Every finding on record at Sea View Hospital Rehabilitation Center and Home

Based on observations and staff interviews conducted during the Recertification survey from 04/15/2025 to 04/23/2025, the facility did not ensure garbage and refuse were disposed of properly. This was evident during the Kitchen Observation task. Specifically, the facility's waste compactor was not kept closed when not in use on multiple occasions which exposed garbage and refuse and had the potential to attract pests. The findings are: The facility's policy and procedure titled Transporting and Disposing of Non-Medical Waste revised 10/28/2023 stated it was to supply a safe environment for all employees when disposing of non-medical waste and recyclables. On 04/21/2025 at 11:01 AM to 11:28 AM Dietary Worker #1 and the Food Service Director were observed removing garbage from the kitchen to the compactor located outside of the building. The compactor was observed full and was not covered. The compactor was not equipped with a lid/cover. The Food Service Director was interviewed immediately and stated that the compactor was not covered because it was full and needed to be emptied. The Food Service Director also stated that they would find out if a pick-up was scheduled for later that day. On 04/22/2025 at 10:25 AM to 10:40 AM, Dietary Worker #1 and the Food Service Director were observed once again removing garbage from the kitchen to the compactor located outside of the building. The compactor was observed with less garbage, but was uncovered, exposing garbage with multiple flies surrounding the pile of garbage. The compactor was not equipped with a lid/cover. On 04/22/2025 at 10:42 AM, the Food Service Director stated that the compactors have always been this model and were never equipped to be covered after use. The Food Service Director also stated that disposed garbage in the compactor was currently left exposed until picked up by the waste company. On 04/22/2025 at 11:01 AM, the Director of Environmental Service stated that there are a total of two compactors and one dumpster located outside of the building. The Director of Environmental Service also stated that they are responsible to ensure that the area is maintained, and that garbage is picked up as per biweekly schedule. The Director of Environmental Service further stated that they did not know that the compactors needed to be kept closed and was not aware the compactors did not have any means to be covered after garbage was disposed. On 04/23/2025 at 11:54 AM, the Director of Facilities stated that the compactors were purchased [AGE] years ago, and they were never made aware of any issue with the compactors. On 04/23/2025 at 12:04 PM, the Administrator stated that they were not aware that garbage needed to be contained in a covered compactor. 10 NYCRR 415.14(h)

Based on record review, and interviews during the Recertification Survey conducted from 04/15/2025 to 04/23/2025, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 1 (Resident #264) out of 4 residents reviewed for Accidents out of 38 total sampled residents. Specifically, Resident #264 had an unwitnessed incident on 12/26/2024 when they were observed on the floor and complained of pain to the right knee area. Hospital trauma workup showed displaced acute fracture of distal femur. Resident #264 was unable to explain the occurrence. The incident was not reported to the New York State Department of Health. The findings are: The facility's policy titled Incident Reporting Within The Nursing Facility With The Abuse Prohibiting Protocol dated 01/03/2023 documented allegations of neglect or exploitation, misappropriation of funds, mistreatment, including injuries of unknown origin are to be reported immediately to the administrator of the facility, and in accordance with state law, to the Department of Health no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Resident #264 had diagnoses of Alzheimer's Disease, Anxiety, and Depression. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #264 had severely impaired cognition, and required moderate assistance with toilet hygiene, and supervision for toilet transfer and walk 150 feet. The Comprehensive Care Plan initiated 10/23/2024 and last revised 02/19/2025 documented Resident #264 was at risk for falls related to resident has Dementia, Alzheimer's, and resident is a wanderer. Interventions included assist resident with ambulation and transfers, utilizing therapy recommendations, and determine resident's ability to transfer. The Accident Investigation dated 12/26/2024 documented at 9:50 AM Resident #264 had an unwitnessed fall in their bathroom. Certified Nursing Assistant #5 last saw Resident #264 sitting in front of the nurse's station at 9:30 AM. Resident #264 complained of pain to the right knee area and there was swelling. Resident was unable to explain the occurrence/injury. Resident #264 was transferred to the hospital and admitted due to a fracture of the right femur. The Risk Management Occurrence Investigation completed 12/26/2024 documented on 12/26/2024 at 9:50 AM, Resident #264 had an unwitnessed fall and was found on the floor in their bathroom. Resident #264 complained of pain to the right knee area and there was swelling of the knee. Resident #264 did not provide any explanation/statement about the occurrence. The Conclusion documented Resident #264 got up to use the bathroom without calling for assistance. Review of the camera shows, there were no other staff, or resident that went inside the room from the time the resident was last seen, up to the time the resident fell . There is no evidence of abuse, neglect, mistreatment, or care plan violation. Upon return to the facility the plan of care will be updated. A Hospital Discharge summary dated 01/06/2025 documented Resident #264 sustained a right femoral fracture from an unwitnessed fall at the nursing home. The resident was taken to the operating room on 12/27/2024 for application of an external fixation system. There was no documented evidence the facility reported Resident #264's unwitnessed fall incident, resulting in major injury, to the New York State Department of Health. On 04/23/2025 at 10:13 AM, the Director of Risk Management was interviewed and stated they completed their investigation and reviewed the video footage which revealed no one entered Resident #264's room before the fall. The Director of Risk Management also stated that they did not report this unwitnessed fall with major injury to the Department of Health because of the video footage. The Director of Risk Management further stated the video system self-deletes footage after 30 days and the facility did not save a copy. On 04/23/2025 at 12:06 PM, the Chief Nursing Officer was interviewed and stated that part of the investigation was reviewing the video footage which determined the team's decision not to report this incident to the Department of Health. The Chief Nursing Officer also stated they were able to ascertain from the video review that no one had entered Resident #246's room prior to the incident. The Chief Nursing Officer further stated they did not report this incident because the team was convinced Resident #246's fall was not the result of abuse. On 04/23/2025 at 2:15 PM, the Administrator was interviewed and stated it is not the facility's practice to save videos if there were no quality concerns noted. The Administrator also stated that the investigation of this incident determined there was no abuse and no breach of Resident #246's Care Plan. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews during the recertification survey conducted 04/15/2025 to 04/23/2025, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. This was evident for 1 (Resident #44) out of 10 residents reviewed during the Medication Administration task. Specifically, functioning of the Gastrostomy tube was not verified before administration of medication to Resident #44. The facility policy titled General Guidelines for Administering Medication Via Enteral Tube last revised 05/26/2023 documented that to assure tube is in the stomach, using syringe, inject 30 ml of air through the tube while auscultating the patient's stomach with a stethoscope, you should hear a whooshing sound. Aspirating stomach contents with a syringe also confirms placement. Resident #44 had active diagnoses of Aphasia, Huntington's Disease, and Gastrostomy Status. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #44 had a feeding tube. During an observation of Medication Administration on 04/17/2025 at 11:13 AM, Registered Nurse #4 administered medication to Resident #44 via a Gastrostomy Tube. Registered Nurse #4 did not verify functioning of the Gastrostomy Tube before administering the medication. On 04/17/2025 at 11:13 AM, Registered Nurse #4 was interviewed and stated that the placement of Resident #44's Gastrostomy Tube was checked earlier in the morning prior to the administration of 9:00 AM medications. Registered Nurse #4 also stated that they confirmed the placement by listening with a stethoscope and hearing a swoosh sound, and they did not check again as it was already checked earlier in the morning. Resident Nurse #4 further stated that the facility policy is to only check residuals if the resident is a new admission for 2-4 hours. Registered Nurse #4 stated that they do not know the policy on how often the Gastrostomy Tube placement should be checked, however, it is not a normal practice to check it every time prior to administration of medications for the same resident, as it was already checked in the morning. On 04/17/2025 at 12:42 PM, Charge Nurse #4 was interviewed and stated that the placement of Gastrostomy tube should be checked each time before any medication is given. Charge Nurse #4 also stated that placement can be checked by injecting air and listening with a stethoscope. Charge Nurse #4 further stated that it is risky if the patency of the Gastrostomy tube is not checked each time prior to medication administration because the resident may have involuntary movements and spasms which can cause the tube to dislodge. On 04/23/2025 at 11:32 AM, the Assistant Director of Nursing #2 was interviewed and stated that the placement of the Gastrostomy Tube should be checked every time before medications are given. The Assistant Director of Nursing #2 also stated that placement can be checked by aspirating air and listening via stethoscope or checking for residuals, and that if the placement is not confirmed, aspiration pneumonia may pose a risk to the resident. The Assistant Director of Nursing #2 further stated that to keep staff up to date, frequent in-services, competencies, evaluations and reminders are done and there are also two educators that are available for guidance. On 04/22/2025 at 04:46 PM, the Chief Nursing Officer was interviewed and stated that placement of gastrostomy tube must be checked either by injecting 30 cubic centimeters of air and listening with a stethoscope for a swish sound or by auscultating for stomach contents. The Chief Nursing Officer also stated that it is important to check that the peg tube is in the right position to ensure the feeding is being absorbed and not sitting in the stomach, and to ensure that the resident is in proper condition to receive medication. The Chief Nursing Officer further stated they are responsible for doing medication checks and observing medication passes which is done along with the Assistant Director of Nurses, and there are also two nurses who observe medication passes with staff. The Chief Nursing Officer stated that there are weekly meetings and monthly audits done on medication administration to ensure medications are being passed properly. The Chief Nursing Officer also stated that they were not sure and would need to check whether the Gastrostomy tube should be checked only once a day or prior to each medication administration. In a subsequent interview on 04/23/25 at 09:28 AM, the Chief Nursing Officer stated that feeding tubes are supposed to be checked each time before medication is given. 10 NYCRR 415.12(g)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 04/15/2025 to 04/23/2025, the facility did not ensure that a resident is free from physical restraints imposed for discipline or staff convenience and not required to treat the resident's medical symptoms. This was evident in 1 (Resident #153) of 1 resident reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #153 was observed on several occasions, lying in bed with the left side of the bed against the wall. The findings are: The facility's policy titled Physical Restraints with a last reviewed date of 03/25/2024 documented that physical restraints are defined as any manual method or physical/ mechanical device, material, or equipment attached to or adjacent to the resident's body that the resident cannot remove easily, and which restricts the freedom of movement or normal access to his or her body. Resident #153 was admitted to the facility with diagnoses that include Traumatic Brain Injury, Dementia, and Anxiety Disorder. On 04/15/2025 at 10:51 AM and on 04/21/2025 at 8:55AM and 11:14AM, Resident #153 was observed lying in bed with the right half side rail raised. The left side of the bed was against the wall, and the left half side rail was also raised. On 04/21/2025 at 11:17 AM, during an observation made by the State Surveyor with Registered Nurse #1, Resident #153 was observed lying in bed with the right half side rail raised. The left side of the bed was against the wall, and the left half side rail was also raised. The Significant Change Minimum Data Set assessment dated [DATE] documented Resident #153's cognition as severely impaired, no behaviors exhibited, dependent on staff for eating, moderate assistance for bed mobility, and required maximal assistance for transfers and no restraints used. The physician's orders dated 04/19/2025 had documented orders for Memantine Hydrochloride for mood disorder. The physician's order dated 04/18/2025 had documented orders for Trazadone for mood disorder. The Comprehensive Care Plan focus initiated 07/02/20 documented the resident has impaired cognition related to history of Traumatic Brain Injury, anoxic brain damage, and acute respiratory failure with hypoxia. Goals include the resident will improve current level of cognitive function through the review date, 4/3/25. Interventions include communicate with the resident/family/caregivers regarding resident's capabilities and needs. The Comprehensive Care Plan focus initiated 9/20/21 documented the resident has a behavior problem with unpredictable agitation related to getting agitated when needs are not me. On 12/24/24 noted with agitated behavior, yelling and cursing with no obvious triggers. Goals include the resident will have no evidence of behavior problems by review date, 4/3/25. Interventions include Depakote sprinkles 125mg, caregivers to provided opportunity for positive interaction, attention and to stop and talk with them as passing by. The Comprehensive Care Plan focus documented that Resident #153 has high risk for falls related to confusion, lack of safety awareness, sliding self, in reclining wheelchair, created 5/8/20. Goals include resident will be free of falls through the review date, 6/6/23, target date 8/21/25. Interventions include floor mats on both sides of the bed. Review of the Comprehensive Care Plan documented resident had 5 falls in the last year: 3/24/24, resident had an actual fall with no injury, noticed resident sitting on the floor mat between bed and the dresser, 5/2/24,resident found lying on their right side with arms and head of bed on the bed, 8/14/24- actual fall,found on his back in front of the nursing station, 11/27/24 found on the floor between beds, 12/7/24, found resident on the left side of the bed on the floor mat. A behavior note dated 4/18/25 documented resident repeatedly yelling out and disturbing surrounding residents using foul language, repeatedly yelling shut the window, despite window being shut. When Staff attempts to redirect him, he becomes louder and more agitated. There is no apparent trigger to behavior and resident does not respond to no pharmacological interventions. Increased Trazadone and Namenda in progress. A Physician's note dated 4/17/25 documented that resident was evaluated by Psychiatry and collaborated with medical director regarding resident's disruptive behavior. Resident with history of Dementia, with anoxic brain damage and will benefit from Namenda, also on Depakote. A behavior note dated 4/14/25 documented resident slept well through the shift, no behavioral issues noted this tour. Compliant with care. A review of the progress notes and the assessments did not reveal any restraints assessments or documentation Review of the medical record revealed no Comprehensive Care Plan or Physician's Order for a Physical Restraint. Review of the policy dated 3/7/22, last reviewed 3/5/24 did not identify that the bed against the wall, was considered a restraint. On 04/21/25, at 11:14 AM, Patient Care Technician #1 was interviewed and stated that the last time that they saw the resident was when they 1st came on the unit and made their rounds and did not notice the bed was against the wall. Patient Care Technician also stated that they believed that the bed was placed next to the wall because the resident is at risk for falls risk and that's why they have a floor mats. On 04/21/25 at 11:17AM Registered Nurse#1 was interviewed and stated that Resident #153's bed should not be against the wall and was probably moved during care. Registered Nurse#1 also stated that the bed should be off the wall at all times. On 4/23/25 at 01:16 PM the Nurse Educator was interviewed and stated that they did a house wide in-service on Restraints, and that the in-service was based on the policy, and stated that anything restraining any kind of movements that restricts the free movement of the resident is considered a restraint, even though its not tied to the bed, such as can be an abdominal binder, and if it prevents the resident from touching the whole body parts, then it's also considered a restraint. The Nurse Educator also stated that they used the same lesson plan that includes all restraints but could not recall if that it mentioned that the beds against a wall as a type of restraint. On 04/23/25 at 01:26 PM, the Chief Nursing Officer was interviewed and stated that they were only made aware of the bed being against the wall on 04/21/25. the Chief Nursing Officer stated that Staff is made aware of the different types of restraints and that meetings are held every Tuesday and Thursdays to discuss any findings on audits done with residents with restraints. The Chief Nursing Officer stated that Resident #135 was not identified with a restraint and that they had educated the Staff that the bed against the wall is a restraint and that they would include that to be more specific when they retrain the Staff again. On 04/23/25 at 01:55 PM, the Administrator stated that any concerns identified will be addressed, and that Resident #135's bed against the wall was not identified. The Administrator also stated that that anything that restricts a resident's movement, is considered a restraint and that the Quality Committee has an audit that is conducted monthly, and to ensure that they are making rounds and that they maintain restraint free. The Administrator stated that Resident#153 identified, had an audit and there were no issues noted and that they would continue to audit and educate the Staff. 10 NYCRR 415.4(a)(2-7)

Based on record review and interviews during the Recertification Survey conducted from 04/15/2025 to 04/23/2025, the facility did not ensure that residents had the right to send and promptly receive mail. This was evident in 8 (Residents #27, #80, #87, #88, #90, #193, #205, and #221) out of 38 total sampled residents. Specifically, the facility did not have a procedure in place for residents to send and receive mail on Saturday. The findings are: The facility policy titled United States Mail with a last revision date of 10/28/2023 documented mail and packages received by the facility mailroom that belongs to a resident will be delivered to the Unit Clerk on each floor for distribution to each resident. On 04/16/2025 at 11:40 AM during the Resident Council Meeting, Residents #27, #80, #87, #88, #90, #193, #205, and #221 stated the facility does not deliver mail to residents on Saturday. They stated this was because the mailroom is closed on the weekends. On 04/22/2025 at 2:34 PM, the Resident Representative was interviewed and stated that the mailroom is open Monday thru Friday only. Any mail that is delivered to the facility on Saturdays is not distributed to the residents until the following Monday. On 04/23/2025 at 10:30 AM, the Assistant Coordinating Manager was interviewed and stated they work in the mailroom and deliver mail to residents on weekdays. The mailroom is not staffed on the weekends so there is no mail delivery to residents on Saturday. On 04/23/2025 at 2:15 PM, the Administrator was interviewed and was unable to provide an explanation for why residents had not been receiving their mail on Saturdays. 10 NYCRR 415.3(e)(2)(i)

Based on observation record review, and interviews during an abbreviated survey (NY00358546), the facility failed to ensure that a resident was treated with dignity included being free from physical or chemical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for one (1) out of 5 (five) residents (Resident #1) sampled. Specifically, on 10/26/2024 at approximately 7:10 AM Resident #1 was observed lying in bed with their left ankle tied with a bed sheet to the bed rail. Patient Care Technician #1 admitted to restraining Resident #1. Resident #1 was restrained for the purposes of discipline or convenience. The findings are: The facility's Policy and Procedure titled Prevention of Abuse, Neglect, Exploitation, and Misappropriation of Property and other reportable incidents date of January 16, 2025, documented the facility residents had a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. The facility's Policy and Procedure titled Physical Restraints had a revised date of 03/07/2022. The policy documented that the facility recognizes and respects the right of their residents to be free from physical and chemical restraints unless medically indicated and permit under applicable laws, guidelines, and standards. Resident #1 was admitted to the facility with diagnoses including Anxiety Disorder, Psychotic Disorder, and Insomnia. The Minimum Data Set, dated [DATE] documented Resident #1 had moderately impaired cognition. The Minimum Data Set documented Resident #1 had physical and verbal behavior directed at others. The Incident Report dated 10/26/2024 at 7:25 AM documented Patient Care Technician #2 called Registered Nurse #1 to Resident #1's room where Resident #1 was observed lying in bed with a bed sheet loosely around their left ankle. The sheet was removed and there was no redness, discoloration, skin tear, or swelling observed. There was no sign and symptom of trauma noted. The facility investigated and concluded that the incident was verified, however, was without mal-intent and did not lead to physical, emotional, or psychological harm. Patient Care Technician #2 was immediately removed from the unit and was suspended. The Patient Care Technician #2 resigned while they were out on administrative leave on 03/13/2025. The facility immediately conducted restraint check on all cognitively impaired residents to ensure they are not being restrained. A nursing progress note dated 10/26/2024 at 10:26 AM documented Registered Nurse #1 was called to Resident #1's room by Patient Care Technician #2. Resident #1 was observed lying in bed with a sheet loosely around their left ankle. The sheet was removed, there was no redness, discoloration, skin tear, or swelling. There were no signs and symptoms of trauma noted. The physician progress note dated 10/26/2024 at 9:00 AM documented Resident #1 was alert and verbally responsive with baseline confusion. There was no trauma. A complete body assessment was done and there was no evidence of any trauma, skin discolorations, or bruises. The skin was intact, and Resident #1 denied pain. There were no changes in range of motion. During an interview on 03/25/25 at 1:10 AM, Patient care Technician #2 stated they were conducting morning rounds at the start of their shift on 10/26/2024 at approximately 7:10 AM and when they entered Resident #1's room, they observed Resident #1 lying in bed with a bed sheet loosely tied over Resident's left ankle and tied to the bottom bed rail. They immediately notified Registered Nurse #1 who removed the sheet from Resident #1's ankle. During an interview on 03/25/25 at 1:19AM, Registered Nurse #1 stated Patient Care Technician #2 informed them Resident #1's ankle was tied with a bed sheet to the lower bed siderail (can't recall the time). They immediately went to Resident #1's room and observed a loosely tied bed sheet over Resident #1's left ankle and tied to the bottom bed rail. They untied the left ankle and assessed Resident #1. There was no redness, discoloration, complains of pain, and range of motion was within normal limit. Registered Nurse #1 stated no emotional or psychological distress was observed. Registered Nurse #1 stated the unit charge nurse was responsibility for supervising the Patient Care Technicians on the unit. Several attempts were made to contact Patient Care Technician #1 but was unsuccessful. A certified mail was sent to Patient Care Technician #1 on 03/27/2025 with no response. Patient Care Technician #1 provided the facility with a written statement dated 10/26/2024 at 7:30 AM. The statement revealed Patient Care Technician #1 was providing activity of daily living care (did not identify to whom) and heard a nurse yelling that another resident had gotten out of bed. They tied Resident #1's foot to the bed so they could help the nurse put the other resident in bed. During an interview on 03/25/25 at 1:37 PM with Registered Nurse Supervisor #1 (Assistant Director of Nursing), they stated when they arrived on the unit Resident #1 was already out of bed sitting in a shower chair. They performed a full body assessment and there were no visible injuries, no discoloration noted. Registered Nurse Supervisor #1 stated Resident #1 was unable to explain due to impaired cognition. During an interview on 03/27/25 at 2:21 PM the Risk Manager who conducted the investigation, stated Patient Care Technician #1 was interviewed and stated they were afraid Resident #1 would fall so they secured the Resident's leg before going to assist Registered Nurse #1's called for help. The Risk Manager stated Patient Care Technician #1 acted outside the facility's policy and procedure. The Risk Manager stated they acknowledged that the incident did occur, and that Patient Care Technician #1 acted outside the facility's policy and procedure. It was not Patient Care Technician #1's intention to restraint Resident #1. During an interview on 03/27/25 at 3:24PM the Director of Nursing stated they were informed of the incident by the Assistant Director of Nursing who stated Patient Care Technician #1 admitted they secure the Resident's left ankle to the bed. The Director of Nursing stated the investigation concluded that Patient care Technician #1 restrained Resident. The Director of Nursing stated the nursing supervisors, and they conduct rounds on the units to ensure staff are being monitored and following the re-education. The Director of Nursing stated that abuse did occur because Resident #1 was restraint. However, it was unintentional with resident safety in mind at the time of the incident. The Director of Nursing stated they are monitoring the residents monthly to ensure restraints are not being used. The Director of Nursing stated that Patient Care Technician #1 has not worked in the facility since the day of the incident. During a telephone interview on 03/28/2025 at 10:11 AM the Administrator stated they were not in the facility at the time but received a from the Assistant Director of Nursing informing them of the alleged incident on 10/26/2024. The Administrator stated they met with Patient Care Technician #1, and they admitted to loosely tying Resident #1's ankle to the bed to prevent the Resident from falling. Based on the following corrective actions taken, there were sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be incompliance on 11/04/2024, prior to Surveyors' entrance on 03/25/2025. On 10/26/2024, Policy on restraint and Abuse was reviewed. No revisions were done. The facility took immediate corrective actions. On 10/26/2024 - Patient Care Technician #2 immediately notified Registered Nurse #1 who removed the bed sheet and assessed the Resident. On 10/26/2024 - Nurse Practitioner #1 was informed and assessed the resident. No new orders were obtained. On 10/26/2024 - Patient Care Technician #1 was suspended pending investigation and did not return to position and then resigned on 03/17/2025. On 03/13/2024 - Patient Care Technician #1 resigned. On 10/26/2024 - Policy on restraint and abuse was reviewed. Abuse policy was revised dated January 16, 2025. On 10/27/2024 - a facility-wide in-service on restraint and alternatives to restraint was conducted - 100% of staff was in-serviced. 100% (127/127) Patient Care Technician in-serviced. 100% (22/22) Licensed Practical Nurse in-serviced. 100% (72/72) Registered Nurses in-serviced. 100% all staff received in-services on Restraint and Purposeful rounding, One-to One Close Monitoring, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property, and Exploitation. On 11/04/2024 to 03/11/2025 - Audit Tool Restraint Observation reviewed. Monthly audits were performed on 30 Residents who are cognitively impaired, there was no restraints identified. On 11/04/2024 - Quality Assurance and Performance Improvement meeting was held Topic: Resident #1 in bed with a bed sheet on their left ankle and secured to the bed by Patient Care Technician #1. Attendance sheet with names of attendees obtained. 10 NYCRR 415.4(a) (2-7)

Based on record review and staff interviews conducted during the recertification and complaint survey conducted from 2/2/23 to 2/9/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #175) of 1 resident reviewed for Dental out of 40 total sample residents. Specifically, there was no documented evidence that a CCP was developed and implemented for oral/dental concerns for a resident who was observed with multiple upper and lower teeth missing. The findings are: The facility's policy and procedure titled Comprehensive Person-Centered Care Planning reviewed 1/25/23 documented it is facility's policy that the Interdisciplinary team performs an accurate standardized and comprehensive assessment of each resident of the nursing facility. Facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident #175 was admitted to the facility with diagnosis that included Benign Neoplasm of Cerebral Meninges, Bell's Palsy, and Dysarthria. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #175 had intact cognition and required the extensive assist of one person for personal hygiene. The residen [NAME] no dental concerns. During an interview on 2/2/23 at 12:09 PM, Resident #175 was observed with multiple upper and lower teeth missing. Resident #175 stated their last dental exam was two years ago. The dental consult dated 7/17/20 documented resident was seen for a new patient examination. The resident's extra and intra oral were examined and the resident was missing most of their natural teeth. The consult documented Resident #175 would be evaluated in the future for fabricating upper and lower partials. The plan was to follow up with resident's oral hygiene and the annual assessment. The dental consult dated 9/2/20 documented resident was seen for new patient examination. It documented resident's extra and intra oral were examined. The following teeth are missing in the upper arch: 1, 2, 3, 4, 6, 7, 8, 10, 11, 13, 15, 16 and in the lower arch: 17, 18, 23, 24, 25, 26, 28, 29, 31, 32. The plans were for an annual examination and treatment upon request. The review of the Comprehensive Care Plan (CCP) created 3/28/20, last reviewed 1/9/23 revealed that there was no care plan addressing resident's dental status. There were no interventions assessing chewing ability, asses for pain, infection, or refer for dental service. Further review of the CCP related to nutritional problem last revised 12/28/22 revealed that there were no interventions addressing resident's dental issues. On 2/9/23 at 10:14 AM, Registered Nurse (RN #1) was interviewed and stated comprehensive care plans are created upon admission and revised by the registered nurse on the unit. RN #1 stated that Resident #175 does not have a care plan developed related to dental because there was no concern. RN #1 stated they were not aware the resident had a dental concern because Resident #175 did not complain about their teeth. On 2/9/23 at 11:37 AM, the Registered Dietitian (RD) was interviewed and stated resident had a care plan developed for nutritional risk. It does not address any concern related to resident's oral/dental problem. RD was not aware that the resident had multiple teeth missing so it was not reflected in the CCP. The RD stated the CCP would be updated to reflect Resident #175's current dental status. On 2/9/23 at 1:13 PM, the Director of Nursing (DON) stated that the resident's baseline care plan is created upon admission by the admission nurse then comprehensive care plans are created by the interdisciplinary team during the initial care plan meeting. The CCP is updated as needed, and any new area of concerns are developed when issues are arises by the unit nurse. 415.11(c)(1)

Based on observations, record review and staff interviews during the recertification and complaint survey conducted from 2/2/23 to 2/9/23, the facility did not ensure that routine dental service was provided to resident. This was evident for 1 (Resident #175) of 1 resident reviewed for dental out of a sample of 40 residents. Specifically, Resident #175, a resident with multiple missing teeth, did not receive an annual dental examination or follow-up regarding partial dentures. The findings are: The facility's policy and procedure titled Oral Hygiene reviewed 1/25/23 documented the oral health program is an integral part of the resident's total care plan. A routine dental service is performed by a dentist to all residents upon admission then yearly thereafter and whenever the need arises. Resident #175 was admitted to the facility with diagnosis that included Benign Neoplasm of Cerebral Meninges, Bell's Palsy, and Dysarthria. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #175 had intact cognition and required the extensive assist of one person for personal hygiene. The resident had no dental concerns. During an interview on 2/2/23 at 12:09 PM, Resident #175 was observed with multiple upper and lower teeth missing. Resident #175 stated their last dental exam was two years ago. The review of the Comprehensive Care Plan (CCP) last reviewed 1/9/23 revealed that there was no care plan addressing resident's dental status. There were no interventions assessing chewing ability, asses for pain, infection, or refer for dental service. Further review of the CCP related to nutritional problem last revised 12/28/22 revealed that there were no interventions addressing resident's dental issues. The physician's order dated 3/27/20 documented dental consult for new admission was ordered and the order status was completed. The dental consult dated 7/17/20 documented resident was seen for a new patient examination. The resident's extra and intra oral were examined, and the resident was missing most of their natural teeth. The consult documented Resident #175 would be evaluated in the future for fabricating upper and lower partials. The plan was to follow up with resident's oral hygiene and the annual assessment. The dental consult dated 9/2/20 documented resident was seen for a new patient examination. It documented resident's extra and intra oral were examined. The following teeth are missing in the upper arch: 1, 2, 3, 4, 6, 7, 8, 10, 11, 13, 15, 16 and in the lower arch: 17, 18, 23, 24, 25, 26, 28, 29, 31, 32. The plans were for an annual examination and treatment upon request. The review of the physician's orders dated from 1/1/21 to 2/2/23 revealed one dental consult was ordered on 6/2/21, and the status of the order was Struck Out. There was no documented evidence in the medical record that a dental evaluation was conducted in 2021 or 2022. On 2/8/23 at 11:18 AM, a Patient Care Technician (PCT #1) stated that Resident #175 does not wear dentures and has missing teeth. Resident #175 requested tough foods be cut into smaller pieces. PCT #1 assisted Resident #175 by cutting foods for them during meals. On 2/8/23 at 11:50 AM, Patient Care Technician (PCT #2) stated they were not aware that Resident #175 had any dental issues. PCT #2 stated the resident does not require assistance for oral hygiene, and they did not know if the resident was missing teeth. On 2/8/23 at 12:19 PM, Registered Nurse (RN #1) was interviewed and stated they did not recall the last time Resident #175 had a dental evaluation. RN #1 stated that Resident #175 was last seen by the dentist in 2020 according to the electronic medical record. RN #1 stated there were no dental consults in paper form found in the resident's chart. On 2/9/23 at 10:14 AM, a subsequent interview was conducted with RN #1 who stated there was an outsource company that schedules residents for annual dental examinations, treatments or as needed basis. The dentist is onsite once a week and will see residents for their scheduled appointments. RN #1 does not know why Resident #175 was not scheduled by the dental service company for annual dental examination or follow up appointment. On 2/9/23 at 10:43 AM, Registered Dietitian (RD) was interviewed and stated that resident was observed eating foods during meal service. RD stated they did not notice the resident was having any issues eating foods during meal service. RD did not know if resident had missing/broken teeth. On 2/9/23 at 11:35 AM, a subsequent interview was conducted with RD. RD stated Resident #175 was seen in the hallway and was observed with multiple teeth missing. On 2/13/23 at 8:46 AM and 1:01 PM, attempts to contact the Dentist were unsuccessful. On 2/9/23 at 1:13 PM, Director of Nursing (DON) was interviewed and stated that resident's oral status is examined by the dentist upon admission, as needed and then yearly. The DON was not aware that Resident #175 has not had dental examination since 2020. DON stated that residents are seen by the dentist annually and as needed for follow up/treatment. 415.17(a-d)

Based on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs was developed. Specifically, comprehensive care plans were not developed for a resident with hearing difficulty. This was evident for 1 of 38 sampled residents (Resident #214). The findings is: The facility's policy and procedure titled Comprehensive Resident Assessment MDS 3.0/CAAS and Person Centered Care Planning revised 1/21/20, documented the interdisciplinary team is responsible for the comprehensive resident assessment and person centered care planning in accordance with the procedures set forth below. At the ICCP meeting establish realistic, resident focused, individualized and measurable goals. The goal(s) must be time limited. It must match the problem identified. The identified problems, conditions, limitations, is aimed towards prevention of deterioration, complication and/or maintenance/promotion of resident's health status, which should be measurable and must have timeframe for completion or evaluation. Develop appropriate intervention, which are specific, individualized steps, or approaches that staff will take to assist the resident care and provide for continuity of care for all staff. These must be short and concise instructions and understood by all staff. On 01/27/20 at 10:58 AM, Resident #214 stated she has hearing difficulty and uses hearing aids. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident as cognitively intact with moderate difficulty in the ability to hear and has a hearing aid. Resident #214 has a [DIAGNOSES REDACTED]. The resident's medical record was reviewed and revealed no comprehensive care plan to address resident's hearing loss, or maintenance of hearing aid. There is no documented evidence of instructions to nursing staff to ensure hearing aid is working properly to ensure that the resident's identified problem of loss of hearing is addressed. On 01/31/20 at 11:43 AM, an interview was conducted with a Patient Care Technician (PCT) who stated the resident uses a hearing aid and with the hearing aid, the resident is able to hear. On 01/30/20 at 01:20 PM, an interview was conducted with a Registered Nurse (RN 1) after review of Resident #214 complete care plan, RN 1 stated there was no care plan related to hearing for Resident #214 and there should be a care plan for hearing for Resident #214. On 01/30/20 at 04:27 PM, an interview was conducted with the Assisant Director of Nursing who stated after review of Resident #214 complete care plan there should be a care plan for hearing impairment and safety. The ADN was not clear on why the care plan related to hearing was not developed but stated possibly if the resident entered the facility with the hearing aids and has no problems related to the hearing aids, the care plan was overlooked. 415.11(c)(1)

Based on observation, and staff interview during the standard recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, in the refrigerator sliced meats were stored after 6 days of initial use, turkey was stored after 4 days of initial use. The findings are: The USDA (United States Department of Agriculture) Food Safety and Inspection Service recommends that leftovers can be kept in the refrigerator up to 3 to 4 days. The facility's policy and procedure reviewed in 3/19 titled Sanitary Methods for Preparing Food dated documented the purpose to ensure infaction control by preventing food from spoiling and to maintain the palatability of prepared foods. Refrigerated left-over foods are discarded after three days. On 01/27/20 at 09:36 AM, during the initial tour the surveyor observed in the # 4 Nourishment Refrigerator sliced salami dated 1/21/20, and 2 bins of turkey dated 1/23/19. On 01/30/20 at 02:05 PM an interveiw was conducted with a Food Service Supervisor that works the afternoon/night shift stated slice meats and foods that were in use are suppose to be thrown out in three days in and which is includes the first day the item was used. The superviosr stated being busy that Sunday doing rounds, she missed it and did not disgard the meats. The supervisor also stated the morning supervisor will also do rounds and ensure that items are thrown out on the third day. The supervisor stated it is the responsibility of the supervisors but when a staff member observe that food needs to be discarded they should inform the supervisor and dump it. The supervisor stated the her duties includes checking the pantries on the floor ensuring foods are labeled with a name, dated and if past 3 days as well as refrigerators are temperature are within normal limits and contains a thermometer. The superviosr stated that all staff were inserviced. On 01/30/20 at 02:17 PM, the Food Service Director was interviewed and stated monitoring includes quality assurance checks, monitoring of staff, correcting staff and also the supervisors oversees the staff and kitchen as well. The FSD stated each supervisor were responsible to ensure that those items were thrown out immediately and it should have been corrected a few days before but it was human error. All staff were inserviced and reminded that everyone needs to check the refrigerators related to discarding foods past three days which includes the date marked as the first day. 415.14(h)

Based on observation, staff interviews, and record review conducted during an abbreviated survey (NY 969), the facility did not ensure that a resident was free from physical restraint. This was evident in 1 of 4 residents sampled (Resident #2). Specifically, on 05/25/2018 at 9:53 AM, Resident #2 was observed sitting in a wheelchair, in hallway across from the nursing station, in restraint. The findings are: The facility policy on Physical Restraints - Nursing Facility dated 04/01/1999 documented that the facility recognizes and respects the rights of residents to be free from physical restraints, unless the use is medically indicated and permitted under applicable laws, guidelines, and standards. The policy also stated that restraints must not be employed as a substitute for a treatment plan, as discipline, as a punitive measure to satisfy request by family, for the convenience of staff, or when the resident refuses their use. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 05/03/2018 documented that the resident was severely impaired in cognition (never/rarely made decision). A Comprehensive Care Plan (CCP) dated 02/21/2018, on at risk for injuries and/or falls noted in place with interventions to use the self-release alarmed seatbelt when the resident was out of bed. A physician's orders [REDACTED]. During an observation conducted on 05/25/2018 at 9:53 AM, Resident #2 was observed sitting in his wheelchair crossed from the nursing station. The resident was wearing a Hook-and-Loop Seatbelt that was equipped with an alarm and had a Velcro closure for ease of release. However, the staff positioned the Velcro to the resident's back preventing the resident from being able to use the self-releasing provision of the Velcro belt. In addition, the belt was tied in a knot and hooked to the brakes of the wheelchair. The resident was unable to untie the knot and was unable to move his body freely in the wheelchair. The State surveyors called the unit Registered Nurse (RN) who witnessed the resident's E-Z Release Alarm Seatbelt tied in a knot and the Velcro positioned behind the resident's back. The RN stated that the seatbelt should not have been tied in a knot because the resident would not be able to release it. The facility investigative summary revealed that Certified Nursing Assistant #1 (CNA#1) observed that Resident #2 was restless and was trying to get up from the wheelchair unassisted. CNA #1 temporarily tied the alarmed seatbelt on the back brakes to attend to another resident. A review of the manufacturers manual for the Hook-and-Loop Seatbelt documented that the Hook-and-Loop Seatbelts are used with an alarm to indicate to staff when a patient is attempting to get out of a wheelchair. The yellow loop handle is easy to release with a simple sweeping motion that does not require individual fingers dexterity. The Hook-and-Loop Seatbelts are not intended to be used as a restraint. In addition, the E-Z Release Seatbelt with TR2 Alarm provides staff with more time to respond to active patients attempting to leave their chairs or wheelchairs. CNA #1 was interviewed on 05/25/2018 at 1:00 PM and stated that she was Resident #2's assigned CNA for more than one year. On 05/25/2018, she tied Resident #2's seatbelt in a knot and tied it to the wheelchair brakes because the resident was agitated. She verbalized that every time Resident #2 was agitated, she would tie the seatbelt like that (in a knot) and that the RN (the unit charge nurse) helped her tied the seatbelt in a knot. The RN was interviewed on 05/25/2018 at 12:45 PM and stated that Resident #2 was at high-risk for falls and that the self-release seatbelt was an intervention to prevent the resident from falling. Resident #2 was restless and kept on releasing the seatbelt. The seatbelt should not have been tied in a knot to the brakes of the wheelchair. The correct way to apply the seatbelt was to have the Velcro in front of the resident so that he would be able to open the belt. This was her first time seen a resident tied in a wheelchair. A follow-up interview was conducted with the RN on 05/25/2018 at 2:00 PM. She stated that she knew that the CNA was tying Resident #2's self-release seatbelt in a knot whenever the resident was agitated and that she did not help the CNA tie the knot. The Director of Care Management (DCM) was interviewed on 05/25/2018 at 2:15 and stated that the facility uses E-Z Release seatbelts as an intervention. The seatbelts must be easily released by the resident and should not have been tied in a knot. The Director of Risk Management was interviewed on 08/08/2018 at 10:30 AM. The DRM stated that the CNA admitted to temporarily restraining Resident #2. She tied the resident's seatbelt in the back of the wheelchair so that he would not stand up while she cared for another resident. The Director of Nursing (DON) was interviewed on 08/02/2018 at 2:50 PM and stated that the DRM informed her that the State surveyors observed Resident #2's seatbelt improperly tied in the back of the wheelchair. She stated that any device used to restrict a resident's movement is considered a physical restraint and that it is not allowed in the facility. 415.4(a)(2-7)

Based on observation and staff interview during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically (1) the glucometer was not cleaned before and after use and a used needle was not disposed of appropriately after use and (2) multiple observations were made of nurses [MEDICATION NAME] inappropriate hand hygiene. This was evident for 5 out of 10 licensed nurses observed during the Medication Administration task. The facility policy and procedure Hand Hygiene Policy' revised (MONTH) (YEAR) documented if using a lever-operated paper towel dispenser, dispense a portion of towel before washing hands. Using tepid water, wet hands .apply soap product according to manufacturer's recommendations. Rub hands together for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands thoroughly. Dry hands with disposable towel. Use towel to turn off faucet. Alcohol gel-a) rub hands together, covering all surfaces of hands and fingers until hands are dry. The policy did not address disposal of sharps. The facility policy and procedure Glucose Meter Utilization dated 2/1/18 documented cleaning and disinfecting is performed after each patient use and when visibly dirty .use a manufacturer approved product to clean and disinfect meter, base unit and accessory box. The facility uses Purple Sanicloths which is a hospital grade disinfectant. The findings are: 1. On 4/10/18 at 04:43 PM, RN#2 was observed on Unit 5 West retrieving the glucometer from the top of the medication cart. The nurse did not perform hand hygiene, donned gloves and performed glucose testing for Resident # 222. The nurse then prepared insulin for the resident without performing hand hygiene before or after preparing the medication. The RN then donned gloves, administered insulin to the resident, and then placed the used insulin syringe in her left smock pocket. The nurse then washed her hands, applied gloves, and disposed of the insulin syringe in the sharps container located inside of the medication cart. The RN then cleaned the top of the glucometer only with an alcohol prep pad and placed it into the accessory box. On 04/11/18 at 05:49 PM, RN #2 was interviewed via telephone and stated that hand hygiene should be performed before and after each resident, and that hand sanitizer can be used up to five times before hands must be washed. The RN stated that she thought she had performed hand hygiene before and after preparing the insulin. RN #2 also stated that she was aware that the used needle was placed into her pocket and should have gone into the sharps container. The RN further stated that she knew that the glucometer should be cleaned before and after use with the designated wipes which contain hospital grade disinfectant. In addition, frequent in-services are given on hand hygiene however return demonstration is not done routinely as part of the in-service. 2. On 04/10/18 at 04:26 PM, Licensed Practical Nurse (LPN) #1 was observed performing hand hygiene on Unit 3 East. The LPN did not wet hands first, instead pulled the lever for soap and then proceeded to wash her hands. When finished washing her hands the nurse turned the lever on the paper towel dispenser with her wet hand, tore off some paper towel, dried both hands, exited the bathroom, and proceeded to medication cart outside of the resident's room. On 04/11/18 at 05:38 PM, LPN #1 was interviewed and stated that in-service is done about three times a year with the last one two months ago. The LPN stated that the instruction included wetting hands before applying soap and that there are signs posted by the sink describing how hand hygiene should be performed properly. She stated that she did not know why he did not re-wash her hands after touching the lever on the paper towel dispenser. On 04/11/18 at 05:44 PM, RN #3 was interviewed and stated she supervises Unit 3 East on evenings. RN #3 stated that staff are observed and reminded to wash hands. RN # 3 also stated that observations are not done every day, maybe 3-5 times a week if I have the time. I have not really observed the LPN's washing hands, I mostly observe the PCT's (Patient Care Technicians). 3. On 04/10/18 at 05:10 PM, LPN #2 was observed performing hand hygiene on Unit 2 West before administering eye drops for Resident #154. LPN turned on the faucet and agitated both hands for approximately five seconds. The LPN did not apply soap to hands, dried hands with paper towel and turned faucet off. LPN # 2 then proceeded to apply eye drop to both eyes of the resident. LPN #2 then returned to the bathroom, turned on the faucet and agitated both hands for approximately five seconds once again. The LPN did not apply soap to hands, dried hands with paper towel and turned faucet off. The LPN was interviewed immediately after the observation and stated that soap is not used with each hand washing, only after two to three times of washing. LPN #2 stated that in-service on hand hygiene was received very often and explained how many minutes hands should be washed for, turn the faucet on, and use soap and some of the group will do return demonstration. LPN #2 also stated that usually I do the proper way. 4. On 04/11/18 at 11:55 AM, LPN #3 was observed performing hand hygiene on Unit 2 West. The LPN was observed wetting her left hand with water while simultaneously pulling the lever on the soap dispenser with her left hand. Multiple observations were made of the nurse doing handwashing while performing blood glucose testing and the nurse consistently washed hands in that manner. On 04/11/18 at 02:40 PM, LPN #3 was interviewed and stated that she had received in-service on hand-washing and had just had a session recently. The LPN could describe the proper sequence of hand-washing and stated that she must be just doing it subconsciously as I was not aware that I was doing it like that. 5. On 04/11/18 at 04:38 PM, RN #4 was observed performing hand hygiene on Unit 2 East. The RN applied soap to hands before wetting hands. While preparing medications the RN used hand sanitizer to clean hands that had become sticky from protein syrup and used a tissue to remove excess sanitizer. Multiple observations were made of RN #4 and she was observed using wet hands to turn the lever on the paper towel dispenser and did not re-wash her hands after, and repeatedly applied soap to her hands without first wetting them . On 04/11/18 at 05:22 PM, RN #4 was interviewed and could describe appropriate hand washing technique, however, was not aware that she had not used the technique during multiple observations. RN#4 also stated that usually I don't have to turn the lever but if I do I pull the paper and continue doing what I'm doing. RN #4 further stated that in-service is provided all the time on hand hygiene by lecture with no return demonstration. The RN also stated I am responsible for observing staff do hand hygiene, probably did not do it right today because I was nervous. On 4/13/18 at 02:03 PM, the Assistant Director of Nursing (ADN) #2 who functions as the Nurse Educator was interviewed and stated staff is in-serviced annually and as needed on Infection Control and this includes hand hygiene. ADN#2 also stated that the Infection Control Nurse is responsible for that portion of the training and the surveillance of the staff to ensure they are doing the right thing. On 04/13/18 at 02:06 PM, Assistant Director of Nursing (ADN) #3 who functions as the Infection Preventionist was interviewed and stated that in-service on hand hygiene is done annually, on orientation, and competencies on due staff are completed on a weekly basis. ADN #3 also stated that presentations are done as lectures and return demonstration is done on the units. She further stated that the other ADN's do the competencies and that hand hygiene, glucometer cleaning and disinfection is part of annual competency and training for new hires. She further stated that rounds are done daily on the unit to observe if staff are [MEDICATION NAME] infection control appropriately. 415.19 (b)(4)

Based on record review and staff interview during the recertification survey, the facility did not ensure care plans were reviewed and revised to accurately reflect the current status of a resident. Specifically, the self-care deficit care plan did not reflect the current Activities of Daily Living (ADL) status of the resident. This was evident for 1 of 38 residents reviewed for Care Planning. (Resident #19). The facility policy and procedure Interdisciplinary Team Conference revised 12/27/17 documented the PCCCP (Person-Centered Comprehensive Care Plan) is completed on initial interdisciplinary team conference for admission, annually, and when there is significant permanent change; and is being reviewed and revised at least quarterly, if not sooner depending on timeframes for each goal. The findings are: Resident #19 is a [AGE] year-old admitted to facility 11/10/10 with [DIAGNOSES REDACTED].>Hypertension, Mental [MEDICAL CONDITION], Mood Disorder, and [MEDICAL CONDITION]. The Quarterly Minimum Data Set (MDS) 3.0 dated 10/18/17 documented intact cognitive status and supervision with set up assistance from staff with all functions except eating which required supervision only. The Quarterly MDS 3.0 dated 1/10/18 documented intact cognitive status and that the resident required extensive assistance of one staff person with dressing and personal hygiene, and limited assistance of one staff person with bed mobility, transfer and toilet use. The Nursing Activities of Daily Living (ADL) Documentation for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) documented supervision only with bed mobility, transfer and toileting. The Nursing Activities of Daily Living (ADL) Documentation for (MONTH) (YEAR) documented that the resident required limited assistance of staff with bed mobility, transfer and toileting. The Nursing Activities of Daily Living (ADL) Documentation for (MONTH) (YEAR) and (MONTH) (YEAR) documented that the resident required limited assistance of staff with bed mobility and toileting. The Patient Care Technician Accountability Record (PCTAR) for (MONTH) (YEAR) and (MONTH) (YEAR) documented that the resident required supervision only with dressing and personal hygiene. The PCTAR for (MONTH) (YEAR), (MONTH) (YEAR). (MONTH) (YEAR), and (MONTH) (YEAR) documented that the resident required extensive assistance of one staff with dressing and personal hygiene. The Nurse' Monthly Summary Form dated 12/5/17, 1/3/18, 2/1/18, and 3/2/18 did not document the change in the resident's ADL status. The Person-Centered Comprehensive Care Plan (PCCCP) titled Resident has Self-Care Deficits dated 5/17/17 and updated monthly documented interventions which included: provide assistance with ADL care, encourage independence, monitor hygiene needs and render as needed each shift. The Comments section of the PCCCP documented the following: 12/5/17-no changes in ADL status, 1/3/18-no change with ADL care, 2/1/18-no change in ADL status, 3/2/18- no change in ADL care. The PCCCP was not updated to reflect that there was a change in the resident's ADL status. On 4/13/18 at 12:29 PM, an interview was conducted with the Head Nurse who stated that the residents are divided up among the nurses and nurses are responsible for documentation on certain residents. The Head Nurse also stated that nurses are expected to review the PCTAR when doing the monthly summary. The Head Nurse further stated that nurses are expected to update the PCCCP to reflect any changes that occur with the resident. I do not review the summaries as they are RN's and expected to do them accurately. On 04/13/18 at 12:52 PM, the Registered Nurse (RN) #1 was interviewed via telephone and stated I usually update changes in residents status on the monthly summary and if there are any new problems I add it in the care plan. I also look at nurse's notes, consults, and the orders. I did not look at the MDS when I did the summary or the update to the care plan. I do not recall if I looked at the PCTAR as most of the time I am there so I can know if there are any changes and I didn't notice any changes with the resident's status. On 04/13/18 at 01:02 PM, an interview was conducted with the Assistant Director of Nursing (ADN) #1 assigned to the unit who stated that revision of the PCCCP should begin with review of the monthly renewal and any change of status or orders. The ADN also stated that the PCTAR and the MDS should also be reviewed. The ADN further stated that she does not routinely review the work of the RN's as they supervise/monitor each other. 415.11(c)(2) (i-iii)

Based on observations and staff interview, the facility did not ensure that the most recent survey results were posted in areas of the facility that are readily accessible (such as a lobby or other area frequented by most residents, visitors or other individuals) where individuals wishing to examine survey results do not have to ask to see them. The facility policy and procedure Examination of Survey Results dated 12/1/17 documented a copy of the most recent survey report as well as our plan for correction for the identified problems will be kept in a binder in the reception area, Executive Office and Social Services Office. The findings are: During multiple observations during the recertification survey conducted 4/9/18 to 4/13/18, notices were observed posted on resident units and in the Lobby Area next to the Guest sign-in book that documented that the survey results were available for review in the Social Services Office, Executive Office, and Reception Desk. The notice also listed telephone numbers and the Social Services Director's email address to contact for further information. On 04/12/18 at 10:00 AM, survey results could not be located in the Executive Office area. The Administrative Assistant was asked for survey results and presented a binder from the top of a filing cabinet behind a desk, and stated that if someone wanted to see it they just had to ask. On 04/12/18 at 10:05 AM, survey results could not be located at the Reception Desk. Two Security Officers seated at the Reception desk were asked for survey results and did not know what it was nor where it could be located. On 04/12/18 at 10:37 AM, the Social Service office was located at the end of a long hallway that was not frequented by residents or visitors. There was no one in the office at that time and survey results were not visible or able to be located. On 04/13/18 at 02:35 PM, an interview was conducted with the Associate Executive Director (AED) who stated we put signs on each of the bulletin boards of each unit that the results are available. The AED also stated that results are at the Reception Desk and was unaware that the results could not be obtained at the desk nor were not readily accessible in any of the stated locations. On 04/13/18 at 02:38 PM, the Social Services Director (SSD) was asked for the survey results. The SSD stated that they were in a binder which she retrieved from the top shelf of a book case in the office. The SSD further stated that anyone wanted to view the document could just ask for it. On 04/13/18 at 02:40 PM, the Clerical Associate (CA) seated at the Reception Desk was asked for the survey results. The CA asked the surveyor we would have it up front here? I don't know what that is but I can find out. 415.3(1)(c)(1)(v)

Based on observation, record review, and interview the facility did not ensure that a resident was free from physical restraints. Specifically, the unit nurses did not identify the resident's seat belt as a restraint or provide ongoing assessments to determine the continued need for the seat belt. This was evident for 1 of 3 residents reviewed for Physical Restraints (Resident #174). The finding is: Resident #174 is an [AGE] year-old with [DIAGNOSES REDACTED]. On 11/9/15 at 9:42 AM, the resident was observed sitting in her w/c with an alarmed Velcro seat belt in place. The resident was confused and was not able to release the seat belt when asked. On 11/12/15 from 9:53 AM to 12:17 PM, the resident was observed on the unit sitting in her w/c with the alarmed Velcro seat belt in place. The resident was calm and had a right hand roll in place. A stuffed animal was on her lap. The resident did not make any attempts to get up, no restlessness was observed and the resident laughed when spoken to (by the state agency). On 11/12/15 at 12:27 PM, the seat belt was released during lunch. The Minimum Data Set (MDS) 3.0 assessments dated 1/2/15, 3/27/15 and 6/19/15 documented the resident had no speech and was rarely/never understood or understands. The MDS further documented the resident had severely impaired cognition with long and short term memory problems. The MDS documented the resident had no behavioral symptoms and no indicators of [MEDICAL CONDITION]. The MDS documented the resident required total assist of one person for locomotion, dressing, eating, and hygiene. Total assist of 2 people was needed for transfer, bed mobility, bathing, toileting and ambulation in the corridor. The resident had no falls since the last assessments. The MDS documented that there was no restraint used. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident did not ambulate and was totally dependent on staff for transfer, dressing, eating, toileting, hygiene, bathing, and bed mobility. The MDS documented that the resident had no restraints. The Comprehensive Care Plan (CCP) for Activities of Daily Living dated 1/14/15 documented: Intervention: W/C (wheelchair) c (with) self releasing seat belt c alarm The CCP for Fall Risk dated 1/14/15 included intervention: W/C (wheelchair) c (with) self releasing seat belt c alarm No falls were noted on the CCP. The CCP does not include specific goals for the monitoring of the seat belt while in use, determinations about when the seat belt should be released. The Fall Risk assessment dated [DATE] documented a score of 10, indicating the resident was not at high risk for falls. (A score of 12 or higher indicates High Risk for falls.) The Physician's (MD) Orders dated 12/9/14 through 10/15/15 documented: OOB to w/c with self releasing seat belt with alarm. The MD (Medical Doctor) Monthly Notes dated 12/9/14 through 10/15/15 documented that the resident did not have any restraints. The Physician's Notes from 12/9/14 to 11/12/15 were reviewed. There was no documented evidence that the Physician documented the rationale and continued need for the for the use of the seat belt. Nursing Notes from 12/14/14 to 11/12/15 were reviewed. There was no documented evidence of behaviors that may have warranted the use a seat belt. There was also no documented evidence that the resident's ability to release the seat belt was demonstrated or assessed. Restorative Nursing Notes documented that resident's floor ambulation program was discontinued because the resident did not want to ambulate. Patient Care Technician (PCT) Accountability Record dated November 2015 documented documented self release alarm belt. An interview was conducted with the assigned PCT (Patient Care Technician) on 11/12/2015 at 12:21 PM. The PCT stated that the resident stopped walking about three months ago. She was no longer able to ambulate and would not do it. The PCT further stated that the resident is not able to follow directions and release her seat belt on her own. She does not have any behaviors, does not try to get up or try to remove the seat belt, she is calm when left alone. The unit RN (Registered Nurse)/ Head Nurse was interviewed on 11/12/2015 at 2:39 PM. The RN stated that the seat belt is in use because the resident is at high risk for falls, though she has not had any falls or behavior symptoms. We add the seat belt with an alarm as a precaution for all residents with dementia. She does not really try to get up. The fall risk assessments are done quarterly by the RN's who are also responsible for care planning. The resident is able to release the belt at times. If the residents is able to release the belt, we do not consider it a restraint. I think in the past she slid from the chair. We also use the seat belts to prevent them from falling out of the w/c during transport. The RN MDS Coordinator was interviewed on 11/12/2015 at 3:42 PM. The RN stated that the unit RN completes the restraint section of the MDS based on what is ordered. The order for a self releasing seat belt was not identified as a restraint. The resident's ability to open it should be documented on the nurses' monthly notes in the behavior or safety devices section and daily behavior notes. If there are no notes in the chart, I would speak to the staff and if they say they are not seeing the behaviors, the doctor would be asked to reassess the seat belt to determine if it is a restraint. There is no evidence that this was done. If there is no demonstration of the residents ability to release the belt and no symptoms to warrant the need for the seat belt, then it should be coded as a restraint and a care plan developed.This resident has had the seat belt for many years. The unit Physician was interviewed on 11/12/2015 at 3:57 PM. The Physician stated that she was unsure about the rationale about why she ordered the seat belt for the resident. The seat belt with alarm is not a restraint if the person can release it. We have to base it on observation. I ask the nurses to observe whether or not she can release it because she can still move her arms. Every month, the seat belt should be re-evaluated. The seat belt should be removed if the resident can no longer release it. 415.4(a)(2-7)

Based on observation, record review, and interview the facility did not ensure that the resident's dental status was accurately assessed. Specifically, the residents dental status was not accurately documented on the comprehensive assessment. This was evident for 1 of 22 residents reviewed for comprehensive assessment in the Stage 2 sample. (Resident #174). The finding is: Resident #174 is an [AGE] year-old with [DIAGNOSES REDACTED]. On 11/09/15 at 9:41 AM, the resident was observed sitting in a wheelchair (w/c). The resident had missing upper teeth. The Annual Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had no speech and was rarely/never understood or understands. The MDS further documented the resident had severely impaired cognition with long and short term memory problems. The resident had no oral problems identified in the assessment. The Dental Note dated 3/21/14 documented the resident had some teeth. The Dental Annual Exam Note dated 3/3/15 documented the resident had some teeth, and the gums were highly inflamed. The exam note further documented a recommendation for good oral hygiene. On 11/12/15 at 3:25 PM, the RN/ MDS Coordinator was interviewed and stated that it is the responsibility of the MDS Coordinator to ensure that all portions of the assessment are correct. She further stated the personnel in the dental clinic is responsible for completing the dental section of the MDS. She stated that no natural teeth or tooth fragments should have been identified as a concern on the MDS because the resident has missing teeth. She further stated that a comprehensive care plan for dental care should have been developed at that time. She also stated that the dental CCP should have been updated to include the resident's identified highly inflamed gums. 415.11(a)(2)

Based on an interview and record reviews, the facility did not ensure that the Minimum Data Set (MDS) accurately reflected the resident's medication status. Specifically, 1) the quarterly assessment did not accurately document the administration of Insulin. 2) the residents dental status was not accurately documented on the comprehensive assessment. This was evident for 2 of 5 residents reviewed for Unnecessary Medication. (Resident #91). The finding is: 1) Resident # 91 is a [AGE] year old with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented: severe cognitive impairment. Section N: 0300: medications: [REDACTED]. Physician orders [REDACTED]. The Medication Administration (MAR) record dated 10/9/15 - 11/6/15 documented: [MEDICATION NAME] 100 units/ml (milliliter) 20 units subcutaneous. On 11/13/15, at 11:17 AM an interview was conducted with the RN MDS Coordinator. The Registered Nurse stated that she is responsible for ensuring that the MDS is accurate and that the Insulin injections should have been documented on the MDS. 2) Resident #174 is an [AGE] year-old with [DIAGNOSES REDACTED]. On 11/09/15 at 9:41 AM, the resident was observed sitting in a wheelchair (w/c). The resident had missing upper teeth. The Annual Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had no speech and was rarely/never understood or understands. The MDS further documented the resident had severely impaired cognition with long and short term memory problems. The resident had no oral problems identified in the assessment. The Dental Note dated 3/21/14 documented the resident had some teeth. The Dental Annual Exam Note dated 3/3/15 documented the resident had some teeth, and the gums were highly inflamed. The exam note further documented a recommendation for good oral hygiene. On 11/12/15 at 3:25 PM, the RN/ MDS Coordinator was interviewed and stated that it is the responsibility of the MDS Coordinator to ensure that all portions of the assessment are correct. She further stated the personnel in the dental clinic is responsible for completing the dental section of the MDS. She stated that no natural teeth or tooth fragments should have been identified as a concern on the MDS because the resident has missing teeth. She further stated that a comprehensive care plan for dental care should have been developed at that time. She also stated that the dental CCP should have been updated to include the resident's identified highly inflamed gums. 415.11 (b)

Based on observation, record reviews, and staff interviews, the facility did not ensure that professional standards of quality were maintained. Specifically, the medication nurses did not discontinue a medication on each medication administration record, and continued to sign for the medication as given. This was evident for 1 of 6 residents reviewed for Unnecessary Medication Use. (Resident # 305) The findings is: Resident # 305 is an [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. On 11/9/15 at 9:43 am the resident was observed alert, oriented and communicative and seated in his wheel chair in his room. The Quarterly MDS (Minimum Data Set) dated 8/27/15 documented: intact cognition, no [MEDICAL CONDITION], mood or behavior symptoms. Extensive assistance for Activities of Daily Living (ADL). The MDS further documented the resident received anti-depressant medications for seven days. The Comprehensive Care Plan (CCP) dated 5/28/15 and revised 11/9/15 for Depression and [MEDICAL CONDITION] Drug Use documented: [MEDICATION NAME] ( [MEDICATION NAME]) 50 mg changed to 25 mg daily on 10/13/15. physician's orders [REDACTED]. Starting 10/13/15- [MEDICATION NAME] 25 mg (milligrams) Po (by mouth) daily x 28 days. Starting 10/13/15. A review of the Medication Administration Records (MAR's) revealed the pre-printed order for [MEDICATION NAME] 50 mg Po daily was discontinued as per the physician's orders [REDACTED]. A further review of the Medication Administration Record (MAR) dated 10/16/15 to 11/8/15, revealed another pre-printed order for [MEDICATION NAME] 50 mg Tablet one Tablet by mouth daily. The MAR further documented nurses initials for the administration of the previously discontinued order for [MEDICATION NAME] 50 mg. A review of the Pharmacy Delivery sheets for the weeks of 1010/16, 10/23, 10/30 and 11/6/15 documents that 25 mg of [MEDICATION NAME] was dispensed by the Pharmacy. The unit medication nurses did not discontinue the pre-printed Physician order [REDACTED]. An interview with the unit RN (Registered Nurse)/ Head Nurse was conducted on 11/9/15 at 12:00 noon. The RN stated that the documentation on the MAR does indicate that the nurses were signing for [MEDICATION NAME] 50 mg as well as the revised order for [MEDICATION NAME] 25 mg Po. The resident was only receiving [MEDICATION NAME] 25 mg Po as per the physician's orders [REDACTED]. The medication nurses mistakenly began signing off on the old [MEDICATION NAME] order on the pre-printed MAR on 10/17/15. On 11/10/15 at 1:40 PM, the RN medication nurse was interviewed. The RN stated that she picked up the order on 10/12/15 to discontinued the previous [MEDICATION NAME] order. The new order for [MEDICATION NAME] 25 mg was then transcribed onto the MAR. A new hand written MAR was initiated. She further stated that she administered [MEDICATION NAME] 25 mg on 10/13/15 through 10/17/15. When the renewal pre-printed medex was implemented on 10/16/15 on the evening shift, with the pre-printed (discontinued order) for [MEDICATION NAME] 50 mg, she acknowledged signing the MAR for [MEDICATION NAME] 25 mg as well as [MEDICATION NAME] 50 mg. This was a mistake and an oversight. The medication ([MEDICATION NAME] 50 mg) had been removed from the residents drawer and placed in the discontinued medication box when it was discontinued. On 11/12/15 at 11:00 AM, the RN/Head Nurse ( RN ) was further interviewed and stated that when the nurse transcribes a physician's orders [REDACTED]. The MAR must match the physician's orders [REDACTED]. The second nurse must verify that the order is picked up correctly. The third nurse also verifies to ensure that the order and the MAR match. All three shifts are responsible for ensuring accuracy. In this case, there was an oversight, the nurses did not pick up the error. The RN further stated that he does not check to see if the nurses transcribe the orders correctly. It is the individual nurses responsibility to transcribe the orders correctly, since they are signing off on the ' Medication check list'. On 11/12/15 at 10:33 AM the Director of Pharmacy was interviewed and stated that on 10/12/15 the pharmacy received the order change for [MEDICATION NAME] 25 mg. The previous order was discontinued and the new order processed. The revised medication dosage was sent to the unit beginning 10/13/15. The pharmacy printed the MAR on 10/6/15 as a monthly renewal and since the order dated 10/13/15 was an interim order, no new medication sheets were printed. The new MARs are printed every 28 days with the renewal orders. The nurses are responsible for the interim order corrections. The Pharmacy sent [MEDICATION NAME] 25 mg to the unit when the order was changed on 10/12/15. The Pharmacist stated that he reviews the MAR's for appropriate crushing of medication, potential drug interactions, omissions and dosage reviews. As part of the Quality Assurance (QA) team, he compares the MAR to the physician's orders [REDACTED]. 415.11(c)(3)(i)

Based on observation, record reviews, and staff interviews, the facility did not ensure that the residents clinical record was accurately documented. Specifically, the medication nurses did not discontinue a medication on each medication administration record, and continued to sign for the medication as given. This was evident for 1 of 6 residents reviewed for Unnecessary Medication Use. (Resident # 305) The findings is: Resident # 305 is an [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. On 11/9/15 at 9:43 am the resident was observed alert, oriented and communicative and seated in his wheel chair in his room. The Quarterly MDS (Minimum Data Set) dated 8/27/15 documented: intact cognition, no [MEDICAL CONDITION], mood or behavior symptoms. Extensive assistance for Activities of Daily Living (ADL). The MDS further documented the resident received anti-depressant medications for seven days. The Comprehensive Care Plan (CCP) dated 5/28/15 and revised 11/9/15 for Depression and [MEDICAL CONDITION] Drug Use documented: [MEDICATION NAME] ( [MEDICATION NAME]) 50 mg changed to 25 mg daily on 10/13/15. physician's orders [REDACTED]. Starting 10/13/15- [MEDICATION NAME] 25 mg (milligrams) Po (by mouth) daily x 28 days. Starting 10/13/15. A review of the Medication Administration Records (MAR's) revealed the pre-printed order for [MEDICATION NAME] 50 mg Po daily was discontinued as per the physician's orders [REDACTED]. A further review of the Medication Administration Record (MAR) dated 10/16/15 to 11/8/15, revealed another pre-printed order for [MEDICATION NAME] 50 mg Tablet one Tablet by mouth daily. The MAR further documented nurses initials for the administration of the previously discontinued order for [MEDICATION NAME] 50 mg. A review of the Pharmacy Delivery sheets for the weeks of 1010/16, 10/23, 10/30 and 11/6/15 documents that 25 mg of [MEDICATION NAME] was dispensed by the Pharmacy. The unit medication nurses did not discontinue the pre-printed Physician order [REDACTED]. An interview with the unit RN (Registered Nurse)/ Head Nurse was conducted on 11/9/15 at 12:00 noon. The RN stated that the documentation on the MAR does indicate that the nurses were signing for [MEDICATION NAME] 50 mg as well as the revised order for [MEDICATION NAME] 25 mg Po. The resident was only receiving [MEDICATION NAME] 25 mg Po as per the physician's orders [REDACTED]. The medication nurses mistakenly began signing off on the old [MEDICATION NAME] order on the pre-printed MAR on 10/17/15. On 11/10/15 at 1:40 PM, the RN medication nurse was interviewed. The RN stated that she picked up the order on 10/12/15 to discontinued the previous [MEDICATION NAME] order. The new order for [MEDICATION NAME] 25 mg was then transcribed onto the MAR. A new hand written MAR was initiated. She further stated that she administered [MEDICATION NAME] 25 mg on 10/13/15 through 10/17/15. When the renewal pre-printed medex was implemented on 10/16/15 on the evening shift, with the pre-printed (discontinued order) for [MEDICATION NAME] 50 mg, she acknowledged signing the MAR for [MEDICATION NAME] 25 mg as well as [MEDICATION NAME] 50 mg. This was a mistake and an oversight. The medication ([MEDICATION NAME] 50 mg) had been removed from the residents drawer and placed in the discontinued medication box when it was discontinued. On 11/12/15 at 11:00 AM, the RN/Head Nurse ( RN ) was further interviewed and stated that when the nurse transcribes a physician's orders [REDACTED]. The MAR must match the physician's orders [REDACTED]. The second nurse must verify that the order is picked up correctly. The third nurse also verifies to ensure that the order and the MAR match. All three shifts are responsible for ensuring accuracy. In this case, there was an oversight, the nurses did not pick up the error. The RN further stated that he does not check to see if the nurses transcribe the orders correctly. It is the individual nurses responsibility to transcribe the orders correctly, since they are signing off on the ' Medication check list'. On 11/12/15 at 10:33 AM the Director of Pharmacy was interviewed and stated that on 10/12/15 the pharmacy received the order change for [MEDICATION NAME] 25 mg. The previous order was discontinued and the new order processed. The revised medication dosage was sent to the unit beginning 10/13/15. The pharmacy printed the MAR on 10/6/15 as a monthly renewal and since the order dated 10/13/15 was an interim order, no new medication sheets were printed. The new MARs are printed every 28 days with the renewal orders. The nurses are responsible for the interim order corrections. The Pharmacy sent [MEDICATION NAME] 25 mg to the unit when the order was changed on 10/12/15. The Pharmacist stated that he reviews the MAR's for appropriate crushing of medication, potential drug interactions, omissions and dosage reviews. As part of the Quality Assurance (QA) team, he compares the MAR to the physician's orders [REDACTED]. 415.22(a)(1-4)

Based on record review and interview the facility did not ensure that a comprehensive care plan was developed for a resident with documented visual impairment. This was evident for 1 of 3 residents reviewed for Vision of a total of 61 residents with potential for concerns with Vision. (Resident # 93). This resulted in no harm with potential for more than minimal harm. Findings included: Resident # 93 was admitted on [DATE] with [DIAGNOSES REDACTED].The Admission MDS (Minimum Data Set) 3.0 assessment dated [DATE] documented moderately impaired vison due to left eye cataract. Further review of the resident's medical record revealed [REDACTED]. An interview was conducted with the MDS coordinator on 9/12/12 at 12:15 PM, who stated it was a mistake since the condition was not triggered in the Care Area Assessment (CAA) summary, hence the care plan was not initiated. 415.11(c)(l)