10/23 documented interventions to increase judgement and safety awareness, Rehab screen for restraint reduction if condition improved, and provide resident with change in position Q (every) 2 hours by toileting, ambulation and/or ROM (Range of Motion) exercise. During an interview on 03/13/23 at 02:40 PM, the Director of Social Work (DSW) stated that if rehab and nursing determines a restraint is necessary, social work will initiate the restraint consent form and notify the family. The DSW also stated that the team meeting concluded the lap tray was a restraint. During an interview on 03/16/23 at 01:05 PM, the MDS Coordinator stated that her staff completed the MDS assessment, and she reviews them. The lap tray is used for positioning because the resident has poor balance. That is why it was not coded as a restraint on the MDS. The facility has a lot of residents that use lap trays. A lap tray is not a restraint if the resident does not have the ability to remove it. If the resident is confused and cannot remove it, the lap tray is not a restraint. During an interview on 03/16/23 01:40 PM, the Director of Nursing (DON) stated that restraints are physical devices that restrict residents' movement. They stated that some residents do not have safety awareness, and the lap tray is used for positioning, not for resident safety. The DON stated that they have tried a series of different alternatives. Even when a resident cannot remove the lap tray, if they need it, it is not a restraint. 18881 2) Resident #54 had diagnoses of Non-Alzheimer's Dementia, Parkinson's Disease, Seizure Disorder and Traumatic Brain Injury. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired . The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS documented no restraints or alarms were used for the resident. On 03/13/23 at 11:59 AM , Resident #54 was observed seated in a wheelchair (w/c) in front of the Nursing station with a lap tray in place, attached to the w/c. On 03/16/23 at 12:07 PM, Resident #54 was observed again in front of the nursing station with a lap tray attached to the w/c. The resident was not able to move or remove the lap tray independently. A chair alarm was in place, and Resident #54 had a wander alert device on the left ankle. The Physician's order dated 02/06/2023,documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. Wander alert device placement and check every shift. Review of the Comprehensive Care Plan (CCP) revealed there was no CCP for the use of the lap tray. On 03/14/2023 at 12:50 PM, the Occupational Therapist (OT) was interviewed and stated Resident #54 had a history of falls and standing all the time. The lap tray was applied for positioning. The OT stated no other devices were tried prior to the use of the lap tray, and a wander alert device and chair alarm are used for the resident. On 03/16/2023 at 12:16 PM, the MDS Coordinator was interviewed and stated the MDS staff do the initial, significant change, and annual CCPs and assessments. The Nursing staff complete the quarterly and episodic CCPs. On 03/16/2023 at 12;20PM, the Registered Nurse (RN #1) was interviewed and stated no other devices were used prior to the lap tray. RN #1 stated Resident #54 likes to get up from the chair, and they will also get out of bed and walk down the corridor. Resident #54 had previous falls. 45349 3) A facility policy titled Minimum Data Set (MDS 3.0) documented a purpose to conduct consistent and periodic review of the resident status to ensure continuing accuracy of assessments. The comprehensive resident assessment (MDS 3.0) is completed for entry/discharge reporting. Resident #179 had a diagnosis of ST Elevation Myocrdial Infarction (STEMI), Hypertension, and Chronic Kidney Disease. The admission MDS dated [DATE] indicated that the resident had intact cognition. Resident #179 and their family participated in the assessment and goal setting. The resident's overall expectation was to be discharged to the community. Resident #179 was discharged from the facility on 12/19/22. The discharge MDS assessment dated [DATE] documented the resident had modified independence with decision-making. The type of assessment was discharge (d/c) with return not anticipated, and the resident was discharged to an acute hospital. Active discharge planning was already occurring for the resident's return to the community. A Comprehensive Care Plan (CCP), titled Discharge, with an effective date of 10/10/2022, documented the resident's d/c plan was to return home, and the Resident/ Representative will be actively involved in discharge goals and planning. The interventions included to Discuss Activities of Daily Living (ADL) needs and potential barriers. Elicit resident/representative goals regarding discharge if possible. Explore alternate living arrangements. Explore family/representative, community, and other support systems. Involve resident/representative in any discharge planning efforts. Monitor for discharge readiness. Provide psychological counseling for discharge planning and goal setting. Reassess needs and condition quarterly and as needed. A nursing note dated 12/19/2022 documented Resident #179 was discharged home to the community with their family. During an interview on 3/14/23 at 3:03 PM, the MDS Coordinator (MDSC) stated the MDS staff complete the discharge MDS. The electronic medical record (EMR) will trigger the discharge MDS for discharge with return anticipated or not anticipated. The MDS Coordinator said they check for accuracy before submission. The MDS Coordinator confirmed the record documented Resident #179 was discharged home with return not anticipated. The MDS Coordinator acknowledged that the discharge MDS documented the resident had an unplanned discharge to an acute hospital (A0310 and A2100). The MDSC stated these sections are not checked for accuracy, only whether or not return is anticipated is checked. During an interview on 3/14/23 at 3:13 PM, the Social Worker stated the resident had a planned discharge to the community. The Social Worker does not answer the MDS sections A0310 or A2100 (regarding where the resident was discharged to or type of discharge). During an interview on 3/14/23 at 3:28 PM, the Registered Nurse MDS (RN MDS) stated they read the nursing notes and the IDT section of the EMR to complete the MDS. The RN MDS stated the error was probably just an oversight. If there was a discrepancy between the notes and the IDT information, they would speak to the nursing supervisor and check a book in the nursing office to clarify the resident's status. During an interview on 3/15/23 at 10:19 AM, the Director of Nursing (DON) stated the MDS is done by the MDS Coordinator and a few MDS Assessors. The MDS Coordinator does the auditing to ensure accuracy and timeliness. The DON stated there have been no problems with MDS accuracy identified in the past. 415.11(b)

Based on record review and interview, during the recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to address a resident's medical, physical, mental, and psychosocial needs that are identified in the comprehensive assessment. This was evident for 3 of 35 sampled residents (Resident #s 93, 54, and 128). Specifically, a CCP for Activities was not developed for Resident #93 upon readmission. A restraint CCP was not developed to address Resident #54's lap tray. A CCP was not developed to address the care needs for Resident #128's midline catheter placement and use to administer Intravenous (IV) medication. The findings are: A facility policy and procedure titled Minimum Data Set (MDS 3.0) updated 8/28/2018, documented: The results of the comprehensive assessment (MDS 3.0) are used by the interdisciplinary team to develop, implement, evaluate, and revise the Comprehensive Care Plan (CCP). The MDS Coordinator/designee reviews the CCP to ensure appropriate care planning. The CCP should be updated at the time of the quarterly assessment. The facility Policy and Procedure titled Comprehensive Person-centered Care Plan dated September 01,2018 states It is the policy of this facility that a Comprehensive Person Centered Care Plan for each resident will be developed to include measurable objectives and timetables to meet resident's physical,medical,nursing,mental and psychosocial needs that are identified in the comprehensive assessment . A Baseline care plan will be developed within 48 hours of admission . A Comprehensive care Plan is developed within seven (7) working days after completion of the comprehensive assessment and is reviewed quarterly and as needed/revised as necessary by the appropriate discipline member of the CCP team . 1)Resident #93 was readmitted from the hospital on 2/14/23, with diagnoses Traumatic Brain Injury (TBI), Seizures, and Hydrocephalus. The Activities CCP dated 9/9/21, last reviewed 11/21/22, was deactivated when Resident #93 was discharged to the hospital. discharged upon resident's transfer to the hospital. It was last reviewed 11/21/22. The quarterly MDS dated [DATE] documented the resident had severely impaired cognition. The resident required extensive assistance of 2 for bed mobility and toilet use; total assistance of 2 for transfer. The physician's orders dated 2/14/23, included an order for out of bed to Geri-recliner. As of 3/14/23, there was no active Activities CCP in the medical record. There was no documented evidence that the Activities CCP was developed and implemented upon readmission and at the time of the quarterly assessment. During an interview on 3/14/23 at 10:00 AM, the Licensed Practical Nurse (LPN) #3 stated that the MDS nurse is responsible for initiating the care plans, and Recreation is responsible for updating the Activities CCP. During an interview on 3/14/23 at 10:06 AM, the Registered Nurse Supervisor (RNS) #2 stated that all disciplines, such as recreation, are responsible for developing and updating their care plans. The MDS department is only responsible for the nursing care plans. Upon readmission, the care plans need to be reactivated and revised to reflect any changes. During an interview on 3/14/23 at 10:17 AM, the Activity Director (AD) stated they are responsible for developing the care plans and completing the MDS. The Activity leaders complete the quarterly notes and care plan updates. The AD further stated that for a readmission, they do a readmission assessment and update the care plans. Upon readmission, they go to the history and reactive the previous care plan. During an interview on 3/14/23 at 10:48 AM, the MDS Coordinator (MDSC) stated an audit, which includes making sure the care plan is updated, is done prior to the care plan meeting. The MDSC stated recreation staff did not attend Resident #93's care plan meeting held in February 2023. The MDSC stated the Activities CCP should have been reactivated by the time the meeting was held. 415.11 18881 2) Resident # 54 admitted to the facility with diagnoses which include Non-Alzheimer's Dementia, Parkinson's Disease, Seizure Disorder and Traumatic Brain Injury. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired. The MDS also documented the resident required extensive assistance of one person for transfers and toilet use. The MDS documented no restraints were used for the resident. On 03/13/23 at 11:59 AM , resident observed several times seated in his wheelchair in front of the Nursing station , outside his room with a lap tray, unable to move, unable to release the laptray independently and a wanderguard to the left ankle and a chair alarm attached to the wheelchair. The Physician's order dated 02/06/2023 documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. Wander guard placement and check every shift. Review of the Comprehensive Care Plan (CCP) revealed there was no CCP for the use of the Lap tray. On 03/16/2023 at 12:16 PM, the MDS Coordinator was interviewed and stated the MDS staff create the significant change and annual CCPs. The Nursing staff complete the quarterly and episodic CCPs. On 03/16/2023 at 12;20PM, the Registered Nurse (RN #1) was interviewed and stated there was no care plan created for the lap tray, and no other device was used prior to the lap tray. 3) Resident #128 was admitted to the facility with diagnoses of Cerebro-Vascular Accident, Hypertension, and Urinary Tract Infection (UTI). The Minimum Data Set 3.0 (MDS) dated [DATE] assessment documented the resident had moderately impaired cognition with a Brief Interview of Mental Status score of 8 out of 15. The resident required supervision for Activities of Daily Living (ADLS). On 03/14/2023 at 2:34 PM, Resident #128 was observed in their room seated in a w/c. Resident #128 had a midline on the left antecubital for Intravenous (IV) antibiotics. The Physician's order dated 03/10/2023 documented orders for Ceftriaxone 1 gram (gm) IV daily (OD) for 7 days and Midline IV care every 3 days and as needed with flush of 10 cubic centimeter (CC) of saline OD. The Nurse Practitioner (NP) notes on 03/10/2023 documented Resident #128 was evaluated for follow up for recurrent UTI with positive retroperitoneal ultrasound (US) for left sided mild hydro nephrosis and increased echogenicity. Resident #128 endorsed some urinary discomfort and back pain, and the last urine culture showed E Coli sensitive to Ceftriaxone. The resident was diagnosed with Recurrent UTI/Pyelonephritis with hydro nephrosis and the recommended treatment was IV Ceftriaxone 1 gm for 7 days. Review of the nurses' notes dated 03/11/2023 documented the resident was started on Ceftriaxone 1 gram intravenous solution with IV Midline, intact and patent, no signs of leakage/bleeding/infection noted. Review of the Comprehensive Care Plan (CCP) revealed no CCP documentation on the Urinary Tract Infection and the insertion of the midline catheter for Intravenous access for antibiotic medication. On 03/15/2023 at 2;40 PM, the Licensed Practical Nurse (LPN # 1) was interviewed and stated there was no CCP addressing the midline catheter and IV antibiotics. LPN #1 stated the care plans are created by the MDS staff. On 03/15/2023 at 2:43 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated MDS staff are responsible for the care plans, and they have per diems who also come to assist. The staff are making the care plan now. On 03/26/2023 at 12:00PM, the MDS staff was interviewed and stated MDS staff does the initial, significant and the annual care plans. The Unit RN is responsible for the episodic and quarterly care plans. 415.11 .

Based on observation, record review, and interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 2 (Resident #45 and Resident #66) of 7 residents reviewed for Limited Range of Motion from a sample of 35 residents. Specifically, Residents #45, a resident with left hand contractures, was observed without a left palm guard in place, as ordered, and Resident #66, a resident with left hand contractures, was observed without a left resting hand roll in place, as ordered. The findings are: 1) Resident #45 was admitted to the facility with diagnoses which include Hemiplegia and Hemiparesis following cerebrovascular disease affecting the left non dominant side, Seizure Disorder and Primary Hypertension. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident required extensive assist of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene. Furthermore, the Resident had functional limitation in Range of Motion on the left upper and left lower extremities. The Physician's Order, renewed on 02/08/2023, documented an order for the resident to wear a left palm guard when out of bed. On 3/13/2023 at 11:16 PM, Resident #45 was observed in the hallway with no left palm guard on. On 3/14/2023 at 9:27 AM, Resident #45 was observed in their room sitting in the wheelchair with no left palm guard on. On 3/15/2023 at 11:19 AM, Resident #45 was observed sitting in the hallway talking to another resident with no left palm guard on. The Occupational Therapy quarterly assessment created on 1/14/3023 and completed on 1/20/2023 documented a rehab nursing recommendation for left palm guard when out of bed for skin protection. The quarterly review for the ADL's care plan updated on 1/26/23 documented Resident #45 has no significant change in ADL functioning. Goals were met and the plan of care was continued. On 3/15/2023 at 12:16 PM, the Certified Nursing Assistant (CNA #3) was interviewed and stated that somebody saw the resident throwing the hand splint in the garbage two to three weeks ago. CNA #3 stated that is why the resident is not wearing the left palm guard. On 3/15/ 2023 at 11:51 AM, the Occupational Therapist (OT) was interviewed and stated that the resident was on rehab from 1/11/2023 to 1/31/2023. The recommendation was for the resident to have a left palm guard to keep the fingers off the palm to prevent any loss of motion. The OT further stated, when out of bed, resident is supposed to have the palm guard in his left hand. The palm guard was missing. As per OT, no one reported to him that the palm guard was missing. That's why the resident was not wearing the palm guard. On 3/15/2023 at 12:02 PM, the Registered Nurse (RN #3) was interviewed and stated that the device was provided to the resident by Occupational Therapy. Resident #45 is non-compliant with the device and put it in the garbage. The medication nurse told her 3 weeks ago, and she did not report it to rehab or document it. 2) Resident #66 was admitted to the facility with diagnoses which include Essential Primary Hypertension, Cerebral Infarction, Diffuse Traumatic Brain Injury, and DiabetesMellitus. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The resident required extensive assist of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene. Furthermore, the Resident had functional limitation in Range of Motion on the left upper and left lower extremities. The Physician's Order, renewed on 02/06/2023, documented an order for the resident to wear a left resting hand roll when out of bed as tolerated. On 3/13/23 at 11:43 AM, Resident #66 was observed in their room sitting in the wheelchair with no left resting hand roll on. On 3/14/23 at 11:39 AM, Resident #66 was observed in the hallway sitting in the wheelchair with no left resting hand roll on. On 3/15/23 at 12:38 PM, Resident #66 was observed in the dining room getting hand fed by the CNA with no left resting hand roll on. The Occupational Therapy quarterly assessment created on 1/14/3023 and completed on 1/19/2023 for resident #66 has a rehab nursing recommendation for left resting hand roll when out of bed as tolerated. The quarterly review for the ADL's care plan updated on 1/26/23 documented that Resident #66 tolerated physical and occupational therapy. Goals were met, and the plan of care was continued. On 03/15/23 at 01:09 PM, CNA #4 was interviewed and stated that Resident #66 was fighting with them, so they needed someone to assist with putting the hand roll on. Then, CNA #4 forgot to put the hand roll on. On 03/15/23 at 01:04 PM, RN #3 was interviewed and stated that Resident #66 wears the hand roll as ordered, and it was just put on the resident. On 03/15/23 at 3:02 PM, the Occupational Therapist (OT}was interviewed and stated that Resident #66 was on rehab from 1/10/23 to 1/27/23. A hand roll was recommended to keep the left hand open. If a device is missing, they replace it right away. The OT further stated this afternoon, nursing staff called them to report Resident #66's hand roll was missing. The hand roll was replaced this afternoon. 415.12(e)(2)

Based on observation, record review, and interviews conducted during the Recertification survey from 3/9//23 to 3/16/23, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (3 North Unit). Specifically, two bottles of expired Bisacodyl tablets were stored in 3 North Unit medication room. The findings are: The facility policy titled Removal of Expired Medications last revised 01/2023 documented, Medication carts, cabinets and refrigerators will be routinely checked by nursing personnel. All expired medications will be removed and discarded. Nursing staff will remove and bring expired or unused medications to the Nursing office for proper disposal or return to pharmacy. On 3/15/2023 at 9:37 AM to 10:09 AM, the 3 North Unit medication room was observed with the Licensed Practical Nurse (LPN #2) and the following was observed in the top drawer of the counter: two unopened bottles of Bisacodyl tablets each with 100 counts (lot # B00STLY13K) with expiration date of 02/2023. On 3/15/2023 at 10:10 AM, LPN #2 was interviewed and stated they check the medication room regularly for expired medications and nothing in the medication room should be expired. LPN #2 stated they did not notice the two expired bottles of Bisacodyl tablets in the medication room cabinet. On 3/16/2023 at 2:13 PM, the Registered Nurse Supervisor (RNS #2) was interviewed and stated the nurse in charge of the unit must check all medications in the medication room for expiration. If expired, the medications must be brought to the nursing office for destruction and they will call the vendor (Tristate) for replacement. The expired Bisacodyl tablets were overlooked and should have been removed from the medication cabinet. On 3/16/2023 at 2:25 PM, the Licensed Consultant Pharmacist was interviewed and stated they inspect medication rooms and medication carts once a month. If medications are expired, they will remove the medications from the unit and bring them to the Director of Nursing. On 3/16/2023 at 2:31PM, the Director of Nursing (DON) was interviewed and stated the nurse in charge of the unit must check the medication room and cart for nearing expiration or expired medications. Corrective Action was taken for the expired Bisacodyl tablets found in 3 North unit medication room. 415.18(e) (1-4)

Based on observations and interviews conducted during the COVID-19 focused survey, the facility did not ensure that infection control protocols were maintained to help prevent transmission of communicable diseases and infections. Specifically, several rooms were observed with no contact/droplet precaution signs on the doors of residents in unit 1 E that was designated for confirmed COVID and non COVID residents. This was evident on 1 of 5 resident units. (Unit East 1) The findings are: The facility policy and procedures titled Contingency plan for [MEDICAL CONDITION] Disease COVID 19 dated 5/1/20 documented the following: Resident with a suspected or laboratory confirmed COVID 19 shall be placed in a private room if possible or cohort and maintained on Contact/Droplet Precautions. Signage will be posted outside the resident room and the type of Transmission based precaution ( i.e. Droplet, Contact). PPE supplies shall be monitored and visually check by the unit charge nurse for its availability and accessibility. Central supply personal will generate a weekly inventory and will report to Nursing Administration. On 05/01/20 at 9:25 AM, during the entrance conference with the Assistant Director of Nursing (ADNS), she stated that COVID 19 confirmed and suspected residents were only on 2 North and 2 South. The ADNS also stated unit East 1 is mostly for residents admitted with [MEDICAL CONDITION] (TBI). The ADNS further stated they were cohorting residents with positive COVID 19 and ensuring that designated staff are assigned to those residents. The facility provided a list of residents who were COVID 19 positive and their location. On 5/1/20 at 10:30 AM, during observations on Unit E 1, the Registered Nurse (RN#1 charge nurse) stated the unit was home to 7 residents who tested positive for COVID 19 along with other residents who were not tested . Multiple observation were made between 10:30 AM and 12 Noon, and there were no Contact/Droplet Precautions signage posted on the doors of any residents. Rooms that were confirmed with COVID 19 were rooms 102, 106, 108, 111, 113, 114 and 120. On 5/1/20 at 11:33 AM, an interview was conducted with the Licensed Practical Nurse (LPN) #1. LPN #1 stated she works 5 days a week and she knows the residents who are positive and those that are negative. LPN #1 also stated the physician orders [REDACTED]. The LPN further stated a list of positive residents was provided to them at the morning report. On 5/1/20 at 1:00 PM, the ADNS was observed on the E 1 unit, posting Contact/Droplet Precautions signage on the doors of those resident who were confirmed positive for COVID 19. The ADNS stated that the residents who are confirmed COVID positive were admitted from the hospital with that [DIAGNOSES REDACTED]. No resident is currently receiving treatment and no resident is having symptoms related to COVID 19, so we are monitoring them. The ADNS further stated that the facility does not do testing to confirm if they are still positive or now negative. The ADNS also stated that she just realized that those residents need signage by their door despite the fact that staff have a list of residents who were positive. 415.19 (a)(2)

Based on observation the facility failed to ensure that its staff demonstrates proper hand hygiene between residents to prevent the spread of infections. Specifically the Licensed Practical nurse (LPN#1) was observed on 2 occasions administering medications and not [MEDICATION NAME] hand hygiene. 2) LPN#1 was also observed not [MEDICATION NAME] hand hygiene after assisting a resident with care and then opening medication to give to another resident. This deficient practice was observed by one nurse on multiple occasions. The findings are: The facility Policy and Procedure on Standards Precaution dated (MONTH) (YEAR) documented wash hands immediately after gloves are removed, between patient contacts, and otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures. Use plain, non-antimicrobial soap for routine hand washing. Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances such as outbreaks. The facility general guidelines on infection control stipulates that standard precautions shall be used when caring for residents at all times regardless of their infection status , it must be used in the care of all residents , in all situations, before preparing or handling medications. 1) On 8/22/18 at 9:00 am during medication observation LPN #1 on 2 south was preparing to administer medication when she noticed a resident was having difficulty propelling his chair. She had stopped, held onto the wheelchair handles and assisted the resident moving. The LPN had not washed her hands but proceeded opening the medication cart and was reaching out for medication packages . She was stopped by the surveyor. The LPN stated: I should have washed my hand prior going into the medication cart. On 8/22/18 at 9:15 AM LPN #1 was interviewed on infection control and prevention, she replied: I did wrong, I should have washed my hands before touching the medication on the cart or used the hand sanitizer, I have it right here on the cart. I did touch the handles of the chairs, a lot of people touch these handles. She was asked about her education regarding infection control as it relates to medication administration. She replied that she was educated in hand hygiene procedure and policies. LPN #1 was interviewed about details regarding the in-service and education. She stated: I was instructed that we must wash our hands before starting medication administration and afterwards, between residents we must maintain universal precautions when caring for residents at all times. The in-service coordinator was interviewed on 8/22/18. She stated that LPN#1 was enrolled in a in-service class on hand washing on 1/17/18, the in-service attendance record indicated the same. 415.19(b)(4) 2) On 8/24/2018 10:00 AM on the 2nd floor LPN #1 was randomly observed giving resident #165 his medication at the medication cart. The LPN then proceeded to position resident #35 in his wheelchair, he was sitting in front of his room. No hand hygiene was observed between giving resident #165 medication and providing direct assistance to Resident #35. 3) After assisting resident #35, the LPN returned to the medication cart and proceeded to retrieve medication from the cart and then proceeded to pop out medication from the blister pack. LPN #1 did not perform hand hygiene after assisting resident #35; or prior to retrieving medication from the medication cart and opening the blister pack and popping out the medication. On 08/28/18 at 11:29 AM a second interview was conducted with LPN #1. She stated hand washing is performed when giving and after medication, between residents, when touching resident equipment, when residents are on contact precautions and residents' bodily fluids. She stated antimicrobial agent is used when given medication between residents. Soap and water is used after medicating three patients, or being in contact with blood or bodily fluid. Hand washing is performed for a duration of 3-4 minutes. She stated that the last time she received in-services were two months ago. On 08/27/18 at 10:27 AM the Infection preventionist was again interviewed. She stated that the protocol on hand washing for example are performed after using the bathroom, visibly soiled and contaminated, before feeding after taking care of residents, nursing care and procedures. She stated that the staff get in-services at least twice per week and when need arises. The staff gets demonstration and then the facility does return demonstration. The staff can also use an online learning service that staff for education. There is also a competency that is performed to ensure compliance. On 08/28/18 at 08:28 AM the ADON (Assistant Director of Nursing) was interviewed. She stated that staff should be washing their hands before care, after care, between residents and during medication administration. Before using the rest room and after using the rest room and if hands become soiled staff are supposed to wash their hands right away. She stated that there is alcohol based hand rub that is available for hand hygiene on each unit, on medication carts and communal areas within the facility. If a resident has [MEDICAL CONDITION] the staff must use soap and water and performed proper hand hygiene. She stated that in-services are given by the infection control nurse. 415.19 (b) (4)

Based on interview and record review during the recertification survey it was determined that the facility did not ensure that two quarterly MDS (Minimum Data Set) resident assessments were transmitted to CMS (Centers for Medicare/Medicaid Services) within 14 days of completing the residents' final assessment. This was evident for 2 out 5 residents reviewed for accuracy and timely submission of assessments out of a sample of 33 residents. ( Resident #1, and #2) The findings are: The policy and procedure on Minimum Data Set (MDS 3.0) reviewed on ,[DATE] documents IDC (Interdisciplinary) team members completes discipline specific assessments. Completes appropriate section of MDS 3.0. Signs completed MDS 3.0 attesting to its completion. Submission and Filing of MDS: MDS coordinator review completed MDS assessments after performing logic checks and corrections. The administrator submits MDS to the state. The MDS assessment for Resident # 1 was completed on [DATE], but was not submitted until [DATE]. The MDS assessment for Resident #2 was completed on [DATE], but was not submitted until [DATE]. An interview was conducted on [DATE] at 9:21 AM with the RN ( Registered Nurse) MDS assessor. The surveyor interviewed the MDS assessor about residents assessment for resident #1 and #2. The RN MDS assessor stated that they submitted both quarterly assessments late. The ARD (Assessment reference date ) was [DATE] end [DATE] and the quarterlies were submitted on (MONTH) 22,2018. The state agency surveyor (SA) asked the RN MDS what the process once there are ready for submission she determines when to submit the MDS complete books. Both assessments were information in Section O (psychotherapy total number of therapy days). Both resident was not receiving psychotherapy. The RN who suppose to complete the section was unaware that the section was completed by the RN MDS assessor. An interview with the Administrator was conducted on [DATE] at 3:15 PM. The MDS process is they have a MDS coordinator and different professional go into the books and complete there sections and once the books are ready for submission the MDS coordinator, and MDS assessor and RN MDS person who covers the coordinator can give the administrator a list of books that are completed to be submitted. Once they provide the list of completed MDS the administrator submits the books right away. The SA asked the administrator what happen to resident # 1 and #2? The administrator responded that the coordinator never gave the assessments to the administrator to submit. The administrator states that his role is to submit the books that are completed, he submits all assessments the day he gets the completed one, whether it is a resident who expired, transferred, or left to the community. If the book is rejected he notifies the MDS personnel right away and they would fix it. Another interview was conducted on [DATE] at 9:45 AM with the MDS assessor. She stated it would be the MDS coordinator responsibility to ensure the MDS is complete and submitted. An interview was conducted with the MDS coordinator on [DATE] at 12:07 PM. The MDS coordinator stated the following is my responsibility: coordinating and completion of the MDS books, care planning schedule for care plans, schedule MDS books along with care plan meeting. The MDS coordinator is responsible Monthly for medicare MDS assessment to be completed reviewed and submitted. She is responsible for all residents MDS assessments. The surveyor asked if she reviews that all books are completed and submitted in a timely manner and what occurred with resident #1 and resident #2 assessments. The MDS coordinator missed looking at Section O to ensure it was completed (the psychotherapy). The new MDS assessor did not want to put in the wrong information and it was missed.

Based on records review and staff interviews conducted during the recertification survey, it was determined that the facility did not ensure that assessment accurately reflected the residents' status. Specifically, The (MDS) Minimum Data Set assessments for Residents #11 and #134 did not accurately reflect the active [DIAGNOSES REDACTED]. This was evident for 2 out 33 of sampled residents reviewed. The findings are: 1) Resident # 11 was observed in a private room on 8/20/18 at 10:33 AM. The room is directly across from the nursing station. During subsequent observations of the resident on 8/23/18 12:008 PM the CNA (Certified Nurses Assistant) was setting up the resident's lunch plate and then fed the resident. The resident refused most of the meal. The resident was also observed in bed fully clothed on most days during the recertification survey. The MDS dated [DATE] documented the following Diagnoses: [REDACTED]. The MDS dated [DATE] only documented the [DIAGNOSES REDACTED]. The resident's most recent medical record documented that the resident was still being treated for [REDACTED]. On 2/27/18 the consultant Opthalmologist documented a [DIAGNOSES REDACTED]. Further documented [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The CCP (Comprehensive Care Plan) dated 7/30/18 Documented the following identified problems and interventions: 1) Dementia, Mood state indicated by easily annoyed, restless, sad affect, little energy, may urinate on floor 2) cognitive deficit 3) [MEDICAL CONDITION] OU dense cataract OD s/p retinal detachment OS [MEDICAL CONDITION] no tx. 4) decreased communication, 5) self care deficit 6) activities 7) psychosocial well being 8) Behavioral problem 9) at risk for falls and injury related to cognitive deficit, sensory deficit, communication deficit, incontinence, handheld assist, [MEDICAL CONDITION] drug use, aggressive behavior, likes to go back to bed after meals, dx [MEDICAL CONDITION], rhobdo[DIAGNOSES REDACTED] and [MEDICAL CONDITION] with interventions to orient to surrounding & environment PRN, call bell within reach, keep bed low & locked, instruct res to request for assistance from staff, PT/OT screen assist with transfers & ADL's as necessary, continual assessment of mobility & need for assist, psych f/u & meds as ordered with eval doc 5/10/18 res has non injurious fall in room - neurocheck done x 24hrs CCP continue no injury. 8/20/18 res was obs on floor lying on left side no injury no s/s of distress, intervention= neurocheck, body check. 2) Resident #134 was observed on 08/23/18 at 2:18 PM seated in high back wheel chair, clean, well groomed, lap tray on wheel chair with lunch tray on top. The resident independently feeding self with use of right hand and left hand splint in place. both feet supported on stirrups. The MDS dated [DATE] documented the resident with [DIAGNOSES REDACTED]. The MDS dated [DATE] only documented that resident with the following Diagnoses: [REDACTED]. The resident's medical record documented that the resident was receiving treatment for [REDACTED]. On 08/28/18 at 1:17 PM the MDS coordinator who was responsible for all assessments was interviewed. The MDS coordinator stated that she missed the review of that section of the MDS that documents diagnoses. 415.11(b)

Based on observation, interview and record review during an abbreviated survey (Complaint ID # NY 403), the facility did not ensure that safe and effective use of assistance devices to prevent serious injury was provided to one of three residents reviewed for accidents (Resident #1). Specifically, Resident #1 fell during a transfer with a mechanical lift (Hoyer) resulting in bleeding from the right ear. The facility staff did not follow correct application of a divided leg sling in accordance with the manufacturer's recommendations that caused the resident to slide out of the sling and fall. Subsequently, Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. The findings are: The undated Policy & Procedure Titled Hoyer Lift documented a procedure on how to use Hoyer slings. The policy included use of a Full Body Sling, and procedure included to place the top of the sling under the resident's head and the bottom part a few inches under the back of the resident's knees. The procedure to use the Divided Leg Sling included to insert the bottom part of the leg sling around and between the thighs then hang the straps or cross the straps. The Lesson Plan entitled Use of Hoyer Lift and Hoyer Lift Sling dated 10/2015 documented the type of Hoyer lift used and the 2 types of slings used (full body sling and divided leg sling). A manual was attached to the lesson plan titled Using (various slings) including Divided leg sling and documented to lift the patient's legs (one at a time) and reach under the patient's leg to pull the front sling until it was behind the patient's knees. The back of the sling should remain in position. The straps may be around, crossed between or underneath the patient's legs. The lesson plan was given to all nursing staff upon hire and whenever a new equipment was bought. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set 3.0 (MDS-an assessment tool) dated 08/07/2016, the resident was severely impaired in cognition and required the total assistance of two persons for transferring. The Comprehensive Care Plan (CCP) dated 01/20/2015 documented resident was at risk for falls and injury related to cognitive deficit, sensory deficit, communication deficit, incontinence and poor safety awareness. Interventions included to assist with transfers and Activities of Daily Living (ADLs) as necessary. Resident had no history of falls. The CCP dated 02/02/2015 documented resident with self-care deficit related to [DIAGNOSES REDACTED]. Interventions included to provide assistance with ADL's, total assist of 2 for transfer via Hoyer lift and out of bed to Geri-chair with helmet. The CCP did not indicate the specific Hoyer sling to be used for Resident #1. The Nursing Assistant Clinical Accountability Record and Assignment dated 08/2016 documented the resident was dependent on transfer with 2 person assist via Hoyer lift. The Nursing Progress Notes (NPN) and CCP had updated entries for fall dated 08/26/2016 at 4:00 PM that documented, when 3 CNAs (Certified Nurse Aide) lifted the resident with a Hoyer lift, resident slid out of the Hoyer lift sling and landed on the floor on her buttocks and resident hit her head on the chair sling. Resident was noted with a small amount of fresh blood coming from right ear. There was no change in level of consciousness, neuro check was done. Vital signs were stable. The MD was made aware and resident was transferred to hospital at 6:30 PM. Resident was admitted to the hospital on [DATE] at 5:45 AM with [DIAGNOSES REDACTED]. The facility's investigative summary dated 08/31/2016 documented that on 08/26/2016 at approximately 4:00 PM, it was reported that the resident slid from the sling of the mechanical lift to the floor while being transferred from chair to bed. The nurse and Supervisor were called and the resident was assisted back to bed. There was no apparent change in condition, however noted a small amount of blood in her right ear. The resident was transferred to the hospital. The facility's investigation also documented a re-enactment of the incident was demonstrated by the CNAs with use of the lifter and at the time of the incident they failed to apply the sling as to avoid possible slippage. The investigation established that this was an unforeseen isolated incident where staff had received competency, in-service and failed to use proper procedure. The staff (three involved CNAs: CNA #1, CNA #2 and CNA #4) were disciplined and re-in-serviced. The personnel record of CNA #1 and CNA #4 documented they received in-service on use of Hoyer lift and 2 types of slings on 10/28/2015 and 1/27/2016. CNA #2 received in-service on Hoyer lift and Hoyer sling on 07/15/2016 however, it was not documented if the CNA received in-servicing on the two different slings utilized by the facility. The facility lacked documented evidence of evaluations for Hoyer Lift and sling use to validate competency for CNA #1, #2 and #4. The hospital emergency room discharge notes 08/26/2016 documented resident with right ear bleeding status [REDACTED]. Resident was transferred to another hospital trauma unit for neurosurgery. Resident was diagnosed with [REDACTED]. CNA #1, who worked the 3:00 PM - 11:00 PM shift, was interviewed on 11/20/2017 at 12:50 PM. CNA #1 stated she worked on 08/26/2016 and assisted CNA #2 in transferring Resident #1 utilizing the Hoyer lift. CNA #4 was also in Resident #1's room and assisted with the transfer. As Resident #1 was lifted, she slipped out from the bottom of the sling and fell to the floor; her head touched the floor. CNA #1 stated they called the nurse. There was bleeding from Resident #1's ears and she was sent to the hospital. CNA #1 stated that the Hoyer sling was already underneath Resident #1 while she was sitting in the Geri chair. It was not the regular sling (full body sling) that the facility currently utilized; it was a divided leg sling. CNA #1 stated the divided leg sling was not normally used by the facility and it was the first time she used this sling and Resident #1 fell . CNA #1 further stated that she had in-service on the use of a full body sling but not the divided leg sling when she was first hired. CNA #1 stated when they were lifting Resident #1 with the sling, she did not know it was a divided leg sling. She noticed the sling when Resident #1 was already lifted but before she could do anything Resident #1 already fell . CNA #1 stated the sling was not placed or crisscrossed under resident's legs. The Registered Nurse In-service Coordinator (RNIC) was interviewed on 11/20/2017 1:37 PM and stated that, when the incident happened, there were two different kinds of sling used by the facility, full body sling and the divided leg sling. The RNIC described that when the divided leg sling was used the resident could be in a reclining or supine position, the right leg of the sling goes underneath the right thigh and the left leg of sling goes underneath the left thigh. The slings divided leg could be crisscrossed or not but should be underneath the thighs. The RNIC stated staff could use either of the slings for Resident #1. The RNIC stated the staff were in-serviced on 10/28/2015 on the use of divided leg sling and on 1/2016 the staff were in-serviced on the use of full body sling. The RNIC stated she provided the in-service to the staff and the supplier of the lifter did a demonstration on how to use the Hoyer slings. A video and actual demonstration was done during in-servicing. The three involved CNAs were in-serviced prior to the incident on the use of both the full body and divided leg slings. The RNIC stated that the staff incorrectly used the sling during the reenactment of the transfer after the incident. The staff did not place the sling legs underneath Resident #1's thighs causing the resident to slide out. The RNIC stated that she demonstrated and asked the staff for return demonstration of the procedure on the use of Hoyer lift periodically but it was not documented. CNA #2, who worked the 3:00 PM - 11:00 PM shift, was interviewed on 11/20/2017 at 2:30 PM and stated she was assigned to Resident #1 on 08/26/2016. Resident #1 was on her Geri-chair (reclining chair) and CNA #1 and CNA #4 came and helped her. CNA #2 stated she knew Resident #1 used a Hoyer lift for transfer. CNA #2 stated there was already a Hoyer sling underneath Resident #1 and she informed CNA #1 and #4. CNA #2 thought that CNA #1 and #4 were familiar with the use of sling. CNA #1 and #4 showed her how to hook the sling. CNA #2 could not recall if the sling was placed underneath the Resident #1's thigh or if the sling was crisscrossed. When they started to move the Hoyer lift Resident #1 slid off through the bottom of the sling and fell . CNA #2 stated she received in-service on the full body sling but not the divided leg sling. The 7:00 AM-3:00 PM CNA #3, who worked on the day of the incident was interviewed on 11/20/2017 at 2:58 PM and stated she was assigned to Resident #1. CNA #3 stated she always used the full body sling for Resident #1's transfer. CNA #3 stated the Supervisor gave her the divided leg sling and she used it that day. She stated the divided leg sling was placed underneath the resident and was crossed underneath the thighs so the resident was secure. She stated she received an in-service from the facility on the use of full body sling but not the divided leg sling but she knew how to use the divided leg sling from her other job. CNA #4, who worked the 3:00 PM - 11:00 PM shift, was interviewed on 11/20/2017 at 3:15 PM and stated that she went to Resident #1's room to get the Hoyer lift for another resident and CNA #1 and CNA #2 were about to transfer Resident #1 to bed. The resident was already hooked up in the Hoyer. When they lifted Resident #1, she slid off the sling and landed in a sitting position and then went down on her side. CNA #4 was in front of Resident #1 and she did not recall who was controlling the lifter. CNA #4 stated that, prior to the incident, she did not know how to use a divided leg sling and she had not received an in -service. She stated she was familiar with the full body sling and she never used the divided leg sling prior to the incident. CNA #4 stated she did not notice the type of sling Resident #1 was using until the incident happened. CNA #4 stated the sling was not placed or crisscrossed underneath Resident #1's thigh. The Director of Nursing Services (DNS) was interviewed on 11/20/2017 at 6:13 PM and stated that most of the staff had been using the full body sling and, although most staff recognized the divided leg sling, it was not used frequently so he told housekeeping to remove the divided leg slings from the units. The staff stated that they did not recognize it was the divided leg sling because the sling was already underneath Resident #1. The sling was not appropriately secured by crossing underneath the Resident #1's thigh. Resident #1 slid out of the sling and landed on her buttocks. Resident #1 fell and her head hit the Geri-chair. Resident #1 was assessed and noted with a small amount of bleeding from ear. Her vitals were stable and she was transferred to the hospital and she was admitted . The DNS stated that all three CNAs were familiar with the divided leg sling. The DNS stated that two involved CNAs (CNA #1 and CNA #4) received education that the facility provided prior to the incident (on the devided leg sling). According to the DNS, CNA #2 was in-serviced at that time on both type of slings, but had stated she did not frequently use the cross sling and did not recognize it. CNA #2 also stated she did not remember that she was in-serviced on the use of divided leg sling. CNA #1 was familiar with the divided leg sling but she was not aware that the divided leg was used for Resident #1 at the time of the incident. CNA #1 and CNA #4 both recognized the divided leg sling but they could not remember how to use the sling because of infrequent use. Based on investigation, an accident occurred and the root of the problem was the unfamiliarity with the Hoyer sling because of infrequent use and, when staff used the sling at that time, they did not recognize it. The Registered Nurse (RN) #1, who stated she was the RN staff nurse assigned to Resident #1 on 08/26/2016, was interviewed on 12/07/2017 at 2:43 PM. RN #1 stated CNA #2 was new to the facility and she was not familiar with the divided leg sling. CNA #1 and CNA #4 were trained on the use of divided leg sling but they forgot how to use it. The Lifter Sales Representative (SR) was interviewed by phone on 1/24/18 at 11:30 AM and stated he provided in-service to the facility staff on the use of lifter (Hoyer) and lifter slings. The SR stated he could not recall if the facility was using divided leg slings or if he had given in-service to the staff for use of divided leg slings. The SR stated that the divided leg sling's legs should be placed behind the resident's knees to secure the resident and prevent sliding out of the sling during transfers. Based on the following corrective action taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -The facility discontinued use of the divided leg Hoyer sling. -Educated all nursing staff related to Hoyer lift and Hoyer sling use. -During an onsite visit 13 staff members (CNAs, and licensed nurses) from various shifts were interviewed and acknowledged that the divided Hoyer sling were not being used by the facility. 415.12(h)(1)(2)

Based on observation, record review and staff interviews during the recertification survey the facility did not address specific behaviors and proper mattress and the use of a side rail for Resident #8 to ensure his safety. This was evident for one of one resident reviewed for Hospice in a total stage two sample of twenty-eight Residents. Specifically, Resident # 8, was found with his right leg caught in the gap between the side rail and the mattress on 10/31/13 and on 11/2/13 it was determined that he had a Fractured Mid Shaft Right Leg. This resulted in actual harm that is not immediate jeopardy for this resident. The finding is: Resident # 8 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated 5/13/13 documented that the resident had severely impaired cognition. The resident's mood score was documented as a 13. The symptoms documented for this resident included included feeling down, trouble falling or staying asleep, trouble concentrating and being short tempered. The MDS also documented that the resident exhibited physical verbal and other behavioral symptoms not directed towards others daily. The overall presence of these behaviors significantly interfere with the resident's care. The behaviors also interfere with the resident's participation in activities or social interactions. Additionally, these behaviors place the resident and others at significant risk for physical illness or injury. The MDS also documented that the resident was totally dependent on staff, requiring a two person assist for bed mobility, transfer, toilet use and bathing. The Resident has a limitation in his range of motion on one side of his upper body and both sides of his lower extremities. A Rehabilitation (rehab) note dated 11/2/13 at 3:00 PM documented that after the resident was showered and transferred back to bed by two Certified Nursing Assistant's (CNA) they noticed some "swelling to the right thigh, deformity and pain upon touching". A nurse's note dated 11/2/13 at 3:00 PM documented that the resident was noted with a deformity to his right thigh. The note further documented that the physician was notified and the resident was transferred to the hospital for further evaluation. The Accident/Incident (A/I) report dated 11/2/13 at 3:00 PM documented that after receiving his shower, the resident was noted with slight swelling to right Femoral area. The A/I further documented that the resident was observed "in bed rubbing his right leg, grimacing and rolling from side to side and unable to extend his right leg". The physician was notified and the resident was transferred to the hospital. The resident was admitted with a Fractured Distal Femur. A hospital x-ray report dated 11/2/13 documented that the resident had sustained an Acute Comminuted Spiral Fracture of the Midshaft right Femur. As part of the investigation into the fracture a statement by CNA #1 documented that on 10/31/13 at 5:45 PM as she entered the resident's room she observed the resident's right leg stuck in the gap between the side rail and the bed. CNA #1 documented that she immediately left the room to notify the nurse and get help. Upon her return to the resident's room the resident's right leg was free. On 3/26/14 at 12:30 PM the 7:00 AM -3:00 PM RN Charge Nurse on the unit where Resident # 8 resides was interviewed. The RN stated that she had called maintenance several times to change the side rails due to too much spacing on Resident # 8's bed. The RN also stated that the rails have been changed more than once. The Maintenance Log book was reviewed with the RN. On 7/23/13 there was an entry that bed side rails needed to be fixed for Resident #8. There was evidence of a check mark, that this repair had been made. On 3/26/14 at 1:00 PM the Director of Maintenance was interviewed. The Director stated that Resident # 8 has a 63 inch length side rail. The Director stated that he was aware of the gap between the side rail and the mattress on this bed. The Director further stated that the side rails are not made to withstand the constant movement which Resident # 8 exhibits. The Director further stated that he is doing constant repairs on side rails but that he does not keep a record of such. The Director did state that he could not recall being asked to repair side rails for Resident # 8 specifically. On 3/26/14 at 1:10 PM the physician for Resident # 8 was interviewed. The physician stated that he was also the Medical Director for the facility. The physician stated that he was aware of the fracture for this resident . The physician stated that if there too much of a gap between the side rail and the mattress this type of injury could have resulted. This type of injury is consistent with a resident with inconsistent behaviors. The physician further stated that it was possible for a couple of days to pass before the fracture would be evident because the resident was non- ambulatory. He also stated that had if he been called when the leg was caught in the gap between the rail and the mattress he would have ordered an x-ray. The physician further stated that when the resident returned to the facility, after the fracture, a different bed should have been in place. On 3/26/14 at 2:00 PM the Administrator was interviewed. The Administrator stated that he knew about an investigation pertaining to Resident # 8 having a Fractured Right Hip on 11/2/13. The Administrator stated that the investigation was initiated on 11/2/13 after the fracture had been identified. The Administrator further stated that at the time the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) were completing the investigation they thought it was "nothing", there was no swelling, no reason to think there had been an incident that caused this fracture. It was not until the Certified Nursing Assistant (CNA #1) made her statement, that on 10/31/13 the resident had gotten his right leg stuck in the gap between the side rail and the mattress, that the DNS felt that was probably when the fracture occurred. On 3/26/14 at 2:45 PM the Registered Nurse (RN) 3:00 PM-11:00 PM per diem float who was assigned to the unit where Resident # 8 resided on 10/31/13 was interviewed. The RN stated that she had no recall of any such incident with Resident # 8 getting his right leg stuck in the gap between the side rail and the mattress. She stated that she did know who the CNA was that stated that she found Resident # 8's right leg stuck in the gap between the side rail and mattress. The RN however, stated that the CNA #1 did not report any incident to her. The RN further stated that had she been informed about Resident # 8 she would have assessed the resident and documented the same in the nurse's notes. The Director of Nursing Services (DNS) was interviewed on 3/26/14 at 2:45 PM. The DNS stated that she was unaware of the 10/31/13 incident for Resident # 8 until 11/2/13. On 11/2/13 when the DNS was made aware of the resident being transferred to the hospital, she examined the bed and found if difficult to imagine how he was able to get his leg through the space between the side rail and the mattress. The DNS stated that had she been aware of the 10/31/13 incident she would have notified the physician and she would have evaluated the side rails herself. On 3/26/14 at 3:00 PM the Certified Nursing Assistant (CNA #1) assigned to Resident # 8 on 10/31/13 was interviewed. CNA #1 stated that she did recall Resident # 8 getting his right leg stuck in the gap between the side rail and the mattress that evening. According to CNA #1 this was a very common occurrence for this resident, a "norm". CNA #1 stated that the resident's side rail has been changed many times on the 3:00 PM -11:00 PM shift. She stated that sometimes the rail is hanging off or a screw is missing and the whole bed has been changed. CNA #1 stated that the resident will usually get help from other CNAs to free his arm or leg if he can't release it himself. On 10/31/13, CNA #1 stated that at about 5:45 PM she walked into the resident's room and observed his right leg wedged in the gap between the side rail and the mattress. She stated that she was not able to release the leg so she left the room to get help. As she left the room she heard the resident "yell" and she went back into the room. When she entered the room she observed the right leg to be free. She stated "if he is released I'm fine". CNA #1 further stated that she never reported this incident to the RN Charge Nurse that evening. On 3/26/14 at 3:20 PM the Assistant Director of Nursing (ADNS) was interviewed. The ADNS stated that she was responsible to ensure the completion of the Accident/Incident Reports. The ADNS also stated that she is responsible to obtain all necessary interviews from staff involved in the incident. The ADNS stated that it is very difficult to obtain all necessary information from the staff involved in A/I's and that it has been an ongoing problem. She stated that she has discussed this concern with the DNS and that there had been inservices done with regards to A/I education and providing the facility with through statements. Specific to Resident # 8 she stated that she believed that the 3:00 PM-11:00 PM shift nurse had seen the resident after the incident on 10/31/13 based on CNA #1's statement obtained. The ADNS spoke with the RN on 11/3/13 or 11/4/13 by phone. The RN told the ADON that when she got to the resident's room the resident's leg was out and nothing was wrong. The RN never stated that she had assessed the resident. This RN never produced a written statement pertaining to this occurrence and the ADNS never asked the RN about it again. It was only after the survey team questioned the ADNS that she recalled never obtaining a written statement. The ADNS stated that she did speak to the CNA that found the resident's right leg stuck in the gap between the side rail and the mattress on 10/31/13. According to the ADNS at that time the CNA informed her that she had reported the incident to the RN Charge Nurse that evening. On 3/27/14 at 9:50 AM The RN Rehab Nurse was interviewed. The Rehab Nurse stated that she reviews all A/I reports. She stated that the resident has only one side rail up on the left of the bed as you face it. The other side rail is padded and up during care only. The bed is in the lowest position which is 13 inches of the floor. There are floor mats on both side of the bed. The Rehab nurse stated that she never noticed a gap between the side rail and the mattress, but the resident was very impulsive. The Rehab Nurse stated that she observes all residents after an A/I is generated. The Rehab Nurse stated that on 11/2/14 she examined Resident # 8 after he was returned to bed and she was unsure if his hip or thigh was fractured so she would not move him. The Rehab nurse stated that she had never been made aware of the 10/31/13 incident, or any incident for this resident placing his legs or arms in the gap between the side rails and the mattress. Had she been made aware, she would have placed a Bed Rail Wedge Pad immediately. The Rehab Nurse further stated that she was unaware of any incident in the facility within the past year of any resident being caught in a gap between a side rails and the mattress. On 3/27/14 at 11:00 AM the ADNS was again interviewed. The ADNS stated that the likes of these incidents are not discussed during the morning meeting but reported as a fall, incident, or skin tear for a specific resident. At a later time these incidents would be discussed with the DNS, MDS or Rehab Nurse. When Resident # 8 was readmitted to the facility the wedge was added to the bed. The Comprehensive Care Plan (CCP) titled Behavioral Problems dated 5/21/13 documented that the resident removes positioning pillows, thrashes about in bed, grabs, hugs and shakes side rails. The interventions documented included providing a safe environment, attempt to divert resident's attention, counsel and redirect and ask for assistance if resident is difficult to handle. On 3/27/14 at 2:30 PM the 3-11 RN Supervisor who worked on 10/31/13 was called. The RN stated that she is usually the 11:00 PM-7:00 AM Charge Nurse on the 1st floor. On 10/31/13 she was the house supervisor. The RN stated that she had not been made aware of any incident pertaining to Resident # 8. The RN stated that had she been informed of the incident she would have assessed the resident, notified the physician and documented in the nurse's notes. The RN further stated that she could not recall any report of a resident with findings similar to Resident # 8. 415.12(h)(1)(2)