Every finding on record at Split Rock Rehabilitation and Health Care Center

Based on record review and interviews conducted during an Abbreviated Survey (NY00373021), the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in one (1) out of five (5) residents sampled (Resident #1). Specifically, on 02/26/2025 at approximately 3:30 PM, Resident #1 reported to Social Worker #1 that they were missing seven thousand dollars, and that Certified Nursing Assistant #1 took their money during care. The facility completed their investigation on 03/11/2025 and submitted the findings to New York State Department of Health on 03/11/2025 at 4:23 PM. The facility did not complete and submit their investigation report within 5 working days to New York State Department of Health. The findings include: The Facility's Policy and Procedure on Abuse, Neglect, Mistreatment and Exploitation dated 03/11/2024 documented the facility will report the results of all reportable investigations to the State Survey Agency, Law Enforcement if needed and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Resident #1 was admitted to the facility with diagnoses including Multiple Sclerosis and Adult Failure to Thrive. The Minimum Data Set (an assessment tool) dated 12/21/2024 documented Resident #1 was assessed with intact cognition. The Resident/Family Complaint/Grievance Form dated 02/26/2025 (no time) documented Resident #1 reported that their seven thousand dollars was missing, and that Certified Nursing Assistant #1 took the money when they were provided care to them. The Facility Summary of Investigation dated 03/11/2025 documented Certified Nursing Assistant #1 was not familiar with Resident #1. The work schedule for Certified Nursing Assistant #1 confirmed that they did not work on Resident #1 unit during the month of January 2025 and at no time was assigned to Resident #1. The facility concluded that there was no corroborating evidence to support Resident #1's claim of missing money or alleged involvement of Certified Nursing Assistant #1. The facility staff were educated on abuse prevention and misappropriation of property. A Webform Submission from the Nursing Home Facility Incident Report showed that the facility submitted their completed investigation to New York State Department of Health on 03/11/2025 at 4:23 PM. During an interview on 05/20/2025 at 2:00 PM, the Director of Nursing stated they were not aware that the follow up report of investigation must be submitted within five business days to the Department of Health. The Director of Nursing stated they submitted the completed investigation on 03/11/2025 at 4:23 PM which was considered late submission. During an interview on 05/20/2025 at 3:00 PM, the Administrator stated that the completed investigation should have been submitted to the Department of Health within five business days. The Administrator stated that they were aware that they submitted the investigation late. 10 NYCRR 415.4 (b)(1)(ii)

Based on record review and interviews conducted during the Recertification Survey from 09/03/2024 to 09/10/2024, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations of abuse were made to the New York State Department of Health. This was evident in 1 (Resident #140) of 4 residents reviewed for Abuse out of 36 total sampled residents. Specifically, 1.) On 09/03/2023, Resident #140 alleged that they were inappropriately touched by a staff. 2.) On 09/05/2024, Resident #140 alleged that, months ago, they were sexually assaulted by a male Certified Nursing Assistant who worked on the evening shift. The facility did not report both allegations to the New York State Department of Health. The findings are: The facility's policy and procedure titled Abuse, Neglect, Mistreatment, and Exploitation Prohibition with an implementation date of 03/11/2024 documented that all allegations of abuse must be immediately reported to the Administrator and no later than 2 hours to other officials, including to the State Survey Agency, after the allegation was made. Resident #140 had diagnoses which included Chronic Inflammatory Demyelinating Polyneuritis, Diabetes Mellitus, and Muscle Weakness. The Minimum Data Set assessment dated [DATE] documented that Resident #140 was cognitively intact, had no physical or verbal behavioral symptoms directed towards others, and had not rejected care. On 09/05/2024 at 12:47 PM, Resident #140 was interviewed and stated that they were sexually assaulted months ago by a male Certified Nursing Assistant who worked on the evening shift. Resident #140 could not recall when this occurred but stated that it occurred multiple times. Resident #140 stated that the Certified Nursing Assistant would stick their fingers in their butt while providing care. Resident #140 stated that after this occurred for the final time, they confronted the Certified Nursing Assistant and threatened to punch them in the face if the sexual assault occurred again. Resident #140 stated that the nurse informed them that the Certified Nursing Assistant would never touch them again and that the Certified Nursing Assistant never provided care or was assigned to them again. 1.) A nurse's progress notes dated 09/03/2023 at 11:53 AM by Licensed Practical Nurse #1 documented that Resident #140 complained that they were inappropriately touched by a staff. The nursing supervisor was made aware and went in for the Resident to explain. Resident #140 refused to talk. An Incident / Accident Investigation Report Summary dated 09/03/2023 documented that Resident #140 refused care from Certified Nursing Assistant #2 on 09/03/2023. Licensed Practical Nurse #1 went in to speak with the Resident, but Resident refused to speak. The investigative summary concluded that no abuse or mistreatment occurred. Review of the facilities investigative report and staff written statements showed no documented evidence that Resident #140's allegation of being inappropriately touched by staff was addressed. On 09/10/2024 at 12:38 PM, Licensed Practical Nurse #1 was interviewed and stated that they wrote a progress note about Resident #140 claiming that Certified Nursing Assistant #2 inappropriately touched them in the groin area. Licensed Practical Nurse #1 stated they reported the allegation to the nursing supervisor. On 09/10/2024 at 12:53 PM, the Administrator was interviewed and stated that on 09/03/2023, Resident #140 stated they were inappropriately touched by Certified Nursing Assistant #2. The Administrator stated that the allegation was not reported because there was nothing to report. The Administrator stated that Resident #140 was not touched. They stated Resident #140 was being cleaned and because of their behavior, Resident #140 claimed it was abuse. 2.) The facility had not provided documented evidence that Resident #140's allegation that they were sexually assaulted by a male Certified Nursing Assistant was investigated. On 09/05/2024 at 02:11 PM, Licensed Practical Nurse #1 was interviewed and stated that months ago, they heard about an accusation made by Resident #140 regarding a Certified Nursing Assistant inappropriately touching Resident #140's buttocks. Licensed Practical Nurse #1 identified the Certified Nursing Assistant being accused as Certified Nursing Assistant #1. Licensed Practical Nurse #1 stated they were unsure if this was reported. On 09/09/2024 at 05:15 PM, Certified Nursing Assistant #1 was interviewed and stated that they cared for Resident #140 until about a year ago when Resident #140 changed rooms and was no longer on their assignment. Certified Nursing Assistant #1 denied ever touching Resident #140 inappropriately or being aware of any accusations made by Resident #140 against them. On 09/09/2024 at 11:27 AM, the Director of Social Services was interviewed and stated that they were unaware of Resident #140's statement that Certified Nursing Assistant #1 sexually assaulted them until Resident #140 reported it to the State Surveyor on 09/05/2024. The Director of Social Services stated they met with Resident #140 on 09/06/2024 to discuss this concern and Resident #140 reported that Certified Nursing Assistant #1 inappropriately touched Resident #140's anus. The Director of Social Services stated that Resident #140 stated that Resident #140 feels that the concern was resolved since Certified Nursing Assistant #1 no longer provided care for them. The Director of Social Services stated that when they receive allegations of abuse, the Director of Nursing is notified, the facility collects statements from staff, and it is reported to the New York State Department of Health. The Director of Social Services stated they were unsure if this concern had been reported to the New York State Department of Health. On 09/10/2024 at 10:08 AM, the Administrator was interviewed and stated that they were not made aware of Resident #140's accusation against Certified Nursing Assistant #1 until it was shared with the State Surveyor. The Administrator stated that they believe the accusation is untrue based on his past behaviors of refusing care, exposing themself, and throwing items. The Administrator stated the allegation was not reported to the New York State Department of Health because they believed that the claim was related to their other claim from a year ago. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification Survey from 09/03/2024 to 09/10/2024, the facility did not ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #140) of 4 residents reviewed for Abuse out of 36 total sampled residents. Specifically, 1.) On 09/03/2023, Resident #140 alleged that they were inappropriately touched by a staff. The facility investigation did not address the allegation. 2.) On 09/05/2024, Resident #140 alleged that, months ago, they were sexually assaulted by a male Certified Nursing Assistant who worked on the evening shift. There was no documented evidence that the allegation was investigated. The findings are: The facility's policy and procedure titled Abuse, Neglect, Mistreatment, and Exploitation Prohibition with an implementation date of 03/11/2024 documented that the Nursing Department with facility Administration will coordinate the investigation of all allegations of physical or verbal abuse. The Director of Nursing is responsible for coordinating a timely and thorough investigation. The investigation should be conducted as soon as possible after the allegation of abuse is made. Resident #140 had diagnoses which included Chronic Inflammatory Demyelinating Polyneuritis, Diabetes Mellitus, and Muscle Weakness. The Minimum Data Set assessment dated [DATE] documented that Resident #140 was cognitively intact, had no physical or verbal behavioral symptoms directed towards others, and had not rejected care. 1.) A nurse's progress notes dated 09/03/2023 at 11:53 AM by Licensed Practical Nurse #1 documented that Resident #140 complained that they were inappropriately touched by a staff. The nursing supervisor was made aware and went in for the Resident to explain. Resident #140 refused to talk. An Incident / Accident Investigation Report Summary dated 09/03/2023 documented that Resident #140 refused care from Certified Nursing Assistant #2 on 09/03/2023. Licensed Practical Nurse #1 went in to speak with the Resident, but Resident refused to speak. The investigative summary concluded that no abuse or mistreatment occurred. Review of the facilities investigative report and staff written statements showed no documented evidence that Resident #140's allegation of being inappropriately touched by staff was addressed. On 09/10/2024 at 12:38 PM, Licensed Practical Nurse #1 was interviewed and stated that they wrote a progress note about Resident #140 claiming that Certified Nursing Assistant #2 inappropriately touched them in the groin area. Licensed Practical Nurse #1 stated they reported the allegation to the nursing supervisor. On 09/10/2024 at 12:53 PM, the Administrator was interviewed and stated that on 09/03/2023, Resident #140 alleged that Certified Nursing Assistant #2 had inappropriately touched them. The Administrator stated that Resident #140 does not want to be cleaned after having diarrhea, so they claimed they were inappropriately touched. The Administrator stated they knew it was not inappropriate touching because Certified Nursing Assistant #2 reported what had occurred. 2.) On 09/05/2024 at 12:47 PM, Resident #140 was interviewed and stated that they were sexually assaulted months ago by a male Certified Nursing Assistant who worked on the evening shift. Resident #140 could not recall when this occurred but stated that it occurred multiple times. Resident #140 stated that the Certified Nursing Assistant would stick their fingers in their butt while providing care. Resident #140 stated that after this occurred for the final time, they confronted the Certified Nursing Assistant and threatened to punch them in the face if the sexual assault occurred again. Resident #140 stated that the nurse informed them that the Certified Nursing Assistant would never touch them again and that the Certified Nursing Assistant never provided care or was assigned to them again. The facility had not provided documented evidence that Resident #140's allegation that they were sexually assaulted by a male Certified Nursing Assistant was investigated. On 09/05/2024 at 02:11 PM, Licensed Practical Nurse #1 was interviewed and stated that months ago, they heard about an accusation made by Resident #140 regarding a Certified Nursing Assistant inappropriately touching Resident #140's buttocks. Licensed Practical Nurse #1 identified the Certified Nursing Assistant being accused as Certified Nursing Assistant #1. Licensed Practical Nurse #1 stated they were unsure if this was reported. On 09/09/2024 at 05:15 PM, Certified Nursing Assistant #1 was interviewed and stated that they cared for Resident #140 until about a year ago when Resident #140 changed rooms and was no longer on their assignment. Certified Nursing Assistant #1 denied ever touching Resident #140 inappropriately or being aware of any accusations made by Resident #140 against them. On 09/09/2024 at 11:27 AM, the Director of Social Services was interviewed and stated they were unaware of Resident #140's statement that Certified Nursing Assistant #1 sexually assaulted them until Resident #140 reported it to the State Surveyor on 09/05/2024. The Director of Social Services stated they met with Resident #140 on 09/06/2024 to discuss this concern and Resident #140 reported that Certified Nursing Assistant #1 inappropriately touched Resident #140's anus. The Director of Social Services stated that Resident #140 stated that the Resident felt that the concern was resolved since Certified Nursing Assistant #1 no longer provided care for them. On 09/10/2024 at 9:59 AM, the Director of Nursing was interviewed and stated this was the first time they heard about Resident #140's allegation, that the Resident was sexually assaulted by a male Certified Nursing Assistant. The Director of Nursing stated they were investigating the allegation but had not provided documented evidence of investigation. On 09/10/2024 at 12:53 PM, the Administrator was interviewed and stated they believed that the sexual abuse claim related to Certified Nursing Assistant #1 was part of the same allegation that Resident #140 made on 09/03/2023 when they alleged of being inappropriately touched. The Administrator stated that Resident #140 was a homosexual and fantasizes about some of this activity. The Administrator stated they were not looking into this allegation any further because it happened a year ago, and that Resident #140 does not remember when the allegation occurred. The Administrator further stated So what am I supposed to do? Take statements a year later when Resident #140 cannot even recall when it was? 10 NYCRR 415.4(b)(3)

Based on observation, interviews, and record review conducted during the Recertification survey from 6/1/2022 to 6/8/2022, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #8) of 1 resident reviewed for respiratory care and 1 (Resident #5) of 4 residents reviewed for pressure ulcers. Specifically, 1) there were multiple observations of Resident #8 with undated oxygen tubing in use; and 2) Registered Nurse (RN) #2 was observed placing a bag of wound care supplies on an unsanitized surface in Resident #5's room and then returning the plastic bag to a medication cart. The findings are: 1) The facility policy titled Oxygen Therapy dated 04/2022 documented all oxygen tubing will be labeled and changed weekly. Resident # 8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #8 was cognitively intact and received oxygen therapy. On 06/03/22 at 11:00 AM and 06/07/22 at 02:08 PM, Resident # 8 was observed in the dining room with undated oxygen tubing connected to their [CONDITION(S)]. On 06/06/22 at 09:15 AM, Resident # 8 was observed sitting in their room with undated oxygen tubing connecting the oxygen concentrator to their [CONDITION(S)]. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/06/22 at 02:07 PM, an interview was conducted with RN #1 who stated the respiratory therapists (RT) change all the oxygen tubing. On 06/06/22 at 02:26 PM, an interview was conducted with RT Supervisor who stated they change the oxygen tubing every Tuesday and Resident #8's oxygen tubing was replaced the prior week. Nursing staff are responsible for changing the tubing connected to the oxygen tank. There was no date on the tubing connected to the portable oxygen tank and the oxygen concentrator because someone may have changed it. On 06/06/22 at 02:48 PM, an interview was conducted with RN Nurse Manager who stated Resident #8 has a [CONDITION(S)] and resides on the respiratory unit therefore the RTs are responsible for changing all the oxygen tubing. On 06/08/22 at 09:37 AM and 11:03 AM, an interview was conducted with the Director of Nursing Services (DNS) who stated RT is responsible for changing a resident's oxygen tubing if they have a [CONDITION(S)]. Resident #8 is non-complaint and has a behavior of changing the tubing. 2) The facility policy titled Pressure Ulcer Prevention and Treatment dated 1/12/22 documented professional standards of nursing practice were used to prevent development of pressure ulcers. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #5 was severely cognitively impaired and had a stage 4 pressure ulcer requiring ointment application. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/07/22 at 10:21 AM, RN #2 was observed entering Resident's #5's room with a plastic bag of supplies to prepare for changing the resident's sacral wound dressing. RN #2 placed the plastic bag on an air conditioner shelf that was not cleaned or sanitized and removed wound care supplies from the bag (drape, gauze, and silver alginate). After performing wound care on Resident #5, RN #2 took a garbage bag with soiled dressing and the plastic bag with unused supplies from the top of the unsanaitized air conditioner shelf in the same hand and left the room. RN #2 then placed the plastic bag of unused supplies into a medication cart drawer. RN #2 was interviewed during the observation and stated the plastic bag of wound care supplies were labeled with Resident #5's name and kept in the medication cart. On 06/08/22 at 12:44 PM, the RN Nurse Manager was interviewed and stated wound care supplies were placed in plastic bags, labeled with the resident's name, and stored in the medication cart. The plastic bags stay in the medication cart. Supplies from the plastic bag are transferred to a tray and the tray is brought into the resident's room when wound care is being performed. On 06/08/22 at 02:33 PM, the DNS was interviewed and stated nurses use a tray to transfer wound care supplies from the medication cart to the resident's room. The plastic bag of wound care supplies is kept in the medication cart and should not be removed or brought into the resident's room. 415.19(a)(1-3)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 390), the facility did not permit a resident to return to the facility after transfer to the hospital. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, on 12/12/2019, Resident #1 was transferred to the hospital for evaluation of Suicidal Ideation. The facility refused to readmit Resident #1 when the hospital notified them that Resident #1 was ready for discharge back to the facility. The Findings Include: The facility's undated Discharge Planning and Transfer Policy documented that the facility will permit each resident to remain in the facility, and not seek to transfer or discharge the resident unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care, to receive necessary care and services, and to participate in the development of comprehensive care plan and in recognition of the rights of other residents in the facility. The facility's Admission Policy reviewed in 09/2019 documented that all resident applicants to the facility will be screened prior to admission to determine whether the applicant is in need of the level of care available at the facility and to determine if the facility can meet the applicant's care needs. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 09/27/2019 identified Resident #1 with short- and long-term memory problems and severely impaired skills for daily decision making. Resident #1 required total assistance of two persons with Activities of Daily Living (ADL) needs. Section Q0400 of the MDS coded that an active discharge planning was not in place for Resident #1 to return to the community. Review of a Discharge Planning Care Plan initiated on 09/14/2019 documented that Resident #1 had no potential discharge date . Resident #1 was in the facility for long term placement due to deteriorated medical and cognitive statuses. Review of a Behavior Symptoms Care Plan effective 09/14/2019 documented that Resident #1 presented with behavioral problems as evidenced by: attempts to get out of bed/chair, lack of safety awareness, poor judgment, reached out to people to try to get out of bed and to leave. A Nurse Practitioner's (NP) Progress Note dated 12/03/2019 at 2:43 p.m. documented that Resident #1 was seen for Agitation. Resident #1 self-decannulated [MEDICAL CONDITION] was successfully replaced by Respiratory. Resident #1 continuously attempted to get up from her Geri-chair. [MEDICATION NAME] 0.5mg twice daily was decreased to 0.5mg daily by Psychiatrist due to [MEDICATION NAME] 25mg twice daily. Plan made to administer [MEDICATION NAME] 1mg via gastrostomy tube then and increase [MEDICATION NAME] to 0.5mg twice daily via gastrostomy tube from the following day (12/04/2019). A Social Worker's (SW) Progress Note dated 12/10/2019 at 3:10 p.m. documented that a meeting was held with Resident #1's two daughters, the Rehab Director and Nursing Supervisor. One of Resident #1's daughter (the Primary contact/HCP) brought up that Resident #1 tried to jump out of the window that morning. Resident #1's daughter also reported that a few weeks ago, Resident #1 threatened to tie her oxygen tubing around her neck. When asked, Resident #1 denied having wanted to self-harm. SW determined that Resident #1 was not at risk to self-harm. The resident was to be followed by Psychiatry, and recommended referral to Psychology with a Spanish speaking therapist to determine if Resident #1 would benefit from Psychotherapy. A physician's orders [REDACTED].#1 to hospital for Mental Evaluation and Assessment. Expressed harm to self and others with a plan of action. A SW Progress Note dated 12/12/2019 at 2:20 p.m. documented that the SW spoke with Resident #1's daughter and informed her that the Medical Director determined that Resident #1 should be transferred to the hospital for Psychiatric evaluation. Resident #1's daughter was not happy with the decision, but Resident #1 needed evaluation. A Transfer Form dated 12/12/2019 documented that Resident #1 was transferred to the hospital for evaluation of Expressed Suicidal Ideation. The Director of Social Services (DSS) and Admissions was interviewed on 11/25/2020 at 11:00 a.m. and stated that she was not the Admissions Director in 2019. She further stated that in general, residents are not discharged to the hospital except under special circumstances because the hospital is not considered a discharge destination. If a resident's previous bed is no longer available when the resident is ready to return from the hospital, that resident will be offered the next available bed. Normally a bed would be held until midnight, but Resident #1 was out of the facility past midnight and into the following day. An administrative decision was made not to accept Resident #1 back to the facility due to the Resident #1's behaviors and safety concerns. The facility could no longer meet her needs. The unit Social Worker (SW) was interviewed on 11/25/2020 at 11:15 a.m. He stated that Resident #1 expressed to her family a wish to jump out the window and die. Resident #1 was seen by Psychiatry twice in November 2019. Recommendations were made for medication changes for Depression and Agitation, but the Psychiatrist was unable to visit emergently when Resident #1 expressed suicidal ideation. Therefore, the decision was made by the Physician and the Nurse Practitioner (NP) to send Resident #1 to the emergency room for evaluation. The SW stated that Resident #1's daughter was contacted and agreed for the transfer. Resident #1's daughter did not sign a discharge notice because in the case of a hospital transfer the notification is not signed by the family but is provided to them in the transfer packet, and a copy is transmitted to the NYS (New York State) Ombudsman's office by email once a month. He further said that after his call to Resident #1's daughter/HCP on the resident's day of transfer, he had no subsequent communication with the family. The Director of Nursing (DON) was interviewed on 11/25/2020 at 1:00 p.m. She stated that on 12/13/2019, she telephoned Resident #1's daughter and told her that Resident #1 would not be accepted back to the facility for readmission. On the same day (12/13/2019), she informed the hospital discharge planner that the facility was not readmitting Resident #1. The facility felt that there was too great a risk of Resident #1 continuing to self-injure due to irremediable agitation. The conversations were not documented in the resident's medical chart. The DON also said that the facility had originally intended to accept Resident #1 back but assumed that Resident #1 would be admitted so that the agitation could be fully addressed. The administrative decision was made not to readmit because it was felt the resident was not ready to be in the facility. Resident #1's Primary contact /Health Care Proxy (HCP) was interviewed on 12/22/2020 at 5:00 p.m. She stated that the facility informed her that they were transferring Resident #1 to the hospital. The facility staff did not tell her that they were discharging Resident #1 and she did not receive a discharge notice from the facility. She further stated that after the hospital representative informed her that the facility was refusing to readmit Resident #1, she made several attempts to contact the facility staff, including the Social Worker and Admissions Department but no one responded to her calls. 415.3(h)(4)(iii)

Based on interviews and record review conducted during an abbreviated survey (NY 390), the facility did not notify the resident and the resident's representative of the discharge in writing with appeal rights. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, on 12/12/2019, Resident #1 was transferred to the hospital for evaluation of Suicidal Ideation. The facility refused to readmit Resident #1 and did not provide Resident #1's representative with a notice of discharge with appeal rights. The Findings Include: The facility's undated Discharge Planning and Transfer Policy documented that the purpose is to establish and implement guidelines to facilitate a smooth transition along the continuum between levels of care. To ensure coordination of services that promotes interdisciplinary collaboration and communication which include the resident and family members in a supportive relationship. To ensure that residents and family members receive and understand their written Discharge Notice and Discharge Plans in a language they understand. If the resident is unable to sign the notice and/ or plan, the Social Worker will inform the next of kin and document their involvement in the resident's clinical record as well as on the written notice and plan. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 09/27/2019 identified Resident #1 with short- and long-term memory problems and severely impaired skills for daily decision making. Resident #1 required total assistance of two persons with Activities of Daily Living (ADL) needs. Section Q0400 of the MDS coded that an active discharge planning was not in place for Resident #1 to return to the community. Discharge Planning Care Plan initiated on 09/14/2019 documented that the resident had no potential discharge date . The resident was in the facility for long term placement due to deteriorated medical and cognitive statuses. A physician's orders [REDACTED].#1 to Hospital for Mental Evaluation and Assessment. Expressed harm to self and others with a plan of action. A SW Progress Note dated 12/12/2019 at 2:20 p.m. documented that the SW spoke with Resident #1's daughter and informed her that the Medical Director determined that Resident #1 should be transferred to the hospital for Psychiatric evaluation. Resident #1's daughter was not happy with the decision, but Resident #1 needed evaluation. A Transfer Form dated 12/12/2019 documented that Resident #1 was transferred to the hospital for evaluation of Expressed Suicidal Ideation. Subsequent interview was conducted with the DON on 12/14/2020 at 1:53 p.m. She stated that Resident #1 was discharged from the facility and was not readmitted due to the hospital not admitting and assessing the resident for psychiatric issues. She further stated that a discharge notice was sent to the hospital on [DATE], but there was no documentation. The DON also stated that she does not believe that Resident #1's family member received a discharge notice. Resident #1's Primary contact /Health Care Proxy was interviewed on 12/22/2020 at 5:00 p.m. She stated that the facility informed her that they were transferring Resident #1 to the hospital. The facility staff did not tell her that they were discharging Resident #1 and she did not receive a discharge notice from the facility. She further stated that after the hospital representative informed her that the facility was refusing to readmit Resident #1, she made several attempts to contact the facility staff, including the Social Worker and Admissions department but no one responded to her calls. The Director of Social Services was interviewed on 12/30/2020 at 1:50 p.m. She stated that she was aware that the facility was not accepting Resident #1 back from the hospital. She further stated that a discharge notice with appeals rights was not issued to Resident #1 or sent to Resident #1's representative because the facility's initial intention was to readmit her. She also stated that the unit Social Worker is responsible for sending out discharge notices. She added that she did not have any communication with Resident #1's representative regarding notification of Resident #1's discharge. 415.3(h)(1)(iii)(a-c)

Based on observations and interviews during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, dirty chairs were observed on the 4th floor, broken furniture and privacy curtains loosely hung with missing hooks on the 3rd floor (Rooms 329, 330, 331, 332, 337). This was evident for 4 out of 6 units reviewed for Environmental Observations (Units 3 North, 3 South, 4 North, and 4 South). The findings are: The facility Policy and Procedure for General repairs on Resident Units dated (MONTH) 17, 2019 was reviewed. The policy documents it is the policy of the facility that all common rooms, resident rooms, unit equipment and unit furnishings be maintain in proper condition. Procedure #4 Maintenance staff members will check the unit log book daily and complete the repairs. When the repairs is complete they will sign off on the log sheet. 1). On 08/15/2019 at 10:15 AM and 08/16/2019 at 8:30 AM, the following were observed on 4 North and 4 South dining room: - 4 South noted with twenty (20) chairs that were in disrepair with the chair arms torn. One chair had no chair back, the back was torn off, and there were three with missing screws. 4 North noted with twelve (12) chairs in the dining room, of which ten (10) were in disrepair with the chair arms torn and five with loose screws. On 08/19/19 at 08:01 AM, the Maintenance Supervisor was interviewed. He stated he does a walk through daily and checks the chairs and other furniture. He also stated I must have missed those chairs. I removed the torn chairs and replaced them with new ones. On 8/20/2019 at 1:10 PM, the RN Nurse Manager for 4 North and South, RN #6 was interviewed and stated she did see the disrepair and torn chairs arms, but did not log it in the log book because she did not know such small tears and disrepair needed to be reported. 2). The following observations were made on the 3rd floor: On 08/14/19 at 9:58 AM, in room [ROOM NUMBER] Bed C- the bedside cabinet had a broken bottom drawer, the privacy curtains were missing hooks. room [ROOM NUMBER] privacy curtains for Bed A, B, C and D were missing hooks. On 08/14/19 at 10:39 AM, the privacy curtain for room [ROOM NUMBER]-Bed A was missing 2 rings, rings were affixed separately from privacy curtain and the privacy curtain for Bed C and Bed D had 1 privacy curtain ring that was not affixed to the curtain. On 08/14/19 at 11:18 AM, in room [ROOM NUMBER]-both of the resident's bedside tables at the door had chipped surfaces in the top and corners and the overhead privacy curtain was missing hooks. room [ROOM NUMBER]-privacy curtains for window bed was hanging with missing hooks and the privacy curtain was ripped at the top. The privacy curtain around the bed by the entrance door had damaged fabric and was missing 2 hooks. On 08/15/2019 at 09:33 AM, in room [ROOM NUMBER]- privacy curtains for window bed was missing hooks and the privacy curtain was ripped at the top. The privacy curtain around the bed by the entrance door had damaged fabric and was missing 2 hooks. On 8/15/19 at 08:50 AM, 08/15/19 at 02:51 PM, 08/16/19 at 03:19 PM, 08/19/19 at 08:54 AM, 08/20/19 at 01:04 PM and 08/20/19 at 04:24 PM-room [ROOM NUMBER]-Privacy curtains hanging with missing hooks for Bed A. On 08/20/19 at 01:18 PM, in room [ROOM NUMBER]-Bed C-lower drawer on resident's dresser was broken. On 08/20/19 at 04:24 PM, in room [ROOM NUMBER]-privacy curtains for Bed A, B, C and D were missing hooks. On 08/20/19 at 04:24, in room [ROOM NUMBER] the privacy curtains for Bed A were missing hooks, and in room [ROOM NUMBER] the privacy curtains for Bed C and D were missing hooks. On 8/20/19 at 4:20 PM, the State Agent reviewed the maintenance log for Unit 3 South. There was no documented evidence that any of these concerns had been identified and addressed by staff. On 8/20/19 at 04:29 PM, an interview was conducted with the Housekeeping Supervisor (HS). The HS stated that he makes facility rounds daily, checks to make sure areas are clean, checks for broken furniture and follows up on reports of housekeeping issues. The HS also stated that his staff make rounds and refer to the maintenance log for work orders to be completed. The HS further stated that he is aware of privacy curtains with missing hooks and is in the process of transitioning to getting new curtains. The clips are available and a special project person has been assigned to replace the hooks. On 8/20/19 at 04:41 PM, an interview was conducted with the Maintenance Manager (MM). The MM stated he is notified of maintenance projects via the maintenance book and from overhead pages. The MM also stated that he takes a walk on the floor every day but does not go into every room. Once an issue is noted in the maintenance book, if the item is in stock the issue is fixed the same day. If replacement parts have to be ordered, the repairs will be made once the parts become available. The MM further stated that he was not aware of the broken dresser in room [ROOM NUMBER]. On 8/20/2019 at 04:38 PM, an interview was conducted with the Housekeeping Director (HD). The HD stated that rooms are observed on a daily basis by him and by the porters who will report to him if anything is broken. The HD also stated Maintenance staff check the maintenance log books on the unit and follow up on issues reported. The HD further stated that the privacy curtains are missing hooks because they are being tugged on by staff and residents, and the facility is going to be changing the system and curtains. The HD stated that new curtains and hooks were delivered to the facility last week and are being replaced according to the priority list that was created. State Agent reviewed the priority list provided by the Maintenance Manager, however none of the rooms listed above were included on this list. 415.5(h)(2)

Based on observation and staff interview during the recertification survey, the facility did not ensure that all equipment was being maintained in a clean, sanitary manner. Specifically, the robot coupe R6N was still covered with grime and debris after staff cleaned it. This was evident for the Kitchen Observation task. The finding is: On 08/16/19 at 04:26 PM and 08/19/19 at 03:28 PM, the robot coupe was observed with brown grime around the on and off knobs. On 08/19/19 at 03:28 PM, the Dietary Aide (DA) was interviewed. The DA stated equipment is cleaned and sanitized at night and sanitized in the morning before use. The DA was observed cleaning the robot coupe, with a toothbrush brushing around the metal pole in the center of the base. The DA wiped the base with soap and water, sanitized, and wiped the dry. The DA stated that the substance around the knobs was rust and discoloration. The DA stated she only needed to clean the top of the base, and the cooks clean the machine after use. The DA stated that an in-service on how to clean equipment is given every Wednesday. On 08/19/19 at 03:50 PM, an interview was conducted with the Food Service Director (FSD). The FSD stated the [NAME]ot coupe R65 is used for therapeutic consistency either puree or chopped mechanical soft. The FSD stated an in-service on cleaning specialized equipment is done every other Wednesday. The FSD was asked to observe the robot coupe knobs. The FSD stated it was clean and was observed clean that morning. On 08/20/19 at 04:32 PM, a follow-up interview was conducted with the FSD. The FSD stated equipment is physically inspected to ensure there are no food particles and the equipment is dry and ready for use by the following shift prior to closing the kitchen. The inspection is documented on the Supervisor checklist. If the equipment is dirty on inspection, the supervisor/manager will clean and sanitize the equipment. 415.14(h)

Based on observation, record review and interviews during the recertification survey, the facility did ensure that Infection Control protocols were maintained to help prevent the development and transmission of communicable disease and infections. Specifically, (1) a Respiratory Therapist (RT) did not practice appropriate hand hygiene before and during [MEDICAL CONDITION] care for two residents (Resident #155 and #116); and, (2) a Licensed Practical Nurse did not practice appropriate hand hygiene during a dressing change (Resident # 125). This was evident for 2 of 2 residents observed during [MEDICAL CONDITION] care and 1 of 2 residents observed during wound care out of a sample of 38 residents. The findings are: The facility policy and procedure titled Infection Control/Respiratory Equipment, from the Respiratory Care Policy and Procedure Manual, dated (MONTH) (YEAR) documented all respiratory Care Personnel should wash their hands frequently as it is the most important means of preventing infection. The facility policy and procedure titled Infection Control and Prevention dated 7/14/16 documented change gloves during patient care if moving from a contaminated body site to a clean body site. Remove gloves promptly after use before touching non-contaminated items and environmental surfaces, and before after caring for another patient. Decontaminate hands after removing gloves. 1. Resident #155 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and received suctioning and [MEDICAL CONDITION] care. Active Physician orders [REDACTED]. On 08/19/19 at 09:56 AM, an observation of [MEDICAL CONDITION] care was conducted with a Respiratory Therapist (RT) who was providing care on Unit 3. The RT gathered equipment from a cart in the hallway, carried the equipment in her hands and entered the resident's room. The RT washed her hands appropriately at the sink located in resident room and donned clean gloves which she removed from a box on the wall. The RT then greeted the resident, placed a clear plastic bag on the resident bed's, and placed a small plastic drape sheet on the bed next to the bag. The RT donned gloves, opened drain sponges, a bottle of Normal Saline Solution (NSS) and placed items on the drape sheet. The RT opened the resident's bedside drawer with gloved hands, rummaged through the drawer and retrieved a vial of NSS (individual pink vial). The RT informed the resident what she was going to do and proceeded to suction the resident. The RT did not remove gloves or perform hand hygiene after setting up the supplies and touching other objects in the room and before suctioning the resident. The RT completed a second round of suctioning, removed her gloves, washed her hands and left the room. She returned with a suction catheter, placed it under her arms while she washed her hands and donned clean gloves. The RT then placed the suction catheter on the drape sheet with the other supplies. The RT removed the dressing at the [MEDICAL CONDITION] site, cleansed the site with sterile water, applied a new dressing and changed the [MEDICAL CONDITION] ties, applying new ties one at a time with the same gloves. The RT then removed her soiled gloves and opened a packet containing sterile blue gloves which she donned. She then proceeded to remove the inner cannula and replaced it with a new inner cannula, suctioned the resident's oral cavity with Suction catheter suction catheter, changed the resident's humidifier then gathered and discarded soiled items removed gloves and washed hands. The RT did not perform hand hygiene when moving from dirty to clean areas and before opening and donning sterile gloves. 2. Resident # 116 is a [AGE] year old admitted to facility on 4/10/02 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented resident as cognitively intact and received suctioning, [MEDICAL CONDITION] care, Ventilator or respirator for resident. Active Physician order [REDACTED]. On 08/19/2019 at 10:15 AM, an observation of [MEDICAL CONDITION] care was conducted with the Respiratory Therapist (RT) who was providing care on Unit 3. The RT gathered equipment, washed her hands and placed a drape on the resident's thigh. RT donned gloves, then opened a drawer in the resident's bedside dresser and removed a pink unit dose vial of Normal Saline Solution (NSS). The RT then opened the NSS, placed in [MEDICAL CONDITION] and proceeded to suction the resident. The RT proceeded to clean [MEDICAL CONDITION] area with a drain sponge moistened with sterile water. The RT placed the soiled drain sponge on the drape sheet. RT placed a new tie around neck, removed old tie and cleaned the area. The old ties were removed, new ties attached and the resident's neck was cleansed and a clean drain sponge was applied to the resident's neck. The RT then removed her soiled gloves and proceeded to open a package containing sterile gloves, donned the sterile gloves, removed inner cannula and attached a new inner cannula. The RT then proceeded to attach a new humidifier to [MEDICAL CONDITION]. The RT then gathered and removed the equipment which she placed in a garbage can and proceeded to wash her hands and exit the residents room. Breaks in infection control were observed which included the RT's failure to perform hand hygiene and change gloves after touching the resident's drawer and before performing suctioning, after suctioning and before cleansing the [MEDICAL CONDITION] site, before applying a clean dressing, and before opening and donning sterile gloves. On 08/19/19 at 10:23 AM, an interview was conducted with the RT. The RT stated she had completed a competency on suctioning in July. The RT also stated when she going to suction a patient, she gathers her equipment, washes her hands, and informs the resident that she is here to perform suctioning. The RT further stated she will suction the patient, clean the [MEDICAL CONDITION] and when finished will removed the discarded items and gloves and then wash her hands. The RT stated she changes her gloves and washes hands as needed as it is a closed suction system. On 08/19/19 at 11:03 AM, an interview was conducted with the Director of Respiratory (DOR). The DOR stated she monitors the work of the Respiratory Therapists through direct observation and completion of competencies. The DOR also stated the competencies are done annually and as needed and had been completed for this RT in July. The DOR further stated the competencies cover multiple areas of Respiratory Care including suctioning, Ventilator care, [MEDICAL CONDITION] care and Oxygen. The facility uses a closed suctioning system so once you start suctioning you are with that patient. The DOR also stated handwashing is a vital part of this process and if there is any break in the process of administering the care then the Respiratory Therapist must start over beginning with the washing of hands. In addition, handwashing should occur whenever moving from a clean to dirty area. 3. Resident # 125 is a [AGE] year old admitted to facility on 04/30/19, with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set ((MDS) dated [DATE] documented the resident with severe cognitive impairment. The MDS also documented in section M Skin Conditions the resident had five (5) Stage 4 pressure ulcers that were present upon admission. physician's orders [REDACTED]. Hydrogel, Cleanse Sacrum with NS (Normal Saline), pat dry apply Hydrogel and Calcium Alginate then cover with [MEDICATION NAME] twice daily and as needed (BID/PRN). Santyl 250 unit/gram topical ointment, Cleanse Left hip (3.2 x 3.5 x 1.0) with NS, pat dry apply Santyl and [MEDICATION NAME] and Calcium Alginate, then cover with foam dressing daily and as needed (QD/PRN). Mupirocin 2% topical cream, Cleanse Left hip with NS, pat dry apply Santyl and [MEDICATION NAME] and Calcium Alginate, the cover with foam dressing daily and as needed (QD/PRN). On 08/19/19 at 08:39 AM, a wound care observation was conducted with the Licensed Practical Nurse (LPN #1). The LPN explained the procedure to the resident, washed hands, set up the supplies needed. The LPN donned clean hand gloves, removed the soiled dressing on the resident's left hip stage 4 pressure ulcer site. The LPN cleansed the site with gauze moistened with normal saline solution. The LPN then removed the gloves, performed hand hygiene, donned clean gloves and applied treatment and clean dressing to the site. The LPN did not perform hand hygiene after removing the soiled dressing and before cleansing the wound site. On 08/19/19 at 09:39 AM, an interview was conducted with LPN #1. The LPN stated that she has been working in the facility for the past five (5) years. LPN #1 also stated that resident was admitted with Stage 4 pressure ulcers on the sacrum and the bilateral hips, and stated that any change in resident's skin condition is reported to the wound nurse, unit manager and the physician for further assessments. LPN #1 further stated she realized that the same gloves used for removing dirty dressing from the resident's left hip pressure ulcer was used to cleanse the wound site. LPN #1 stated that she made the mistake because she was nervous at the beginning of the procedure, and was able to regain confidence and carry out proper hand hygiene when doing the second site. On 08/20/19 at 10:48 AM, an interview was conducted with the Infection Control Coordinator (ICC). The ICC stated that there has been infection control problem regarding the respiratory and is currently being followed up by the QAA (Quality Assessment and Assurance). The ICC stated that she was not aware of infection control issues regarding wound care dressing change and hand washing. ICC stated that spot checking is done every unit shift by the nursing supervisors and the unit manager to ensure that the staff are [MEDICATION NAME] the correct hand hygiene. If any staff is noted to break the protocol, in-service is done to correct the situation and prevent re-occurrence The ICC stated that the concern will be followed up by re-educating the staff on the need for proper hand sanitization. 415.19 (b) (4)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, (1) the Minimum Data Set (MDS) assessment incorrectly coded a resident received [MEDICAL TREATMENT] when they did not and (2) the MDS did not capture a resident's hand mitten as a restraint. This was evident for 3 out of 38 sampled residents (Resident #s 223, 143, and 165). The facility policy for MDS Completion /Transmission revised/reviewed 10/2018 documented every department will be responsible for accurate completion of assigned MDS sections. The findings are: 1) Resident #223 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had severely impaired cognition with long and short-term memory problems. The MDS did not document [MEDICAL TREATMENT] care in the Special Treatment section O for the resident. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had severely impaired cognition with long and short-term memory problems. The MDS documented the resident received [MEDICAL TREATMENT] care while a resident. The physician's orders [REDACTED]. On 8/19/19 at 11:27 AM, an interview was conducted with the Licensed Practical Nurse (LPN). The LPN stated the resident is not on [MEDICAL TREATMENT]. On 08/20/19 at 09:45 AM, an interview was conducted with MDS Assessor. The MDS Assessor stated the resident is not on [MEDICAL TREATMENT], and it was a mistake that [MEDICAL TREATMENT] was checked. The MDS assessor stated when completing the MDS, she meant to check hospice due to the physician's orders [REDACTED]. She did not go back to Section O to correct it. The MDS assessor stated the MDS will be modified. The MDS assessor stated she is responsible for ensuring that the MDS is accurate. The Coordinator oversees and schedules the MDS and care planning. 2) Resident #143 was admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented the resident is in a persistent vegetative state. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is in a persistent vegetative state. The MDS further documented the resident was receiving [MEDICAL TREATMENT] while a resident in Section O. On 8/145/2019 at 09:36 AM, resident observed lying in bed with Home Health Aide (HHA) sitting at bedside. The physician's orders [REDACTED]. On 08/19/19 at 12:25 PM, the Registered Nurse MDS Coordinator (RN #5) was interviewed. The RN stated this was an error. She meant to check hospice, but she checked [MEDICAL TREATMENT] instead because the line is so close. The MDS Coordinator stated the resident is not on [MEDICAL TREATMENT], and she will modify the MDS now. On 08/20/19 at 04:14 PM, an interview was conducted with the MDS Coordinator. The Coordinator stated monitoring for accuracy includes three parts. There is a monthly MDS audit for all Medicare Part A patients that correlates the information coded with documentation in the record such as Activities of Daily Living, Medicare certifications, and Notice of Medicare Non-Coverage letters and skilled documentation through an auditing company. The MDS Coordinator personally monitors validation reports, completion dates, and any warnings from CMS through an internal review of MDS completion and submission logs on a weekly basis. Ten randomly selected charts are reviewed for MDS accuracy weekly. 3) Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessments dated 4/1/19, 5/6/19 5/10/10, 5/17/19, 5/27/19, 6/5/19, 7/1/19, and 7/9/19 documented the resident had severely impaired cognition with long and short term memory problems. The assessments further documented the resident had no restraints or alarms used in Section P. On 8/15/2019 at 03:02 PM, 8/16/2019 at 08:36 AM and 3:12 PM, and 8/19/2019 at 08:33 AM and 11:30 AM, the resident was observed lying in bed in no distress with a white mitten on the right hand. The Comprehensive Care Plan (CCP) for Hand Mitten, initiated 8/27/17, documented the resident had a right hand mitten in place to prevent the resident from dislodging the [MEDICAL CONDITION] and [DEVICE]s. The CCP was last reviewed 8/10/19. The Resident Nursing Instructions report generated 8/20/19 documented the resident had a right hand mitten restraint. The schedule for the restraint was last changed in the medical record on 8/25/17, and the type of restraint was last changed in the medical record on 9/20/17. The active physician's orders [REDACTED]. The order was initiated 5/10/19. On 08/19/19 at 12:29 PM, the Registered Nurse MDS Coordinator (RN #5) was interviewed. The RN stated the resident does not have a restraint. She stated that hand mittens that are attached to the side rails and prevent the patient from touching their body are restraints. Hand mittens are not restraints if the resident can touch part of the body and can elevate their arm. The RN stated that her supervisor in-serviced her on restraints. On 08/20/19 at 11:02 AM, the Registered Nurse MDS Coordinator (RN #4) was interviewed. The MDS Coordinator stated as per MDS language, if the mitten is tied to the bed it is a restraint. As long as the resident is able to move their hands and touch his or her body, she does not consider the hand mitten a restraint. MDS language documents if the resident has limitations in the hands, the hand mitten should be considered a restraint. The resident has a history of pulling the G- Tube and the Trach, and the resident has had the hand mitten since since (YEAR). The RN stated the mitten is not tied to the siderails, and the resident can move his hands. Therefore, it is not a restraint. The MDS Coordinator added she gets the definition of restraint from the MDS manual, CMS (Centers for Medicare & Medicaid Services) guidelines, and her supervisor. On 08/20/19 at 11:29 AM, the Director of MDS was interviewed. The MDS Director stated he reviewed the RAI manual for coding restraints in the MDS. He stated Chapter 3- Section P entitled Restraints and Alarms on page 6 documents that hand mittens is not restraints. The MDS Director stated the hand mitten the patient has and how it is attached is not considered a hand restraint. The resident cannot remove the mitten, and it is for a safety issue. The resident cannot use his hands. He does not consider the mitten as a limb restraint based on how he read the guidelines in the MDS RAI Manual. The MDS Director stated he is responsible for the in-service of the MDS staff, and he was educated that if the mitten is not tied to anything, it does not restrict movement. The MDS Director stated a restraint is when a patient is tied down. 415.11(b)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect during care. Specifically, during an observation of [MEDICAL CONDITION] care, the Respiratory Therapist failed to knock on the door before entering the resident's room. This was evident for 1 of 2 residents reviewed for Dignity (Resident #155). The finding is: The facility policy entitled Dignity, Privacy and Confidentially dated 8/20/2019 documented: it is our policy to provide care and services to residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. It is our policy to maintain residents personal privacy and confidentiality, in all care and communication settings. Bullet number six (6) documented All interaction with resident will be conducted in full recognition of his/her privacy. Resident #155 was admitted to facility on 6/18/2018 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition with long and short term memory problems. The MDS documented the resident was receiving Oxygen, Suctioning, [MEDICAL CONDITION] Care, and ventilator or Respirator while a resident. On 08/15/19 at 02:58 PM, the resident was observed lying in bed attached to a ventilator. The resident was able to communicate and stated she was ok. On 08/19/19 at 09:56 AM, the Respiratory Therapist (RT) was observed preparing for the resident's [MEDICAL CONDITION] care. The RT gathered equipment from the cart in the hallway and proceeded to enter the resident's room without knocking on the door. On 08/19/19 at 10:23 AM, the Respiratory Therapist (RT) was interviewed. The RT stated when she is going into a room to suction a patient she should gather all her equipment, knock on the door, wash her hands, introduce self and let the patient know she is here to perform suctioning. 415.5(a)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was provided with personal privacy during care. Specifically, during observations of [MEDICAL CONDITION] care and suctioning for two residents, the Respiratory Therapist did not close the door and draw the curtain. This was evident for 1 of 3 residents reviewed for Ventilator/[MEDICAL CONDITION] (Resident #155) and one random observation (Resident #116). The findings are: The facility policy entitled Dignity, Privacy and Confidentiality dated 8/20/2019 documented: it is our policy to provide care and services to residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. It is our policy to maintain residents personal privacy and confidentiality, in all care and communication settings. Bullet number six (6) documented All interaction with resident will be conducted in full recognition of his/her privacy. 1) Resident #155 was admitted to facility on 6/18/2018 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition with long and short term memory problems. The MDS documented the resident was receiving Oxygen, Suctioning, [MEDICAL CONDITION] Care, and ventilator or respirator while a resident. On 08/15/19 at 02:58 PM, the resident was observed lying in bed attached to a ventilator. The resident was able to communicate and stated she was ok. On 08/19/19 at 09:56 AM, the Respiratory Therapist (RT) was observed doing the resident's [MEDICAL CONDITION] care and suctioning. Resident #155 is in a room with three other residents. The RT entered the room, set up the supplies, and proceeded to perform care without closing the door or drawing the curtain to provide privacy. 2) Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is cognitively intact. The MDS documented the resident received Oxygen, Suctioning, [MEDICAL CONDITION] care, and Ventilator or Respirator while a resident. On 08/14/19 at 10:36 AM, the resident was observed lying in bed attached to a ventilator in no distress. The resident was able to communicate well and verbalized she was ok. On 08/19/2019 at 10:15 AM, the Respiratory Therapist (RT) was observed doing the resident's [MEDICAL CONDITION] care and suctioning. The RT performed the resident's care with the door and privacy curtain open. On 08/19/19 at 10:23 AM, the Respiratory Therapist (RT) was interviewed. The RT stated she had an in-service and competency on privacy, suctioning and sexual harassment some time in (MONTH) before going on vacation. The RT stated she respects patient right for privacy. The RT stated, for example, if there are people in the room, such as family members, she will ask them to leave and call them back into the room when the care is finished. The RT stated sometimes, she will pull the curtains to make the resident feel comfortable, and she closes the door sometimes. She stated that she leaves the door open sometimes just in case there is an emergency and she needs help with the resident. On 08/19/19 at 11:03 AM, the Director of Respiratory Care (RTD) was interviewed. The Respiratory Director stated he is responsible for monitoring the Respiratory Therapist through observations and annual competencies. The RTD stated the competencies for the RT were done before the RT went on vacation. The RTD stated the competencies cover multiple areas including suctioning, Ventilator care,[MEDICAL CONDITION], and Oxygen. The RTD stated it is a big package that is reviewed with each Respiratory Therapist, and they sign off when it is done. The RTD stated part of the process is respecting resident privacy by closing the door or pulling the privacy curtain. RTD stated if the door is closed, no one would be able to hear the staff call for assistance, but the curtain must be drawn for privacy when giving care if the door remains open. 413.3(d)(1)(ii)

Based on observations, record review and interviews, the facility did not develop and implement a Comprehensive person-centered Care Plan that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, no care plan to address the care concerns for restraint use was developed for a resident with a hand mitten (Resident #165). The finding is: The facility policy entitled Physical Restraints documented under the section Philosophy All residents with restraints will be monitored for continued need and justification as need arises. Documentation by nursing and physician shall state the medical symptom requiring the needs for the restraint and the need for the restraint and the continued use in the CCP and all other relevant documentation. The facility policy went on to document restraints shall be defined as any manual method of physical, mechanical device, material or equipment, and/or adjacent to the resident's body that the individual cannot remove easily or restricts freedom of movement or normal access to one's body (Federal Interpretive Guidelines). Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessments dated 4/1/19, 5/6/19 5/10/10, 5/17/19, 5/27/19, 6/5/19, 7/1/19, and 7/9/19 documented the resident had severely impaired cognition with long and short term memory problems. The assessments further documented the resident had no restraints or alarms used. On 8/15/2019 at 03:02 PM, 8/16/2019 at 08:36 AM and 3:12 PM, and 8/19/2019 at 08:33 AM and 11:30 AM, the resident was observed lying in bed. The resident had a white mitten on the right hand. The facility document entitled Resident Notification of Restraint Use dated 8/27/17 with signatures identified as Resident/Designated Representative and Social Worker documented restraint use Right (R) Hand Mitten and Medical reason Pulling [MEDICAL CONDITION] GT ([DEVICE]). The Comprehensive Care Plan (CCP) for Hand Mitten, initiated 8/27/17, documented the resident had a right hand mitten in place to prevent the resident from dislodging the [MEDICAL CONDITION] and [DEVICE]s. The CCP had the following intervention: Mitten applied to resident right hand every shift , release every two hours for 15 minutes during ADL care and meals. The CCP was last reviewed 8/10/19. The active physician's orders [REDACTED]. The order was initiated 5/10/19. The Resident Nursing Instructions report generated 8/20/19 documented the resident had a right hand mitten restraint. The schedule for the restraint was last changed in the medical record on 8/25/17, and the type of restraint was last changed in the medical record on 9/20/17. There was no documented evidence that a Comprehensive Care Plan with goals and interventions for Restraints had been developed. On 08/20/19 at 11:02 AM, the Registered Nurse MDS Coordinator (RN #4) was interviewed. The MDS Coordinator stated as per MDS language, if the mitten is tied to the bed it is a restraint. As long as the resident is able to move their hands and touch his or her body, she does not consider the hand mitten a restraint. MDS language documents if the resident has limitations in the hands, the hand mitten should be considered a restraint. The resident has a history of pulling the G- Tube and the Trach, and the resident has had the hand mitten since since (YEAR). The RN stated the mitten is not tied to the siderails, and the resident can move his hands. Therefore, it is not a restraint. The MDS Coordinator added she gets the definition of restraint from the MDS manual, CMS (Centers for Medicare & Medicaid Services) guidelines, and her supervisor. On 08/20/19 at 11:29 AM, the Director of MDS was interviewed. The MDS Director stated he reviewed the RAI manual for coding restraints in the MDS. He stated Chapter 3- Section P entitled Restraints and Alarms on page 6 documents that hand mittens is not restraints. The MDS Director stated the hand mitten the patient has and how it is attached is not considered a hand restraint. The resident cannot remove the mitten, and it is for a safety issue. The resident cannot use his hands. He does not consider the mitten as a limb restraint based on how he read the guidelines in the MDS RAI Manual. The MDS Director stated he is responsible for the in-service of the MDS staff, and he was educated that if the mitten is not tied to anything, it does not restrict movement. The MDS Director stated a restraint is when a patient is tied down. On 08/20/19 at 12:33 PM, the Registered Nurse Unit Manager (RN #1) was interviewed. The RN stated that the resident has had a right hand mitten since she began working on the unit a year ago. The resident has a right hand mitten to prevent him from pulling at the [MEDICAL CONDITION] and [DEVICE]s. Unit Manager stated the mitten is not a restraint because the resident is still able to move his hand. The mitten is used to cover all the resident's fingers so he will not be able to pull at his trach. The RN stated it is not a restraint, and the resident has a care plan for Mitten. 415.11(c)(1)

Based on interviews and record review conducted during an abbreviated survey (Complaint # NY 681), the facility did not ensure that a resident was free from physical abuse. This was evident in 1 of 3 residents sampled for physical abuse (Resident #1). Specifically, on 12/28/2018 at approximately 9:20 AM, Registered Nurse #2 (RN #2) witnessed Respiratory Therapist #1 (RT #1) slapped Resident #1 on his right cheek. The findings are: The Facility Policy and Procedure Titled Abuse Prohibition revised on 02/23/2017 documented that the facility shall not use or permit verbal, mental, sexual, or physical abuse, including corporal punishment and involuntary seclusion of residents/patients, or order mistreatment or neglect. This prohibition extends to abuse by anyone, including, but not limited to, other residents, staff, consultants, volunteers, a staff of other agencies serving the residents, family members, legal guardians, friends or other individuals. The policy defines physical abuse as inappropriate physical contact with a resident/patient while the resident/patient is under the supervision of the facility, which harms or is likely to harm the resident/patient. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 10/06/2018, documented that Resident #1 had long/short-term memory problems and was severely impaired (never/rarely made decisions). The Comprehensive Care Plan (CCP) dated 08/27/2017 documented that Resident #1 was at risk for abuse. The interventions included that staff should monitor for signs and symptoms/evidence of abuse. Review of the respiratory department staff schedule and assignment sheet dated 12/28/2018, revealed that RT #1 was assigned to the 3rd floor on the day shift. The Nursing Note dated 12/28/2018 at 4:26 PM recorded that the nurse (RN #2) observed RT #1 used his left hand, to slap Resident #1 on his right cheek. Resident #1's face was noted to have marks of fingerprints. Tylenol 650mg administered and cold compress applied. The physician's orders [REDACTED]. The Medicaton Administration Record (MAR) dated 12/28/2018, revealed that Tylenol 650mg was administered. The Radiology Report dated 12/28/2018, revealed no facial bones fracture. The Facility's Occurrence Report dated 12/28/2018 documented that on 12/28/2018 at approximately 9:20 AM, RN #2 observed RT #1 slapped Resident #1 on his right cheek while providing [MEDICAL CONDITION] care (trach care). Resident #1's face was observed with fingerprint marks. The Respiratory Therapy Administration Record dated 12/2018 documented that the accused Respiratory Therapist provided treatment to Resident #1 on 12/28/2018. The Nursing Note dated 12/29/2018 to 12/30/2018, revealed that the redness to Resident #1's right cheek was visible and subsiding. RN #1 was interviewed on 01/17/2019 at 11:28 AM and stated that during her rounds on 12/28/2018 at 7:15 AM, Resident #1 was resting in bed and there was no redness or swelling on the resident's face. However, when she went back to Resident #1's room around 10:00 AM, she observed red marks on the resident's face. She reported her observation to RN #2 and RN #2 informed her that she witnessed RT #1 slapped Resident #1 on his face. RN # 2 was interviewed on 01/17/2019 at 12:20 PM and stated that she went to see RT #1 regarding another resident. She observed that RT #1 was about to suction Resident #1, so she waited for him to complete the task. While she was waiting in the room, the curtain was half-way drawn to the foot of the bed, she observed RT #1 picked up the suction catheter and was about to suction Resident #1. Resident #1 raised his right hand and RT #1 used his gloved, left hand to slap Resident #1 on the right side of his face. She asked RT #1 why he did that, and told the RT that it was not right. The RT verbalized that Resident #1 hit him on his face. She told the RT that she had been standing there and that Resident #1 did not hit him. RT #1 was interviewed on 01/25/2019 at 9:30 AM and stated that he was assigned to Resident #1 on 12/28/2018 and provided [MEDICAL CONDITION] to the resident. He said that as he was turning the suction machine on, Resident #1 struck him on his right temple. He lost his balance and his right hand landed on the right side of Resident #1's face. The Assistant Director of Nursing (ADON) was interviewed on 01/17/2019 at 12:55 PM and stated that RN #2 came to her office shaking and crying. RN #2 informed her that she just witnessed RT #1 slapped Resident #1 on the right side of his face. 415.4(b)(1)(i)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that extra [MEDICAL CONDITION] (trach tube; an incision is made into the trachea where [MEDICAL CONDITION] is inserted as an artificial airway) of the same or lesser size and manual resuscitative devices (ambu bags) were stored at a location that was easily accessible for 4 out of 10 residents [MEDICAL CONDITION] (Residents #62, #73, #275, #276) in case of emergency or accidental dislodgement of [MEDICAL CONDITION] in order to maintain a patent airway. The findings are: An undated facility policy on respiratory care titled Decannulation of [MEDICAL CONDITION] and Mechanical Ventilation revealed that emergency equipment such [MEDICAL CONDITION] sizes 4, 6, and 8, suction tubings, surgi-lubes, non-rebreather oxygen masks, suction catheters, 4x4 gauze, 10 cc syringes (if needed), closed suction sets, [MEDICATION NAME] suction tip, facemasks, and gloves should be kept at the residents' bedside. The policy also stated that all [MEDICAL CONDITION] and ventilator residents will have an accessible manual resuscitator at the bedside. The Respiratory Therapist (RT) is responsible for ensuring that all equipment is at the bedside. 1. The room of Resident #62 was observed on 11/8/17 at 2:55 PM with RT #1. Resident # 62 has [DIAGNOSES REDACTED]. The resident had a size #[MEDICAL CONDITION] in place. There was no [MEDICAL CONDITION] of the same or lesser size available at the bedside for immediate use in case of an [MEDICAL CONDITION] dislodgement. RT #1 was interviewed on 11/8/17 at the time of this observation and stated that maybe someone had used [MEDICAL CONDITION] and did not replace it. RT #1 stated the [MEDICAL CONDITION] set should have been at the bedside for emergency use. 2. A follow-up room observation was conducted on 11/9/17 at 11:15 AM with RT #2, on 10 other residents who have [MEDICAL CONDITION] in place or ventilator dependent. Three of the 10 residents did not have either the [MEDICAL CONDITION] or resuscitative devices (Ambu Bag) available at the bedside. - Resident #73 has [DIAGNOSES REDACTED]. There was no [MEDICAL CONDITION] set available at the bedside for immediate replacement in case [MEDICAL CONDITION] dislodgement. - Resident #275 has [DIAGNOSES REDACTED]. There was no ambu bag at the bedside for emergency use. - Resident #276 has [DIAGNOSES REDACTED]. There was no [MEDICAL CONDITION] set available at the bedside in case of [MEDICAL CONDITION] dislodgement. RT #2 was interviewed on 11/9/17 at the time of the observation and stated that it is the responsibility of the RTs to ensure that all residents on trachs, ventilators, and oxygen use, have [MEDICAL CONDITION] sets and ambu bags available at the bedside for emergency use. RT #2 stated that the RTs should make daily rounds to ensure that the items are in place. RT #2 further stated that emergency supplies should be kept at the bedside. RT #3 was interviewed on 11/9/17 at 1:00 PM and stated it is the role and responsibility of the RTs to secure ambu bags,[MEDICAL CONDITION], suction machines, oxygen, at resident's bedside who are dependent on these items. RT #3 stated that she did not check for the emergency supplies this morning. RT #2 was further interviewed on 11/9/17 at 3:10 PM regarding where to obtain the [MEDICAL CONDITION], ambu bags, and other emergency supplies that were missing from the bedside. RT #2 stated she would go to the supply storage closet, which was kept under lock and key. RT #2 stated that if she can't find the needed supplies in the storage closet, she would have to go to another cabinet in the respiratory therapy room to obtain the desired [MEDICAL CONDITION] set and ambu bag. 415.12(k)(5)(4) 415.12(k)(6)

Based on observation, interview and record review the facility did not ensure that the Consultant Pharmacist provided consultation on all aspects of the provision of pharmacy services. Specifically, 1) Controlled Substances were not stored in separately locked compartments(Nursing Units 2-North, 4-South and 4-North); 2) Medications were not stored under the proper temperature as required by the drug manufacturer. (3-South). This was evident on 4 of 6 Nursing units during observations conducted for Medication Storage. (2N, 4S, 4N and 3S) The findings are: 1) On 8/8/16 at 6:49 AM during the initial tour of the 2nd floor North, an observation of the narcotic cabinet was conducted. The Licensed Practical Nurse (LPN) /Medication Nurse was observed opening the outer door lock as well as the inner door lock with the same silver key. The narcotic cabinet contained blister packs containing the following Controlled Substances: Percocet 5/325 mg tablets, Lyrica 150 mg capsules, Tramadol 50 mg tablets, Morphine sulfate ER 15 mg tablets, Morphine Sulfate IR 15 mg tablets and Lorazepam 2 mg tablets. On 8/8/16 at 6:53 AM the Licensed Practical Nurse (LPN) was interviewed and stated I just used the silver key to open both locks. I was taught the narcotic box has two doors and two locks with one lock on each door. You should have a separate key for each separate door. On 8/8/16 at 7:36 AM during the initial tour of the 4th floor South, an observation of the narcotic cabinet was conducted. The Medication Nurse was observed opening the outer door lock as well as the inner door lock with the same key marked with a white circle. The narcotic cabinet contained the following blister packs: Oxycodone 5/325 mg tablets, Lorazepam 1 mg tablets, and Hydrocodone 5/325 mg tablets. On 8/8/16 at 7:40 AM the LPN Medication Nurse was interviewed and stated One key enabled both the outer door lock and the inner door lock to open. The key for the first outer door lock has a white paper ring on it which opened both the lock on the first door as well as the lock on the second inner door. I was taught that there should be individual keys for both doors. On 8/08/2016 at 7:45 AM the LPN Charge was interviewed and stated, The narcotic box has two doors, with one lock on each door. Each lock on each door should have its own key. It is not correct that one key should open both locks. Three shifts of nurses perform the narcotic count each day. They should make sure that there is a separate key for each lock. On 8/8/16 at 7:50 AM during the initial tour of 4th floor North, an observation of the narcotic cabinet was conducted. The Medication Nurse was observed opening the outer door lock as well as the inner door lock with the same key. The narcotic cabinet contained: Lorazepam 1 mg tablets, Alprazolam 0.5 mg tablets, Oxycodone 5/325 mg tablets, Clonazepam 1 mg tablets, Clonazepam 0.5 mg tablets, Vimpat 150 mg tablets, Fentanyl 75 mcg/hr patches and Fentanyl 25 mcg/hr patches. On 8/8/16 at 7:55 AM the LPN Medication Nurse was interviewed and stated, The doors to the narcotic box must be locked at all times. The narcotic box should have 2 doors, a first door and a second inner door, with a lock on each door. There should be two different keys but one key has always opened both doors. On 8/08/2016 at 8:01 AM the Registered Nurse (RN) Unit Manager was interviewed and stated Narcotics are supposed to be double locked. One key should open the lock on the outside door and the second key opens the lock on the inside door, there should be 2 different keys. The medication nurses are responsible for making sure that they have two separate keys. On 8/11/2016 at 11:15 AM, the Registered Pharmacy Consultant was interviewed and stated, The Pharmacy Tech checks the narcotic boxes. The nurse opens the narcotic cabinet for the Tech for inspection. The Tech observes the nurses use of two different keys to open each door of the cabinet. We could ask the nurse to reverse the keys. I don't know if the Tech asks them to do this. I tell the tech to make sure one key does not open both locks. Sometimes the nurse will give the Tech the key to check themselves. A review of paperwork filled out by the Pharmacy Tech titled Pharmacon - Nursing Station Evaluation for 2nd floor North , 4th floor North and 4th floor South dated 7/28/16, 6/18/16 and 5/22/16 documents under the header 1) Are all drug cabinets and drug carts properly secured - a) kept locked when not in use - checked. b) Are all locks in proper working order - checked c)Are Double Locks on controlled drug cabinets- checked. The facility policy titled, Controlled Drugs and Biological's- Acquiring medication, Dispensing , Storage and Disposition Destruction updated 5/2016 documents, Procedure- Storage and Access 1) All drugs and biological's must be stored in a separately double locked, double keyed metal cabinet that is permanently mounted on the wall inside the medication room on the unit. 6) The medication nurse (RN, LPN) is responsible for: a) Proper storage of controlled drugs in a separately double locked, double keyed, metal, controlled cabinet inside the medication room during non-med pass times. 2) On 8/09/2016 at 1:41 PM, an observation of the 3rd floor South medication room refrigerator was conducted. The refrigerator contained: four boxes of unopened Acetylcysteine 10%. The temperature of the refrigerator was 40 degrees F (Fahrenheit). It was observed that each of the 4 boxes were labeled by the manufacturer as follows: Store at 20 to 25 degrees C (68 - 77 degrees F) (See USP Controlled Room Temperature). Store in refrigerator at 2 to 8 degrees C (36 - 46 degrees F) after opening. Discard opened vial after 96 hours. On 8/09/2016 at 1:52 PM The Registered Nurse in Charge was interviewed and stated, If the box is not opened the medication should be stored at a controlled room temperature of 68 - 77 degrees F. The medication refrigerator is 40 degrees F. It is not supposed to be in the refrigerator until it is opened. The nurse receives the medication from the pharmacy and puts it away. The nurse made a mistake by storing the medication in the refrigerator. A review of paperwork filled out by the Pharmacy Tech titled Pharmacon - Nursing station Evaluation 3rd floor south - dated 7/28/16, 6/18/16 and 5/22/16 documented: 1) Are all drug cabinets and drug carts properly secured - Are double locks on controlled drug cabinets- checked. 2) Are medications Properly stored - b) are refrigerated drugs stored in a clean refrigerator with no unrelated food or beverages present - checked c) Is medication refrigerator temperature within normal limits ( 36 -46 F)- 20 degrees F under normal limits- noted There is no documented evidence that the acetylcysteine bottles were observed or removed. On 8/10/2016 at 1:06 PM the Pharmacy Consultant was interviewed and stated, A Pharmacy Tech performs the nursing unit inspections. She checks the medication cabinets and the medication refrigerators with the nurse present who signs the inspection forms which includes- are medications properly stored. The Tech made a check mark next to this statement. Previously the closed Acetylcysteine were stored in the refrigerator because the package did say to store in the refrigerator. I am aware that the current box is labeled to store only opened bottles of Acetylcysteine in the refrigerator not the unopened bottles. It was a matter of the nurses not aware that the manufacturer's recommendations had changed and the new box had different storage directions then the old box. It was an oversight by the Pharmacy Tech. She did not remove the Acetylcysteine from the refrigerator. I will in service the tech, she missed it. The facility policy titled Storage of Drugs revised 6/2016 documents, Procedure: All drugs in the nursing home shall be stored under the following conditions: b) Drugs shall be stored at appropriate temperatures. For reference, a cold place is defined as between 2 and 8 degrees C. (36 - 46 degrees F). Room temperature is between 15 and 30 degrees C. (59-86 degrees F). 415.18(a)

Based on observation, interview and record review the facility did not ensure that 1) Controlled Substances were stored in separately locked permanently affixed compartments. (2-North, 4-South and 4-North). 2) Medications were stored under the proper temperature as required by the drug manufacturer. (3-South). This was evident on 4 of 6 Nursing units during observations conducted for Medication Storage. (2N, 4S, 4N and 3S) The findings are: 1) On 8/8/16 at 6:49 AM during the initial tour of the 2nd floor North, an observation of the narcotic cabinet was conducted. The Licensed Practical Nurse (LPN) /Medication Nurse was observed opening the outer door lock as well as the inner door lock with the same silver key. The narcotic cabinet contained blister packs containing the following Controlled Substances: Percocet 5/325 mg tablets, Lyrica 150 mg capsules, Tramadol 50 mg tablets, Morphine sulfate ER 15 mg tablets, Morphine Sulfate IR 15 mg tablets and Lorazepam 2 mg tablets. On 8/8/16 at 6:53 AM the Licensed Practical Nurse (LPN) was interviewed and stated I just used the silver key to open both locks. I was taught the narcotic box has two doors and two locks with one lock on each door. You should have a separate key for each separate door. On 8/8/16 at 7:36 AM during the initial tour of the 4th floor South, an observation of the narcotic cabinet was conducted. The Medication Nurse was observed opening the outer door lock as well as the inner door lock with the same key marked with a white circle. The narcotic cabinet contained the following blister packs: Oxycodone 5/325 mg tablets, Lorazepam 1 mg tablets, and Hydrocodone 5/325 mg tablets. On 8/8/16 at 7:40 AM the LPN Medication Nurse was interviewed and stated One key enabled both the outer door lock and the inner door lock to open. The key for the first outer door lock has a white paper ring on it which opened both the lock on the first door as well as the lock on the second inner door. I was taught that there should be individual keys for both doors. On 8/08/2016 at 7:45 AM the LPN Charge was interviewed and stated, The narcotic box has two doors, with one lock on each door. Each lock on each door should have its own key. It is not correct that one key should open both locks. Three shifts of nurses perform the narcotic count each day. They should make sure that there is a separate key for each lock. On 8/8/16 at 7:50 AM during the initial tour of 4th floor North, an observation of the narcotic cabinet was conducted. The Medication Nurse was observed opening the outer door lock as well as the inner door lock with the same key. The narcotic cabinet contained: Lorazepam 1 mg tablets, Alprazolam 0.5 mg tablets, Oxycodone 5/325 mg tablets, Clonazepam 1 mg tablets, Clonazepam 0.5 mg tablets, Vimpat 150 mg tablets, Fentanyl 75mcg/hr patches and Fentanyl 25 mcg/hr patches. On 8/8/16 at 7:55 AM the LPN Medication Nurse was interviewed and stated, The doors to the narcotic box must be locked at all times. The narcotic box should have 2 doors, a first door and a second inner door, with a lock on each door. There should be two different keys but one key has always opened both doors. On 8/08/2016 at 8:01 AM the Registered Nurse (RN) Unit Manager was interviewed and stated Narcotics are supposed to be double locked. One key should open the lock on the outside door and the second key opens the lock on the inside door, there should be 2 different keys. The medication nurses are responsible for making sure that they have two separate keys. On 8/11/2016 at 12:42 PM the Director of Nursing was interviewed and stated Narcotics should be locked in a metal cabinet with two doors, an inner and outer door each having a separate key in the nursing station. We have two keys and one should open the outer door and the other one should open only the inner door. The nurses are responsible for making sure the keys are working appropriately. The nurses count the narcotics at the shift change. The outgoing nurse opens the cabinet and counts the narcotics, in the presence of the incoming nurse. My responsibility is to make sure the narcotics are secure and available when needed and to prevent diversion from the nurses. The Supervisor should be conducting monitoring and this should be in the policy. 2) On 8/09/2016 at 1:41 PM, an observation of the 3rd floor South medication room refrigerator was conducted. The refrigerator contained: four boxes of unopened Acetylcysteine 10%. The temperature of the refrigerator was 40 degrees F (Fahrenheit). It was observed that each of the 4 boxes were labeled by the manufacturer as follows: Store at 20 to 25 degrees C (68 - 77 degrees F) (See USP Controlled Room Temperature). Store in refrigerator at 2 to 8 degrees C (36 - 46 degrees F) after opening. Discard opened vial after 96 hours. On 8/09/2016 at 1:52 PM The Registered Nurse in Charge was interviewed and stated, If the box is not opened the medication should be stored at a controlled room temperature of 68 - 77 degrees F. The medication refrigerator is 40 degrees F. It is not supposed to be in the refrigerator until it is opened. The nurse receives the medication from the pharmacy and puts it away. The nurse made a mistake by storing the medication in the refrigerator. The facility policy titled, Controlled Drugs and Biologicals- Acquiring medication, Dispensing , Storage and Disposition Destruction updated 5/2016 documents, Procedure- Storage and Access 1) All drugs and biological's must be stored in a separately double locked, double keyed metal cabinet that is permanently mounted on the wall inside the medication room on the unit. 6) The medication nurse (RN, LPN) is responsible for: a) Proper storage of controlled drugs in a separately double locked, double keyed, metal, controlled cabinet inside the medication room during non-med pass times. The facility policy titled Storage of Drugs revised 6/2016 documents, Procedure: All drugs in the nursing home shall be stored under the following conditions: b) Drugs shall be stored at appropriate temperatures. For reference, a cold place is defined as between 2 and 8 degrees C. (36 - 46 degrees F). Room temperature is between 15 and 30 degrees C. (59-86 degrees F). 415.18(d)

Based on observation, record review and staff interviews, the facility did not ensure that the Physician reviewed the residents total program of care. Specifically, the unit Physician and the Pulmonologist did not follow-up on the recommendation for ventilator weaning. (Resident #97) The finding is: Resident # 97 a [AGE] year old admitted to the facility with Diagnoses: [REDACTED]. The MDS (Minimum Data Set ) 3.0 dated 5/11/2016 documented: severely impaired cognition and total dependence on staff for activities of daily living. On 8/11/2016 at 12:30 PM the resident was observed in his room with tracheal tube connected to ventilator with AC (Assist/Control) mode, Tidal volume of 400, FIO2 (Fraction of Inspired Oxygen) 40 %, Peep-5 (Positive End Expiratory Pressure). The Pulmonologist progress note dated 7/12/2016 documented: Plan-wean on daily basis, goal is HME (Heat and Moisture Exchanger), monitor saturation, chest PT (Physiotherapy). Physician's Order dated 7/29/16 documented: Pulmonary Consult weekly as needed. The Respiratory Therapist (RT) assigned to the resident was interviewed on 8/11/2016 at 12:10 PM and stated I have not started the weaning, because there is no order. When informed that the Pulmonologist had revised the written plan of care on 7/12/2016, the therapist stated the Director of Respiratory care makes her rounds with the Physician and is responsible for picking up the orders for the respiratory therapists to follow. The Director of the Respiratory Therapy was interviewed on 8/11/2016 at 12:45 PM and stated that she accompanies the pulmonologist when he makes his rounds and discusses the resident's care. If there are any changes to the ventilator settings, then she writes the orders for the therapist to implement and added that she must have overlook the Pulmonologist plan dated 7/12/16. The Medical Director was interviewed on 8/12/2016 at 10:00 AM and stated that the Pulmonologist is part of the team and his recommendations are to be implemented because he is the primary Physician. The Pulmonologist was interviewed by phone on 8/12/2016 at 1:45 PM and stated I make my rounds with the RT Director and we discuss the residents. I write my recommendations and plan of care. The expectation is that my plan is to be carried out. The Physician was unable to explain why he did not follow-up on his recommendation for the resident's weaning. 415.15(b)(2)(iii)

Based on observation, record review and staff interviews, the facility did not ensure that the resident received proper treatment and care for ventilator services. Specifically, the Pulmonologist orders for ventilator weaning was not implemented. (Resident #97) The finding is: Resident # 97 a [AGE] year old admitted to the facility with Diagnoses: [REDACTED]. The MDS (Minimum Data Set ) 3.0 dated 5/11/2016 documented: severely impaired cognition and total dependence on staff for activities of daily living. On 8/11/2016 at 12:30 PM the resident was observed in his room with tracheal tube connected to ventilator with AC (Assist/Control) mode, Tidal volume of 400, FIO2 (Fraction of Inspired Oxygen) 40 %, Peep-5 (Positive End Expiratory Pressure). The Pulmonologist Order dated 7/12/2016 documented: Plan-wean on daily basis, goal is HME (Heat and Moisture Exchanger), monitor saturation, chest PT (Physiotherapy). The Respiratory Therapist (RT) assigned to the resident was interviewed on 8/11/2016 at 12:10 PM and stated I have not started the weaning, because there is no order. When informed that the Pulmonologist had revised the written plan of care on 7/12/2016, the therapist stated the Director of Respiratory care makes her rounds with the Physician and is responsible for picking up the orders for the respiratory therapists to follow. The Director of the Respiratory Therapy was interviewed on 8/11/2016 at 12:45 PM and stated that she accompanies the pulmonologist when he makes his rounds and discusses the resident's care. If there are any changes to the ventilator settings, then she writes the orders for the therapist to implement and added that she must have overlook the Pulmonologist plan dated 7/12/16. The Medical Director was interviewed on 8/12/2016 at 10:00 AM and stated that the Pulmonologist is part of the team and his recommendations are to be implemented because he is the primary Physician. The Pulmonologist was interviewed by phone on 8/12/2016 at 1:45 PM and stated I make my rounds with the RT Director and we discuss the residents. I write my recommendations and plan of care. The expectation is that my plan is to be carried out. 415.12(k)(6)

Based on observation, record review and staff interviews, the facility did not ensure that resident received the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, a resident was not reassessed for pain by the Registered Nurse (RN) when he initially exhibited signs of pain when the dressing to his unstageable right foot pressure ulcer was removed or when the wound was cleansed and the resident exhibited facial grimacing and leg retraction. This was evident for 1 of 3 residents reviewed for Pressure Ulcers. (Resident # 147) The finding is : Resident #147 is a [AGE] year old admitted to the facility with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) 3.0 dated 7/27/2016 assessment documented: severely impaired cognition, total assistance for activities of daily living and pain management. The resident was observed on 8/10/2016 in his room, seated in his gerichair with trachea to ventilator, contractures of bilateral upper and lower extremities, bilateral booties, knee separators and unresponsive to verbal stimuli. On 8/11/2016 at 10:30 AM, a wound care observation of the resident's unstageable right foot pressure ulcer was conducted and the following observed: The unit RN (Registered Nurse), assisted by two CNA's (Certified Nurse Assistants) for positioning, attempted to remove the dressing which was noted to be adhered to the wound. When the RN applied pressure to remove the gauze, the resident was observed retracting his leg towards his chest. The RN then removed her gloves, washed her hands, donned clean gloves and cleansed the wound with normal saline solution. While cleansing the wound with the moistened gauze, the resident again retracted his right leg and exhibited facial grimacing. During the observation, the RN did not stop the wound care to re-assess the residents comfort when the resident initially demonstrated signs of discomfort by retracting his leg or when he further exhibited signs of discomfort with facial grimacing and retraction of his leg during the wound cleansing. An immediate interview was conducted with the RN who stated that Tylenol was administered prior to the start of the wound care and the residents pain was assessed. The resident stated that he was not in pain. The RN further stated that the residents body language is observed for indications of pain such as facial grimacing and that he had not been aware of the resident's facial grimacing or leg retraction during the wound care. physician's orders [REDACTED]. Schedule: Every 6 hours (PRN) ( as needed). Monitor: Pain Follow-up (30 min) (minutes). Medical progress note dated 8/11/16 at 4:37 PM documented: patient with multiple decubitus ulcers to sacrum, B/L (Bilateral) trochanter, left lower leg, B/L heels, mid-lateral foot, left lateral foot, left medal foot, right lateral malleolus, right lateral foot, and right shoulder. Currently on Tylenol for dressing change, will add [MEDICATION NAME] q (every) am 1/2 hr prior to dressing change. d/c (discontinue) Tylenol order and leave prn for breakthrough. physician's orders [REDACTED]. 5 mg -325 mg tablet - give 2 tablets by [DEVICE] once daily 1/2 hr (one half hour) before dressing change. schedule: every day at 7:00 am - 3:00 PM. Diagnosis: [REDACTED].>The facility policy for Pain Assessment, Education and Management dated 05/2015 documented: all residents who have wound treatment are to be assessed for pain during wound care and when [MEDICATION NAME] therapy is provided in accordance with physician's orders [REDACTED]. 415.12