Every finding on record at Recuperative Services Unit-Hebrew Rehab Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, unable to give consent and had an activated Health Care Proxy (HCP), the facility failed to ensure Resident #1 was treated in a dignified and respectful manner, when on 12/22/25 during the day shift, Resident #1's hair had been cut (which was against his/her cultural beliefs) by a staff member, and was cut without consent from his/her Health Care Agent (HCA).Findings include:Review of the Facility's Policy titled Patient [NAME] of Rights and Responsibilities, dated as approved 07/22/25, indicated the following:-ensure all patients are treated fairly with consideration of individual needs and respecting their rights.-staff is committed to provide high quality care while respecting the rights, individuality, dignity, and culture of each patient.-if there is a suspected instance where we failed to meet these goals, or if a patient or family member feels that rights have been violated, they are encouraged to discuss their concerns with the people involved directly in their care.Resident #1 was admitted to the Facility in December 2025, diagnoses included dementia, and anxiety. Resident #1 was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact).Review of Resident #1's Medical Record indicated Resident #1's Health Care Proxy was activated on 12/05/25.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as created 01/02/26 and submitted on 01/09/25, indicated that on 01/02/26 the Social Worker reported that Resident #1's HCA complained that after his/her admission to the long-term care unit, that Resident #1's hair [without being requested] was cut [without consent] sometime during his/her stay on the Recuperative Services Unit (RSU). The Report indicated that approximately four inches of Resident #1's hair was cut.The Report indicated that the Facility determined an employee on the RSU indicated that she had cut some of Resident #1's hair. The Report further indicated that the Personal Care Associate (PCA, identified as PCA #1) said she had showered Resident #1, was unable to untangle his/her hair and used scissors to cut out knots that were in Resident #1's hair.During an interview on 01/21/26 at 1:52 P.M., the Social Worker said on 01/02/26 Resident #1's Health Care Agent (HCA) told her that sometime around Christmas while Resident #1 was on the short-term unit his/her hair had been cut significantly, by about four inches and was uneven. The Social worker said that Resident #1's HCA was upset about his/her hair being cut and the HCA explained that due to Resident #1's cultural background the cutting of his/her hair was something he/she would not have consented to.The Social Worker said she immediately notified the Risk Manager after speaking to Resident #1's HCA. The Social Worker said Resident had a diagnosis of Dementia, his/her HCP was activated, and he/she could not consent for his/herself. During a telephone interview on 01/27/26 at 3:28 P.M., the Risk Manager said on 01/02/26 the Social Worker notified her that Resident #1's HCA had reported that approximately four inches of Resident #1's hair had been cut (while on the short-term unit) one to two weeks prior to him/her transferring to the long-term care unit. The Risk Manager said an investigation was started and the Director of Nursing (DON) was made aware. The Risk Manager said that Patient Care Associates (PCAs) provide basic Activities of Daily Living (ADLs) to their residents and should not be cutting residents' hair because it is not their role to do so.During a telephone interview on 01/27/26 at 2:44 P.M., (which included review of her written statement) Patient Care Associate (PCA) #1 said she worked 6:45 A.M. until 3:15 P.M. on 12/22/25 and was assigned to provide care to Resident #1. PCA #1 said Resident #1 had Dementia and could not make his/her needs known. PCA #1 said she gave Resident #1 a shower, washed his/her hair, towel dried it and noticed Resident #1's hair had a lot of knots that were tangled.PCA #1 said she brushed Resident #1's hair and tried to undo the tangled knots but she could not undo all of them. PCA #1 said she used a pair of scissors to cut the knots from Resident #1's hair and said she never told the nurse on duty that she had cut the knots out of Resident #1's hair.PCA #1 said she was trying to make Resident #1 look nice but said she should not have cut his/her hair because it was not part of her job. PCA #1 said that she should have told the nurse about the knots in Resident #1's hair.During an interview on 01/21/26 at 2:32 P.M., the Director of Nurses (DON) said he was made aware there was a concern that Resident #1's hair was cut without his/her HCA's consent. The DON said Resident #1 had Dementia, his/her HCP was activated and that he/she was unable to give consent by him/herself. The DON said after speaking to staff on the unit he determined that PCA #1 had cut Resident #1's hair on 12/22/25.The DON said cutting residents' hair is not part of a PCA's standard job description. The DON said PCA #1 should not have cut Resident #1's hair and should have informed the Nurse on duty that Resident #1 had knots in his/her hair.The DON said it is his expectation that the PCAs ask the nurse about resident's care needs that are on their assignments and said if a PCA is unsure that a resident can consent for themselves, they should be asking the nurse.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 - March 31), in accordance with the schedule specified by CMS.Findings include:Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility failed to submit data for the quarter.Review of the facility's submission report titled ‘CMS Payroll Based Journal - Upload Data File', dated 5/7/25, indicated a submission had been made for PBJ data. This submission report indicated:-Your submission has been received and will be checked for errors within 24 hours.-Note: This screen does not confirm that your submission is error free.-This is a reminder to: Check CASPER for a system generated PBJ File Validation Report within 24 hours.During an interview on 7/23/25 at 7:13 A.M., the Quality and Regulatory Compliance Nurse said she was responsible for submitting the PBJ staffing data. The Quality and Regulatory Compliance Nurse said she uploaded the PBJ staffing data file to CMS on 5/7/25 and then went on vacation. The Quality and Regulatory Compliance Nurse said the facility process is the PBJ data submission status should be checked for errors within 24 hours to ensure it was accepted by CMS, as indicated on the PBJ submission report titled ‘CMS Payroll Based Journal - Upload Data File', dated 5/7/25. The Quality and Regulatory Compliance Nurse said the PBJ data submission status was not checked 24 hours later, so it was not identified that the submission had been rejected for errors.During an interview on 7/24/25 at 1:38 P.M., the Administrator said the PBJ staffing data was uploaded on time, but there was an error, and it was rejected from the system. The Administrator said the status should have been verified as accepted, but that step in their process was missed.

Based on Minimum Data Set (MDS) assessment review and interview, the facility failed to ensure staff completed comprehensive MDS assessments within the required time frame for 11 Residents (#46, #17, #21, #40, #73, #51, #7, #66, #60, #23, and #10), out of a total sample of 20 residents.Findings include: The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated for admission (Comprehensive) Assessments, should be completed no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days) 1. Resident #46 was admitted to the facility in June 2025. Review of Resident #46's admission MDS assessment, dated 6/30/25, indicated the assessment was completed 30 days after his/her admission date. 2. Resident #17 was admitted to the facility in June 2025. Review of Resident #17's admission MDS assessment, dated 7/2/25, indicated the assessment was completed 27 days after his/her admission date. 3. Resident #21 was admitted to the facility in June 2025. Review of Resident #21's admission MDS assessment, dated 7/3/25, indicated the assessment was completed 26 days after his/her admission date. 4. Resident #40 was admitted to the facility in June 2025. Review of Resident #40's admission MDS assessment, dated 7/3/25, indicated the assessment was completed 26 days after his/her admission date. 5. Resident #73 was admitted to the facility in June 2025. Review of Resident #73's admission MDS assessment, dated 7/1/25, indicated the assessment was completed 26 days after his/her admission date. 6. Resident #51 was admitted to the facility in June 2025. Review of Resident #51’s admission MDS assessment, dated 7/6/25, indicated the assessment was not completed at the time of survey, which was 24 days after his/her admission date. 7. Resident #7 was admitted to the facility in July 2025. Review of Resident #7’s admission MDS assessment, dated 7/8/25, indicated the assessment was not completed at the time of survey, which was 23 days after his/her admission date. 8. Resident #66 was admitted to the facility in June 2025. Review of Resident #66's admission MDS assessment, dated 7/6/25, indicated the assessment was completed 22 days after his/her admission date. 9. Resident #60 was admitted to the facility in July 2025. Review of Resident #60's admission MDS assessment, dated 7/9/25, indicated the assessment was completed 20 days after his/her admission date. 10. Resident #23 was admitted to the facility in July 2025. Review of Resident #23's admission MDS assessment, dated 7/14/25, indicated the assessment was completed 15 days after his/her admission date. 11. Resident #10 was admitted to the facility in July 2025. Review of Resident #10's admission MDS assessment, dated 7/14/25, indicated the assessment was completed 15 days after his/her admission date. During an interview on 7/23/25 at 9:55 A.M., 7/23/25 at 10:41 A.M., 7/24/25 at 8:30 A.M., 7/24/25 at 11:31 A.M., the MDS Coordinator said that all MDS assessments should be completed according to RAI guidelines for data entry and timeliness. The MDS Coordinator said admission MDS's should be completed within 14 days of admission. The MDS Coordinator said she was behind on the MDS's and that these eleven admission MDS's (for Residents #46, #17, #21, #40, #73, #51, #7, #66, #60, #23, and #10) were not completed within the required time frame. During an interview on 7/24/25 at 11:27 A.M., the Director of Nursing said admission MDS assessments should be completed within 14 days of admission to the facility.

Based on observation, policy review, and interview, the facility failed to serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff did not use contaminated gloves to directly handle ready-to-eat food. Findings include: Review of the facility's policy titled Personal Hygiene and Uniforms, revised January 2024, indicated, but was not limited to, the following: -Culinary and Nutrition Staff will adhere to the highest standard of personal hygiene. -Proper hand washing is the single most effective way to minimize the transfer of food-borne illness. All staff must wash their hands frequently and particularly in the following situations: After coming in contact with any soiled utensil, equipment or surface and before touching anything unsoiled. On 7/17/24 from 7:49 A.M. to 8:03 A.M., the surveyor made the following observations during a continuous tray line observation during breakfast service: -The cook contaminated his gloves by picking up a toaster and moving it, he then further contaminated his gloves by touching a hanging ceiling outlet and two toaster cords when he unplugged the toaster from the hanging ceiling outlet and plugged another toaster in; the hanging ceiling outlets had visible dust/debris. The cook further contaminated the same gloves by touching the bottom of plates, and when moving a box of gloves. The cook then, using the same contaminated gloves, touched the middle of a plate where ready-to-eat food was then served. -The cook further contaminated the same gloves by touching the handle of a scoop. The cook then used the same contaminated gloves to grab a ready-to-eat muffin and removed the bottom wrapper. While removing the wrapper the cook's contaminated gloves contacted the edible portion of the muffin which he then placed on a resident plate to be served. -The cook further contaminated the same gloves by touching the bottom of a plate; the cook used the same contaminated gloves to grab a slice of ready-to-eat toast which he placed on a resident plate to be served. -The cook further contaminated the same gloves by touching the outside of two packages of bread, and a package of bagels. The cook then further contaminated his gloves when he went to the walk-in refrigerator; the cook opened the walk-in door, and brought back a package of bread. The cook then, using the same contaminated gloves, touched the middle of a plate where food was then served, and a slice of ready-to-eat toast with his contaminated gloves which he placed on a resident plate to be served. -The cook further contaminated the same gloves by touching the outside of a package of bread, and with the same contaminated gloves grabbed two pieces of toast and placed them on a plate to be served to residents. -The cook further contaminated the same gloves by touching the handle of a knife, the bottom of a plate, and the handle of a scoop, and then, with the same contaminated gloves, grabbed a ready-to-eat muffin to remove the wrapper. While removing the wrapper the cook's contaminated gloves contacted the edible portion of the muffin which he then placed on a resident plate to be served. -The cook did not replace his gloves or wash his hands throughout the entire, continuous observation. During an interview on 7/17/24 at 8:05 A.M., the food service staff said that the observed food was to be served to residents on the north side of the facilities' unit. During an interview on 7/17/24 at 8:03 A.M., the Food Service Director (FSD) said he would expect his staff to change gloves after they contaminate them, and/or when switching between tasks.

Based on observations, interviews, and record review, the facility failed to implement the plan of care for one Resident (#434) out of a total sample of 12 residents. Specifically, the facility failed to provide supervision with eating for Resident #434. Findings include: Resident #434 was admitted to the facility in July 2024 with diagnoses including failure to thrive and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 7/16/14, indicated Resident #434 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #434's plan of care related to dysphagia, dated 7/16/24, indicated: - Supervision recommendations: 100% of the time, need for cueing, Encourage self-feeding. - Supervision: Feeds self with close, line of sight/direct supervision to load to utensil with food, encouragement to continue eating. Review of the speech therapy evaluation, dated 7/12/24 and signed by the physician on 7/14/24, indicated: - Pt (patient) presents with presbyphagia (age-related swallowing changes) in conjunction with dentition changes and superimposed by delirium. Presence of delirium is influencing his/her mealtime efficiency which may influence his/her nutritional status if the correct level of mealtime support is not supplied. - Supervision recommendations: 100% of the time, need for cueing, Encourage self-feeding. - Safe Swallow strategies comments: Supervision: Feeds self with close, line of sight/direct supervision to load to utensil with food, encouragement to continue eating. Review of speech therapy progress note, dated 7/16/24, indicated: -Supervision: Feeds self with close, line of sight/direct supervision to load to utensil with food, encouragement to continue eating. On 7/16/24 at 8:26 A.M., the surveyor observed Resident #434 eating a cut up muffin, oatmeal, and coffee alone in his/her room. Resident #434 had a basin filled with vomit next to him/her. Resident #434 said he/she throws up every morning at breakfast and staff was aware. There were no staff within direct sight line of Resident. The staff communication board in his/her room indicated: - 1:1 set up and support at meals (encouragement, spoon loading). On 7/17/24 from 8:53 A.M to 9:03 A.M., the surveyor observed Resident #434 eating cut-up pancakes, cut-up bananas, orange juice, and coffee alone in his/her room. There were no staff within direct sight line of the Resident or in the corridor near his/her room during this time frame. During an interview on 7/17/24 at 9:03 A.M., Resident #434 said he/she was discouraged because he/she was having trouble eating breakfast. The Resident said this was because his/her arms were weak, and he/she couldn't see the food on his/her breakfast tray. On 7/17/24 from 12:14 P.M. to 12:27 P.M., the surveyor observed Resident #434 eating mashed potatoes, minced meatloaf, and juice alone in his/her room. There were no staff within direct sight line of the Resident or in the corridor near his/her room during this time frame. During an interview on 7/17/24 at 12:27 P.M., Resident #434 said he/she often gags on food and has a history of difficulty with swallowing. Resident #434 said he/she was very concerned about having difficulty swallowing and gagging. Resident #434 said staff does not supervise or provide assistance with his/her meals even though his/her staff communication board in his/her room says they should. Review of Resident #434's Certified Nurse Assistant documentation indicated the following assistance was provided with meals: - 7/11/24 at 1:39 P.M., cue/setup. - 7/11/24 at 6:36 P.M., independent. - 7/12/24 at 1:48 P.M., cue/setup. - 7/13/24 at 6:00 P.M., cue/setup. - 7/14/24 at 2:32 P.M., cue/setup. - 7/15/24 at 2:53 P.M., cue/setup. - 7/15/24 at 6:00 P.M., cue/setup. - 7/16/24 at 9:39 P.M., independent. During an interview on 7/17/24 at 12:44 P.M., Certified Nurse Assistant (CNA) #2 said she was not aware Resident #434 required supervision with meals, and that staff usually sets-up the meal and he/she eats it independently. CNA #2 said if Resident #434 required supervision it would either be listed on the staff communication board in his/her room, or it would be communicated to the CNA by the nurse in report at the beginning of the shift. The surveyor and CNA #2 went into Resident #434's room and observed the staff communication board, which indicated 1:1 set up and support at meals (encouragement, spoon loading). CNA #434 said she did not see that, and it was probably old because Resident #434 didn't need supervision. During an interview on 7/17/24 at 12:59 P.M., Nurse #3 said she was not aware Resident #434 required supervision with meals and said the Resident required set-up assistance only. Nurse #3 said if Resident #434 required supervision with meals she would communicate it to staff in report or it would be written on the staff communication board in the Resident's room. Nurse #3 said CNAs are expected to review each Resident's staff communication board each shift. Nurse #3 said care plan interventions and speech therapy interventions should be followed. Nurse #3 then looked into Resident #434's record with the surveyor and said based on the dysphagia care plan and speech therapy progress note, dated 7/16/24, Resident #434 should have had a CNA or nurse within direct line of sight of the Resident while eating. During an interview on 7/17/24 at 1:22 P.M., Speech Therapist #1 said Resident #434 had been recommended the intervention for direct supervision during meals on admission because of difficulty swallowing and was evaluated to continue this direct supervision during meals by speech therapy on 7/16/24. Speech Therapist #1 said this intervention should have been followed, because the physician signed this evaluation, and it was listed on the Resident's care plan. Speech Therapist #1 said ten minutes is too long for Resident #434 to not be within direct line of sight of staff while eating. During an interview on 7/17/24 at 1:32 P.M., the Director of Nursing (DON) said interventions listed in the dysphagia care plan should have been followed. The DON said based on Resident #434's dysphagia care plan he would expect staff to be close enough to the Resident to see or hear if the Resident was choking. The DON said the facility did not have a policy addressing assistance with meals or activities of daily living (ADLs), but the facility's expectation is to provide supervision with meals if indicated in care plan.

Based on record review, interview and observation for one Resident (#81) of 12 sampled residents, the facility failed to provide respiratory care consistent with professional standards of practice. Specifically, the facility failed to develop a resident care policy for oxygen administration and failed to obtain a physician's order for oxygen use, which staff were actively administering to the Resident. Findings include: Review of the Healthcare Quality Association on Accreditation, dated 5/4/2017, indicated physician orders must be obtained for oxygen use and should include the amount of oxygen (flow rate) and duration. Review of policies indicated the facility had not developed a policy for oxygen use. Resident #81 was admitted to the facility in June 2024, and had diagnoses which included chronic obstructive pulmonary disorder (COPD, a lung disease limiting the ability to breath), dyspnea (labored breathing) and multiple fractured ribs. Review of Resident #81's Minimum Data Set assessment, dated 7/9/24, indicated there was no reference to use of oxygen therapy. Review of Resident #81's care plan, dated 7/9/24, indicated he/she had an unstable respiratory status due to COPD. Interventions included Oxygen per order. Review of Resident #81's physician orders, dated 7/9/24 through 7/16/24, indicated there was no physician's order for the use of oxygen. Review of his/her Medication Administration and Treatment Administration Records, dated 7/9/24 through 7/16/24, failed to indicate a reference to oxygen administration. Review of Resident #81's nurses' notes, dated 7/9/24, 7/13/24 and 7/16/24, indicated references to his/her use of oxygen. Review of Resident #81's physician note, dated 7/11/24, indicated continue with supplemental oxygen with goal O2 sat [saturation] 88% or above - wean off as tolerated. During an interview and observation on 7/16/24 at 7:52 A.M., the surveyor observed Resident #81 awake, lying in bed, and wearing a nasal cannula. The oxygen flow rate was set to one liter of oxygen per minute. Resident #81 said sometimes he/she has difficulty breathing and that during those times staff will offer oxygen through a nasal cannula. Resident #81 then terminated the interview. On 7/17/24 at 7:45 A.M., the surveyor observed Resident #81 awake and lying in bed, wearing an oxygen mask. A nebulizer was attached to the mask and the oxygen flow rate was set to one liter per minute. During an interview on 7/17/24 at 8:01 A.M., Nurse #4 said she was unable to locate a physician's order for Resident #81's use of oxygen in either the Medication Administration or Treatment Administration Records. Nurse #4 said there was no record of the dates or times staff administered oxygen to the Resident. Nurse #4 said a physician's order was required for the administration of oxygen. On 7/17/24 at 8:08 A.M., the surveyor and Director of Nurses (DON) observed Resident #81 awake, lying in bed, and wearing a nasal cannula. The oxygen flow rate was set to one liter per minute. The DON said there was no order for Resident #81's use of oxygen, and that an order is required for its administration. The DON said the physician indicated in a progress note the Resident should receive oxygen, but that an order was not written for its use. The DON said the facility did not have a policy for oxygen use.

Based on observation, policy review, record review and interview for one Resident (#18) of 12 sampled residents, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, for Resident #18 the facility failed to ensure nursing stored his/her physician's ordered nasal spray and timolol (medicated eye drops used to treat high pressure in the eyes) according to State and Federal requirements. Findings include: Review of the facility policy, Medication Storage, Security and Access, dated as revised 10/25/21, indicated all medications will be stored and secured in accordance with all state and federal regulations. Medications stored in patient care areas: 1. Medication storage areas are accessible only to authorized personnel, as designated by the Director of Pharmacy. 2. All medications are stored in a secured location or in an area where the medication storage area is under continuous surveillance by licensed personnel. The Director of Pharmacy has authority to designate storage areas for all medications. 3. Medications are stored in specialized compartments in automated dispensing machines or in secured cabinets/drawers or medication rooms when not in use. Review of the facility policy, Patient Self-Administration of Medication, dated as revised 2/22/22, indicated: II. Purpose: a. To provide a process that maintains a safe environment of care as it supports self-administration of medication for patients who meet the criteria for self-administration of medication. III. Policy: d. A Provider order must be obtained permitting medication self-administration for each medication individually. Resident #18 was admitted to the facility in July 2024 with diagnoses including bradycardia and spinal stenosis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/9/24, indicated that Resident #18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 7/16/24 at 8:13 A.M., Resident #18 was in bed, the surveyor observed one bottle of saline nasal spray on Resident #18's overbed table. There was a bottle of timolol eye drops on the table along the side of the room. On 7/16/24 at 8:49 A.M., Resident #18 was in a chair, the surveyor observed one bottle of saline nasal spray on Resident #18's nightstand. There was a bottle of timolol eye drops on the table along the side of the room. Resident #18 said that he/she keeps the nasal spray at his/her bedside and will use it for nose pain. Review of Resident #18's physician's order, dated 7/3/24, indicated: - sodium chloride 0.65% nasal spray, two sprays in both nostrils three times daily as needed for nasal congestion and dryness. Further review of the physician's order failed to include instructions to self-administer. Review of Resident #18's physician's order, dated 7/3/24, indicated: - timolol 0.25%, one drop in both eyes every morning. Further review of the physician's order failed to include instructions to self-administer. Review of the Medication Administration Record (MAR), dated 7/16/24 at 9:27 A.M., indicated nursing administered the timolol eye drops as ordered. Review of Resident #18's physician's order, dated as active on 7/16/24, failed to include orders for self-administration of medications. Review of Resident #18's plan of care, dated as active on 7/16/24, failed to include orders for self-administration of medications. On 7/16/24 at 10:53 A.M., 7/16/24 at 1:18 P.M., and on 7/16/24 at 3:11 P.M., the surveyor observed the bottle of saline nasal spray on Resident #18's bedside table. During an interview on 7/17/24 at 12:18 P.M., Resident #18 said that he/she no longer has his/her nasal spray. Resident #18 said nursing took it away on 7/16/24 and locked it up. During an interview on 7/17/24 at 12:19 P.M., Nurse #2 said saline nasal spray and eye drops should be locked up and not left out at the bedside. Nurse #2 showed the surveyor Resident #18's saline nasal spray and timolol eye drops secured in a locked medication box. Nurse #2 said she routinely cares for Resident #18 and Resident #18 has not been assessed for self-administration of medications and will ask for nasal spray. During an interview on 7/17/24 at 1:30 P.M., the Director of Nursing (DON) said eye drops should be locked away, but the nasal spray could be left at the bedside. During an interview on 7/18/24 at 11:20 A.M., the Quality Assurance (QA) Nurse said that saline nasal spray and the timolol eye drops should be secured. The QA Nurse said that Resident #18 was not assessed for self-administration of medications.

Based on record review and interviews the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for one Resident (#28) out of three sampled closed records. Specifically, for Resident #28, the facility failed to accurately code the correct discharge location on the MDS assessment. Findings include: Resident #28 was admitted to the facility in May 2024 with diagnoses that include diabetes, chronic kidney disease, and hyponatremia (levels of sodium in the blood is low). Review of MDS assessment, dated 6/5/24, indicated Resident #28 was discharged to a short-term general hospital. Review of Resident #28's Case Management/Social Work Discharge Assessment, dated 6/4/24, indicated he/she would discharge home on 6/5/24 with services for Nursing, Physical Therapy, and Occupational Therapy. During a phone interview on 7/17/24 at 10:06 A.M., the MDS Nurse said that the discharge destination should have been coded as discharge to home and it was not. During an interview on 7/17/24 at 3:12 P.M., the Director of Nursing (DON) said the MDS assessment should be coded according to the RAI (Resident Assessment Instrument) manual.

Based on observation, record review and interviews, the facility failed to implement a personalized mood care plan for 1 Resident (#1A) out of a sample of 13 Residents. Findings include: Review of the facility policy titled 'Nursing Documentation Policy' with a revision date of 12/13/21 indicated the following: *A care plan will be initiated for active problems and updated regularly, and when change in condition is noted. *Care plans will be initiated during change in condition and include individualized care plans with person specific approaches. Review of the facility policy titled 'Medical Management' with no revision date, indicated the following: *Upon admission to the Recuperative Services Unit, each patient is assessed by our team of professionals including case managers/social workers and psychiatrists. *At the conclusion of the assessment process, the team initiates a plan of care to be followed during the patient's stay, depending on the care needs of the patient, the following clinical specialties are also available upon request-psychiatric services Resident #1A was admitted to the facility in April 2023 with diagnoses including dysphagia and feeding by Gastrostomy tube (G-tube). A review of a Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an observation and interview on 5/22/23 at 9:03 A.M., Resident #1A was observed in bed, he/she was irritable and angry, he/she angrily declined an interview with the surveyor. During an interview with Resident #1A on 5/24/23 at 10:10 A.M., he/she said that his/her life has changed overnight, he/she is angry and sad, he/she hates eating through a G- tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), it is not easy dealing with this life change especially since his/her future includes using the feeding tube full time, he/she has to get education on how to manage the G-tube at home and it is very frustrating for him/her. Review of the medical record indicated a physician's progress note dated 5/19/23 indicating that Resident #1A's G-tube was placed on 5/16/23. Further review of the medical record indicated a social service admission assessment dated [DATE] indicating the following: *Able to communicate needs-Yes *Mood- Resident was down on themselves, was unhappy because he/she now needs to get his/her meals through a G-tube. *Specify mood-he/she is unhappy that he/she needs to be on tube feedings. Further review of the medical record indicated shift assessments dated, 5/22/23, 5/23/23, and 5/24/23 indicating the following: *Psychosocial assessment-Anxious During an interview with the Case Manager on 5/24/23 at 8:42 A.M., she said she should have initiated a personalized mood care plan with personalized interventions indicating that the Resident had recently gone through a major life change, and was feeling unhappy, angry and frustrated. During an interview with the Director of Nurses on 5/24/23 at 10:23 A.M., he said Residents with mood and behavior concerns should have a personalized care plan that include personalized interventions.

Based on observation, record review and interview, the facility failed to make a psychiatric service referral for 1 Resident (#1A) out of a sample of 13 Residents. Findings include: Review of the facility policy titled 'Medical Management' with no revision date indicated the following: *Upon admission to the Recuperative Services Unit, each patient is assessed by our team of professionals including case managers/social workers and psychiatrists. *At the conclusion of the assessment process, the team initiates a plan of care to be followed during the patient's stay, depending on the care needs of the patient, the following clinical specialties are also available upon request-psychiatric services Resident #1A was admitted to the facility in April 2023 with diagnoses including dysphagia and feeding by Gastrostomy tube (G-tube). A review of a Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an observation and interview on 5/22/23 at 9:03 A.M., Resident #1A was observed in bed, he/she was irritable and angry, he/she angrily declined an interview with the surveyor. During an interview with Resident #1A on 5/24/23 at 10:10 A.M., he/she said that his/her life has changed overnight, he/she is angry and sad, he/she hates eating through a G- tube (( a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), it is not easy dealing with this life change especially since his/her future includes using the feeding tube full time, he/she has to get education on how to manage the G-tube at home and it is very frustrating. He/she needs a lot of emotional support to get through this significant change in his/her life. Review of the medical record indicated a physician's progress note dated 5/19/23 indicating that Resident #1A's G-tube was placed on 5/16/23. Further review of the medical record indicated a social service admission assessment dated [DATE] indicating the following: *Able to communicate needs-Yes *Mood- Resident was down on themselves, was unhappy because he/she now needs to get his/her meals through a G-tube. *Specify mood-he/she is unhappy that he/she needs to be on tube feedings. Further review of the medical record indicated shift assessments dated, 5/22/23, 5/23/23, and 5/24/23 indicating the following: *Psychosocial assessment-Anxious During an interview with the Case Manager on 5/24/23 at 8:42 A.M., she said she should have made a referral for psychiatric services for the Resident so they could assist him/her process the feelings of anger, sadness, and frustration after the recent G-tube placement.

Based on observations, policy review and interviews, the facility failed to ensure medications were stored securely in the resident care unit affecting 4 Residents (#65, #170, #268 and #273). Findings Include: Review of facility policy titled 'Medication Storage,Security, and Access' Revised 5/1/2023, Indicated the following: Policy: All medications will be stored and secured in accordance with all State and Federal regulations. Definition: *Secure Area: A secure area is an area in which drugs and biologicals are stored in a manner to prevent unmonitored access by authorized individuals. Procedure: Medications stored in patient care areas: *2. All medications are stored in a secured location or in an area where medication storage area is under continuous surveillance by licensed personnel. The Director of Pharmacy has authority to designate storage areas for all medications. Patient's own medication storage: Patient's own medication that cannot be sent home with a family member must be secured in a tamper evident bag and stored in the pharmacy department until discharge. During medication administration pass on 5/22/23 at 8:33 A.M., the following were observed: 1. Nurse #1 was observed leaving a cup full of medications on the mobile computer and entered into Resident #65's room. The mobile computer was out of the nurse's site. 2. During a medication pass with Nurse #3 on 5/22/23 at 9:15 A.M., for Resident #170, the surveyor observed the medication locked box in the Resident's room was unlocked, 2 bottles of eye drops were in the open medication box. 3. During an interview with Resident # 268 on 5/22/23 at 9:31 A.M., the surveyor observed a medicine cup with an orange and white capsule on the Resident's breakfast tray. The Resident said it was his/her Omeprazole medication (medication for treating acid reflux) and the nurse had left it with him/her. 4. During an interview with Resident #273 on 5/22/23 at 8:49 A.M., the surveyor observed a bottle of eye vitamins (Areds) and inhalers in the Resident's room. The Resident's family member was also present and indicated that the facility did not have the eye vitamins so they brought from home. During an interview on 5/24/23 at 9:31 A.M., Nurse #2 said that it is the facility policy for nurses to keep possession of medication at all times, to stay with the resident during administration and confirm all medications are taken. She further said the medication lock boxes in the rooms should be locked at all times and medications brought from home should be checked by the pharmacy and locked in the medication room under resident specific. During an interview on 5/24/23 at 10:22 A.M., the Director of Nursing said during a medication pass the nurses should have the medications with them at all times, especially if they would be out of site. He further said the medication lock boxes should be locked at all times and medications brought in from home should be sent to the pharmacy for verification and re-labeling, and a physicians order should be obtained to administer a resident's own supply.

Based on records reviewed and interviews, the facility failed to ensure MDS (Minimum Data Set) data was transmitted to the CMS (Center for Medicare and Medicaid System) for 35 resident assessments. Findings include: During record reviews on 5/23/23 and 5/24/23, the surveyor observed several records with MDS assessments overdue for transmission. During an interview with the Senior Director of Utilization Management on 5/23/23 at 11:30 A.M., she said that we have been without an MDS Nurse since November, and we are currently using contract MDS nurses as well as the MDS nurse from a sister facility to help us catch up. During a phone interview with the MDS Nurse covering from the sister facility on 5/23/23 at 1:09 P.M., she said that she has been assisting with the MDS transmission backlog and hired a few contract nurses as well. She said that she is now running a report every 2 days to transmit MDS assessments more often to avoid further backlog. Review of the MDS report provided by the Senior Director of Utilization Management on 5/24/23 at 8:50 A.M., indicated there were 35 MDS assessments overdue for transmission to CMS.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) the Facility failed to ensure staff implemented and followed their Abuse Policy, which included gathering written and signed statements from all person's involved as part of the Facility's Internal Investigation. Findings include: The Facility's Policy titled Patient and Patient to Patient Abuse: Reporting and Investigating, dated 12/15/21, indicated that the Facility defined neglect as the intentional failure to provide services necessary to avoid physical harm or mental anguish. Further review Policy indicated the Facility's Abuse Allegation Checklist, Appendix B, would be used as a guide to conduct the investigation which included obtaining written and signed statements, and interviews with all person's identified. Review of the Facility's Internal Investigations, dated 04/28/22, indicated the Investigation found that Certified Nurse Aide (CNA) #1 neglected Resident #1 when she ignored Resident #1's multiple complaints of pain and failed to report Resident #1's pain to the assigned nurse. Further review of the Investigation indicated there was no documentation to support the Facility gathered or attempted to gather any written and signed witness statements from potential person's involved in an incident of alleged neglect. During an interview on 05/31/22 at 8:30 A.M., and throughout the Survey, the Clinical Risk Manager said the Facility's Internal Investigation included typed interview notes with all person's involved in the alleged incident of neglect of Resident #1. The Clinical Risk Manager said the Facility did not obtain any written and signed witness statements as part of the Facility's Internal Investigation into the alleged neglect. \

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), for whom the Facility determined through their internal investigation that Certified Nurse Aide (CNA) #1 neglected Resident #1 during a shift beginning on 04/27/22, the Facility failed to ensure they notified local law enforcement in accordance with the Facility's Policy and Federal Regulations. Findings include: The Facility's Policy titled Patient and Patient to Patient Abuse: Reporting and Investigating, dated 12/15/21, indicated that the Facility defined: - neglect as the intentional failure to provide services necessary to avoid physical harm or mental anguish, and - abuse as the willful infliction of injury, unreasonable confinement, intimidation, including verbal or mental abuse, or punishment with resulting in physical harm, pain, or mental anguish or assault and battery. The Policy indicated that during an internal abuse investigation, a possible crime was considered, that would trigger the policies and procedures for Reporting to Law Enforcement and Reasonable Suspicion of a Crime. Review of the Facility's Policy titled, Reporting to Law Enforcement Reasonable Suspicion of a Crime, indicated the Facility defined a crime as a term defined by law of the applicable subdivision where the Facility was located. The Policy indicated that all events that causes reasonable suspicion and did not result in serious bodily harm to a resident, the Facility would notify local law enforcement within 24 hours after forming the suspicion. Review of the Facility's Internal Investigations, dated 04/28/22, indicated the Investigation found that CNA #1 neglected Resident #1 when she ignored Resident #1's multiple complaints of pain and failed to report Resident #1's pain to the assigned nurse. Further review of the Investigation indicated there was no documentation to support that local law enforcement was notified, in accordance with the Facility's Policy and Federal Regulations. During an interview on 05/31/22 at 8:30 A.M., and throughout the Survey, the Clinical Risk Manager said the Facility's Internal Investigation determined that CNA #1 neglected Resident #1 on 04/27/22. The Clinical Risk Manager said the Facility did not report the findings of neglect to local law enforcement because the Facility did not think the neglect was a potential crime. During an interview on 06/16/22 at 9:00 A.M., the Administrator said the Facility's Investigation determined that CNA #1 neglected Resident #1 on 04/27/22. The Administrator said the Facility did not report the findings of neglect to local law enforcement because the Facility did not think the neglect was a potential crime.

Based on interview and record review, the facility failed to implement a safety protocol for 1 Resident (#72) expressing suicidal ideation out of a total sample of 12 residents. Findings include: Review of the facility policy, titled Suicide Precautions, dated 4/26/21, indicated the following: Suicidal ideation (expressing the wish to end one's life) and suicidal behavior (behaviors of self-harm or having the potential to place a patient at risk) by a patient will receive immediate nursing assessment. Procedure: - During the assessment, the patient at risk will be placed on 1:1 constant observation for safety. The 1:1 constant observer is to remain with the patient unless physically relieved by another staff member. Patient to be examined by the medical provider within 24 hours of initiation of the 1:1 observation. Only a medical provider can discontinue constant observation once it is initiated. - After the completion of the nursing assessment, nursing will contact the medical provider. If, after 15 minutes, nursing has been unable to contact the medical provider, nursing will begin to call in the following order according to telephone algorithm below: the psychiatrist, the covering provider, or the medical director until contact is made. Resident #72 was admitted in March, 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #72 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Review of the care plan did not indicate that Resident #72 had a mood/behavior care plan in place. Review of the Progress notes indicated that, on 3/22/22, Chaplin #1 visited Resident #72 and Resident #72 said if I had the opportunity to take myself out I would, I do not care what happens to me anymore. I don't want to be around anymore. I don't care if it's all over for me. Review of the clinical record does not indicate that Resident #72 was ever put on 1:1 or 15 minute checks after expressing suicidal ideation. During an interview on 4/5/22 at 10:45 A.M., Chaplin #1 said that Resident #72 really opened up to her and when Resident #72 made statements of suicidal ideation, she did not feel qualified to assess the seriousness of the statements and went to tell Case Manager #1. During an interview on 4/5/22 at 10:55 A.M., Case Manager #1 said that Chaplin #1 did tell her about Resident #72's suicidal ideation and said that she tried to reach the family regarding the suicidal ideation. When asked if she assessed Resident #72, Case Manager #1 said that it is the responsibility of the provider to do an assessment. During an interview on 4/5/22 at 9:55 A.M., the Director of Nursing said that he was aware of the situation regarding Resident #72 and that staff were checking on him frequently and was seen by the provider, but could not specify how frequent the checks were. Review of the clinical record indicated that 15 minute safety checks were put in place on 3/25/22, which was 3 days after the initial report of suicidal ideation. Review of the psych notes indicated Resident #72 was seen on 3/23/22; one day after the suicidal ideation. Review of the clinical record indicated Resident #72 was seen by the provider on 3/23/22; one day after the suicidal ideation.

Based on observation, interview and record review, the facility failed to follow the Centers for Disease Control (CDC) guidance for the control and management of infectious diseases, including COVID-19, and did not follow the facility's own infection control policy. On 2/9/21, facility staff failed to wear eye protection in a resident care area. Finding include: Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, published by the Centers for Disease Control, dated 7/15/20, indicated when health care personnel (HCP) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. The facility's policy titled, What You Need to Know: HSL (Hebrew Senior Living) Guidelines during COVID-19: RSU (Recuperative Care Unit), TCU (Transitional Care Unit), MCU (Medical Care Unit), updated 10/2/20, indicated that when staff enter any patient care area all staff are encouraged to wear protective eye wear (goggles or face shields). During an observation on 2/9/21 at 9:45 A.M., Maintenance Staff #1 installed a wall sconce in the hallway outside a resident bedroom on the South Unit. The surveyor observed that Maintenance Staff #1 did not wear eye protection while on the South Unit. The surveyor observed approximately six staff members walk by Maintenance Staff Member #1, without reminding or educating him to wear eye protection while in a resident care area. At 9:51 A.M., Maintenance Staff #1 left the South Unit to enter the elevator area and was still not wearing eye protection. During an interview on 2/9/21, at 11:39 A.M., the Infection Control Nurse said that all staff members are required to wear eye protection in resident care areas, and that the hallway on the South Unit was considered a care area. The Infection Control Nurse said that the resident's on the South Unit consist of COVID-19 negative and COVID-19 recovered status.

Based on observation and interviews, the facility failed to ensure staff donned full personal protective equipment (PPE) (gown, gloves, eye shield and face mask) while caring for COVID-19 negative residents (COVID-19 negative residents are at risk for exposure to COVID-19 from staff and/or visitors to the facility). Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance, dated 4/2/20, included the following: Guidance for Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per Centers for Disease Control (CDC) guidance on conservation of PPE. · Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE. · If COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED]. On 6/30/20 at 8:30 A.M., during an interview, the Director of Nursing (DON), she said that all the residents were COVID-19 negative with the exception of two residents that were determined to be negative in the hospital but had pending tests obtained while in the facility. The DON said they had no recovered or positive COVID-19 residents currently. The census was 37 and 35 of those residents were COVID-19 negative. The DON said that staff caring for the negative residents adhered to the facility's Droplet Precaution policy and all staff were expected to wear masks. He said that staff caring for residents that were in a pending status adhered to the facilities Enhanced Precautions policy which indicated the need for full PPE while caring for the resident. The DON said they had residents develop COVID-19 during their stay (which indicates community spread) as well as admitting residents that were COVID-19 positive. On 6/30/20 at 9:15 A.M., observation on the North Unit revealed Certified Nursing Assistant (CNA) #1 as she was coming out a COVID-19 negative resident's room. CNA #1 was only wearing a mask. On 6/30/20 at 9:15 A.M., CNA #1 said she only needs to wear a mask, no other PPE when caring for the COVID-19 negative residents. On 6/30/20 at 9:35 A.M., observation on the South Unit revealed CNA #2 coming out of a resident's room, the only PPE she was wearing was a mask. The resident was on Enhanced Precautions (which requires full PPE) due to his/her pending status. On 6/30/20 at 9:35 A.M., during an interview, CNA #2 said that she walked the resident to the bathroom and back to his/her room and provided care while the resident was in the bathroom. She said she discarded her gown and gloves prior to exiting the resident's room. CNA #1 said she forgot to use eye protection when she was working with the resident. On 6/30/20 at 10:00 A.M., during an interview, the Infection Preventionist said the the facility Infection Prevention team developed their own protocols for staff in regard to wearing PPE during the COVID-19 pandemic. She said that they did not require staff to wear full PPE for COVID-19 negative residents, just a mask. She said that due to the vulnerability of the COVID-19 negative residents, she would revisit this policy with the team.

Based on observation, staff interview and review of facility policy, the facility failed to ensure that facility staff followed proper infection control practices for the prevention and spread of infection for 1 of 11 Sampled residents (#2) while performing a dressing change. Findings include: For Resident #2, the facility failed to ensure staff appropriately preformed hand hygiene and change gloves while performing a dressing change to ensure there was no cross contamination and to prevent the possible spread of infection . Resident #2 was admitted to the facility 3/2017 with [DIAGNOSES REDACTED]. Review of the facility education guide, entitled, Clean Dressing Techniques, not dated, included the following: Preparation for Dressing Change * Wash hands with alcohol gel or soap and water * Apply gloves * Prepare patient Set Up * Wash surface of dressing prep station * Wash hands with alcohol gel or soap and water * Arrange dressing supplies on cleaned surface * Date and initial appropriate part of dressing Change Dressing * Remove old/soiled dressing from wound * Remove soiled gloves * Wash hands with alcohol gel or soap and water * Apply new gloves * Apply dressing per treatments orders * Remove soiled gloves * Wash hands with alcohol gel or soap and water Hand Hygiene Centers for Disease Control (CDC) * Clean your hands: After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient and if hands will be moving from a contaminated-body site to a clean-body site during patient care. On 5/31/17 at 10:00 A.M., during a wound dressing change observation, the surveyor observed Nurse #1 perform hand hygiene and don gloves. Nurse #1 prepared the needed dressing supplies and placed them on the table. Nurse #1, moved to the end of the bed and with her gloved hands, touched the controls to raise the bed up and to lower the resident's head. Nurse #1 moved back to the side of the bed and picked up the resident's remote control and placed it away from the resident. With the same gloved hands, Nurse #1 repositioned Resident #2 and released the straps of his/her adult briefs to expose the resident's buttocks (in order to perform the dressing change). Nurse #1, with contaminated gloves, began to cleanse the resident's wound with wound cleanser and a gauze pad. Nurse #1 discarded the contaminated gauze pad. Nurse #1 (still wearing the same, contaminated gloves) opened a container of wound gel and applied the wound gel to the contaminated gloved index finger. Nurse #1 then applied the wound gel directly onto the resident's wound. During interview on 5/31/17 at 10:15 A.M., Nurse #1 said she should have changed her gloves and performed hand hygiene after touching the resident's bed and prior to applying the wound gel to the resident's wound.

Based on observation, record review and interview, the facility failed to assess one non-sampled Resident (NS) A in a total sample of 12, for the ability to self administer medications. Findings include: Resident (NS)A was admitted to the Facility with [DIAGNOSES REDACTED]. Resident (NS) A is cognitively intact and alert and oriented, and is able to ambulate independently. Surveyor observation during the medication pass on 1/14/15 at 1:50 P.M., revealed the Resident was to receive one [MEDICATION NAME] suppository 10 milligrams per rectum for constipation. When the medication nurse entered the room she assisted the resident put on a plastic glove, opened the dulcoax suppository, and handed the Resident the [MEDICATION NAME] suppository. The Resident entered the bathroom alone and inserted the [MEDICATION NAME] suppository. Record review, on 1/14/15, revealed no self administration assessment for medications and no physician's order for self administration. The facility policy for self administration is that the Resident must meet certain criteria for the ability to self medicate, before the Resident is allowed to self administer any medication. Interview with the Director of Nurses on 1/15/15 at 7:30 A.M. confirmed the facility failed to assess for the ability to self administer medications prior to the incident.

Based on record review and interview, for one of three sampled residents (Resident #1), who was assessed as being at risk for falls, the Facility failed to ensure the direct care staff followed the fall prevention plan of care. Resident #1's plan of care indicated Resident #1 required assistance with the use of a gait belt and a rolling walker for transfers. On 4/21/14 Resident #1 was transferred without a gait belt by Certified Nurse Assistant (CNA) #1 and during the transfer, Resident #1 fell and sustained a fractured rib as a result of the fall. Findings include: The nursing mobility assessment, dated 4/16/14, indicated that Resident #1 was at minimal risk for falls due to the need for staff assistance during transfers and ambulation while using an assistive device. The physical therapy plan of care, updated 4/21/14, indicated Resident #1 required the physical assistance of one staff member while using a gait belt and a rolling walker during all transfers. The rehabilitation resident care Kardex (used as a reference for direct care staff regarding a resident's care needs) indicated that Resident #1 was dependent upon a staff member for all mobility and toileting needs. The nurse's notes, between 7:00 P.M. on 4/21/14 and 7:00 A.M. on 4/22/14, indicated that Resident #1 fell while being transferred from the toilet while using a rolling walker, he/she sustained a hematoma (collection of blood) on back of the head and a skin tear on the right upper arm. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 2:45 P.M. on 5/19/14 and at 1:00 P.M. on 5/22/14. CNA #1 said she was normally assigned to the Hospital unit, was floated to the skilled nursing unit, and was unfamiliar with Resident #1's plan of care. CNA #1 said she was told during shift report the personal care and transfer needs of each resident, and was told that Resident #1 required the physical assistance of one staff member during transfers while using a rolling walker, and denied that she was told that Resident #1 required the use of a gait belt during transfers. CNA #1 said at about 8:00 P.M. on 4/21/14 she transferred Resident #1 from the chair to the toilet while using a rolling walker without the use of a gait belt. CNA #1 said, during the transfer, Resident #1 fell forward, hit his/her head on the wall of the bathroom, and landed on the floor. CNA #1 said she could not prevent the fall because she had not used the gait belt because she did not know that Resident #1 required the use of a gait belt per the plan of care. The Surveyor interviewed Nurse #2 at 6:30 P.M. on 5/19/14 and at 7:10 P.M. on 5/31/14. Nurse #2 said CNA #1 transferred Resident #1 without the use of a gait belt and a fall occurred when the rolling walker tipped over and CNA #1 was unable to prevent the fall. The Nurse Practitioner's progress note, dated 4/22/14, indicated that following the fall last evening (4/21/14) Resident #1 had a new complaint of left rib pain and an x-ray indicated that he/she had a fractured left 10th rib. The x-ray report, dated 4/22/14, indicated that Resident #1 had sustained an acute [MEDICAL CONDITION] left rib. The Surveyor interviewed Physician #1 at 1:00 P.M. on 5/19/14. Physician #1 said Resident #1 sustained a fractured left 10th rib as a result of the fall. Refer to F323

Based on record review and interview, for one of three sampled residents (Resident #1), who were at risk for falls, the Facility failed to ensure a staff member used a gait belt when she assisted Resident #1 during a transfer. CNA #1 said she was unfamiliar with Resident #1's care plan interventions, was verbally told by Nurse #1 Resident #1 required physical assistance during transfers while using a rolling walker. CNA #1 said on 4/21/14, she transferred Resident #1 without the use of a gait belt, which was not consistent with the fall prevention plan of care, and Resident #1 fell and sustained a fractured left rib as a result of the fall. Findings include: The nursing mobility assessment, dated 4/16/14, indicated that Resident #1 was at minimal risk for falls due to the need for staff assistance during transfers and ambulation while using an assistive device. The physical therapy plan of care, updated 4/21/14, indicated Resident #1 required the physical assistance of one staff member while using a gait belt and a rolling walker during all transfers. The Admission Minimum Data Set (MDS) assessment, observation period (between 4/18/14 and 4/24/14), indicated that Resident #1 was usually understood and he/she understood others. The MDS indicated that Resident #1 had no behaviors. The MDS indicated that Resident #1 required extensive assistance of 1 staff for transfer activities and toilet use while using a walker. The MDS indicated that Resident #1 was not steady during surface to surface transfers (moving on and off the toilet) and was only able to stabilize with staff assistance. The Surveyor interviewed the Risk Manager at 8:20 A.M. and 3:20 P.M. on 5/19/14. The Risk Manager said the Facility used the rehabilitation resident care Kardex (used by the CNAs to know a resident's care needs) that was placed on the wall in each residents room hidden by a nondescript cover sheet (for confidentiality) that when lifted, indicated Resident #1 required the physical assistance of one staff member while using a gait belt and a rolling walker during all transfers. The rehabilitation resident care Kardex indicated that Resident #1 was dependent upon a staff member for all mobility and toileting needs. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 at 2:45 P.M. on 5/19/14 and at 1:00 P.M. on 5/22/14. CNA #1 said she was normally assigned to the Hospital unit, and on 4/21/14, was floated to the skilled nursing unit, and was unfamiliar with Resident #1's plan of care. The Surveyor interviewed Nurse #1 at 11:45 A.M. on 5/19/14. Nurse #1 said she was aware that CNA #1 was unfamiliar with resident #1's plan of care thus told her during shift report that Resident #1 required the physical assistance of one staff member while using a gait belt and a rolling walker during transfers. CNA #1 said she was told during shift report the personal care and transfer needs of each resident, and was told that Resident #1 required the physical assistance of one staff member during transfers while using a rolling walker, and denied that she was told that Resident #1 required the use of a gait belt during transfers. The nurse's notes, between 7:00 P.M. on 4/21/14 and 7:00 A.M. on 4/22/14, indicated that Resident #1 fell while being transferred from the toilet, the rolling walker tipped over during the transfer, and Resident #1 sustained a hematoma (collection of blood) on the back of the head and a skin tear on the right upper arm. The nurse's note indicated that the rolling walker was replaced by a standard walker. The Surveyor interviewed Nurse #2 at 6:30 P.M. on 5/19/14 and at 7:10 P.M. on 5/31/14. Nurse #2 said she was assigned to Resident #1's nursing care needs from 7:00 P.M. on 4/21/14 to 7:00 A.M. on 4/22/14. Nurse #2 said she was summoned to Resident #1's bathroom because he/she had fallen to the bathroom floor during a transfer from the toilet. Nurse #2 said CNA #1 had transferred Resident #1 without the use of a gait belt and a fall occurred when the rolling walker tipped over and CNA #1 was unable to prevent the fall. CNA #1 said at about 8:00 P.M. on 4/21/14 she transferred Resident #1 from the chair to the toilet while using a rolling walker without the use of a gait belt. CNA #1 said she assisted Resident #1 with toileting needs. CNA #1 said when she assisted Resident #1 to a standing position Resident #1 stood up, placed his/her hands on the bar of the rolling walker, and suddenly tipped the rolling walker forward, and she was unable to prevent the fall. CNA #1 said Resident #1 fell forward, hit his/her head on the wall of the bathroom, and landed on the floor. CNA #1 said she could not prevent the fall because she had not used the gait belt because she did not know that Resident #1 required the use of a gait belt per the plan of care. CNA #1 said Nurse #2 was immediately summoned for assistance. The Nurse Practitioner's progress note, dated 4/22/14, indicated that following the fall last evening (4/21/14) Resident #1 had a new complaint of left rib pain and an x-ray indicated that he/she sustained a fractured 10th left rib. The x-ray report, dated 4/22/14, indicated that Resident #1 sustained an acute fracture of the 10th left rib. The Surveyor interviewed Physician #1 at 1:00 P.M. on 5/19/14. Physician #1 said Resident #1 sustained a fractured left 10th rib as a result of the fall. Refer to F282.