Every finding on record at Sprain Brook Manor Rehab

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure residents had the right to a dignified dining experience and that staff wore their identification badges while working for two of two residents (Residents #12 and #73) reviewed for dignity. Specifically, 1) Certified Nurse Aide #3 stood over and was not at eye level with Resident #12 while they were feeding Resident #12 their breakfast and 2) Dietary Aide #1, Dietary Aide #2, Certified Nurse Aide #20 and the Director of Social Work were observed without a visible identification badge. The findings include:The policy titled Resident's Rights- Policy and Procedures, revised 03/2025, documented that the facility is committed to protecting and promoting the rights of every resident. The facility should comply with all applicable state and federal laws governing resident rights.The policy titled Dress Code Policy, revised 05/2025, documented that name badges provided by the facility must be worn at all times, above the waist, and readily visible. Name badges may not be defaced with stickers or pins, nor altered in any way to change the information on the badge.A review of the Resident Council Group meeting minutes dated 05/26/2026 documented that multiple residents had complained that nurses and certified nurse aides had not announced or introduced themselves during their shift, leaving residents guessing the name of the person caring for them.1). Resident # 12 had diagnoses that included non- Alzheimer's dementia, depression, and cerebrovascular accident (stroke).The annual Minimum Data Set (a resident assessment tool) dated 06/11/2026 documented that the resident had severe cognitive impairment and was dependent on staff assistance for eating.The physician order dated 07/28/2026 documented feeding assistance by one person.During an observation and interview on 08/03/2026 at 9:11 AM, Resident #12 sat in a wheelchair with a towel draped over their shoulders as a clothing protector, and Certified Nurse Aide #3 stood over the resident, feeding them scrambled eggs and oatmeal mixed on the plate. Certified Nurse Aide #3 stated they normally sat down to feed Resident #12 but were standing so they could position themselves to feed Resident #12. They stated they were told to be seated while feeding the residents. During an interview on 08/05/2026 at 11:02 AM, Charge Registered Nurse #8 stated the nursing staff was in-serviced that they should be seated and facing the residents when they were feeding residents. They stated chairs were available at the bedside.2). Resident # 73 had diagnoses that included Parkinson's disease, diabetes mellitus, and schizophrenia.The quarterly Minimum Data Set (a resident assessment tool) dated 11/13/2025 documented that the resident was cognitively intact and required assistance with their activities of daily living.During an observation on 08/02/2026 at 9:05 AM, Dietary Aide #2 did not have a visible identification badge when they were at the entrance to the residents' dining room and lobby area.During an interview on 08/02/2026 at 11:35 AM, Resident #73 stated that, at times, staff did not wear identification badges, and they did not know names or who was providing care.During an observation on 08/02/2026 at 1:35 PM, Dietary Aide #1 did not have a visible identification badge when they were at the entrance to the residents' dining room and lobby area.During an interview on 08/02/2026 at 1:58 PM, Dietary Aide #1 stated their identification badge was on, and the badge was pulled out from in their shirt. They stated the badge was tucked in while washing dishes in the kitchen because it was getting in the way and getting wet.During an interview on 08/02/2026 at 2:26 PM, Dietary Aide #2 stated their identification badge was not on that morning because it was forgotten at home. At the time of interview, the badge was on and was retrieved from home.During an observation and interview on 08/04/2026 at 10:47 AM, the Director of Social Work did not have a visible identification badge when they entered the conference room. They stated the badge was in their bag.During an observation and interview on 08/04/2026 at 3:56 PM, Certified Nurse Aide #20 did not have a visible identification badge when they were in the residents' care area on the second floor. Certified Nurse Aide #20 stated their identification badge was in the car.During a telephone interview on 08/07/2026 at 10:04 AM, the Director of Human Resources stated all staff should have their identification badges on when in the facility. They stated department heads were responsible for ensuring staff receive their identification badges.During an interview on 08/07/2026 at 10:17 AM, the Food Service Director stated kitchen staff were usually reminded to always wear identification badges when working in the facility.During an interview on 08/07/2026 at 10:31 AM, the Director of Nursing stated staff were required to wear their identification badges once they were in the facility. They stated that during rounds, staff not wearing their identification badges were reminded to wear them.10 New York Codes Regulations and Rules 415.3(d)(1)(i)

Based on observations, interviews, and record review conducted during survey, the facility failed to ensure residents were free from accident hazards for three of five residents (Residents #1, #5 and #12) sampled for accident hazards. Specifically, 1) On 02/07/2026, Resident #5, who was identified as high risk for falls, with a history of falls, had an unwitnessed fall in the dayroom when the day room was not monitored by facility staff. Resident #5 was transferred to the emergency room on [DATE] with a laceration on left side of face, facial fractures, and an acute subarachnoid hemorrhage (medical emergency characterized by bleeding in space between the brain and the tissues that cover it). 2) On 03/29/2026, Certified Nurse Aides #2 and #3 did not properly inspect a transfer sling prior to transferring Resident #1 with a mechanical lift and the transfer sling broke, causing Resident #1 to fall on the floor and sustain swelling and bruising to the left side of their face. 3) On 06/23/2026, Resident #12, who was identified as at risk for bruising, was observed with left eye bruising after laying their head on a table without cushioning. These incidents resulted in actual harm to Resident #1 and #5 that was not Immediate Jeopardy.The findings are:The undated facility policy titled Accident and Supervision Patients, Visitors, Volunteers documented avoidable accidents occurred when the facility failed to identify the need for supervision, analyze hazards and risks, and implement interventions consistent with the resident's needs.The facility policy titled Mechanical Lift dated December 2025 documented, before each use, check the sling for wear, tears and loose stitching.1) Resident #5 had diagnoses of Alzheimer's dementia (disease characterized by decline in cognitive function, affecting memory and ability to perform daily activities) and metabolic encephalopathy (disruption in normal brain activity due to chemical or metabolic imbalances).The Minimum Data Set 3.0 (a resident assessment tool) dated 12/04/2025 documented Resident #5 was severely cognitively impaired.The Comprehensive Care Plan related to falls, initiated 10/29/2024 and last revised 05/25/2025, documented interventions to prevent Resident #5 from falling included encouraging the resident to tell staff when they felt weak, a referral to therapy, a psychiatry consult, toileting every two to four hours, maintaining a clutter-free environment, placement in a room closer to the nursing station, taking the resident out of bed when they wake, and placing the resident in high visibility areas when awake.The Incident Investigation dated 09/29/2025 documented Resident #5 had a witnessed fall in front of the nursing station at 2:30 PM when they got up from their wheelchair and staff were unable to catch the resident before they fell to the floor. Resident #5 was bleeding from their left temporal lobe and was transferred to the hospital for Cat scan (computed tomography - imaging test that uses special x-ray equipment to make detailed pictures of the inside of your body). The Incident report further documented that staff were to supervise Resident #5 keeping them in close proximity and to intervene promptly.The Fall Risk assessment dated [DATE] documented Resident #5 was at high risk for falls.The Care Plan related to falls was revised 09/29/2025 and included an intervention to redirect Resident #5 to sit back down in their wheelchair when they attempted to get up unassisted, and responding promptly when Resident #5 attempts to get up unassisted.The Incident Investigation dated 10/03/2025 documented Registered Nurse #3 responded to a thud in the dayroom at 6:30 PM and found Resident #5 on the floor. Resident #5 was placed on one-to-one supervision pending result of bilateral hip and pelvis x-rays. The 10/03/2025 incident investigation included Staff Education and that staff monitoring the dayroom would sit next to Resident #5 for immediate intervention.The care plan related to falls dated 10/29/2024 included a revision added on 10/03/2025 to that Resident #1 be placed on one-to-one supervision, which was then was discontinued on 10/06/2025. The care plan intervention dated 10/06/2025 documented staff monitoring of Resident #1 in the dayroom will be closer in proximity to the resident to intervene as soon as the resident attempted to stand. The Incident Investigation dated 11/11/2025 documented Resident #5 fell from their wheelchair in the dayroom at 2:35 PM when Certified Nurse Aide #6 turned their back to attend to another resident.The Fall Risk assessment dated [DATE] documented Resident #5 was at high risk for falls.The Care Plan related to falls created 11/11/2025 documented Resident #5 was at risk for falls due to poor safety awareness and interventions included offering toileting every two to four hours and as needed, and repositioning.The Incident Investigation dated 02/07/2026 documented staff responded to a thud in the dayroom at 8:09 AM and observed Resident #5 lying face down on the floor bleeding from the left side of their face. Resident #5 was transferred to the hospital and did not return to the facility. Registered Nurse #2 was suspended for one day for failure to assign staff to monitor residents in the dayroom.There was no documented evidence that Resident #5 was provided with adequate supervision and monitoring to prevent falls while in the unit dayroom on 02/07/2026.The Hospital Discharge summary dated [DATE] documented Resident #5 was admitted to the hospital on [DATE] after an unwitnessed fall from their wheelchair in the facility. Resident #5 was admitted to the hospital with Brain Injury Guideline 3 (a classification for traumatic brain injury severity of the most serious kind with significant intracranial hemorrhage and presence of skull fractures), subarachnoid hemorrhage in the left temporal lobe and sylvian fissure (blood in the spaces of the brain membranes), left orbital (eye socket) fracture, displaced fractures of the anterior, medial, posterolateral walls of the left maxillary sinus (nasal fracture), left-sided forehead laceration, and moderate cerebral volume loss (reduction of brain tissue). Resident #5 was deemed unsafe to eat anything, was placed on comfort care, and was transferred to hospice.The Death Certificate dated 02/13/2026 documented Resident #5's cause of death was complication of blunt force impact trauma of head and torso with facial bone and pelvic fractures and intracranial hemorrhage due to an unwitnessed low-level fall from wheelchair to the floor. An interview was conducted on 06/29/2026 at 12:32 PM with Registered Nurse #1, who stated they were the regular daytime charge nurse on the 4th floor and was familiar with Resident #5 who was a high risk for falls. Registered Nurse #1 stated Resident #5 was placed on unofficial one-to-one supervision, and the aides were instructed to always sit by Resident #5 when the resident was in the dayroom. Resident #5 would end up on the floor as soon as staff turned their backs. Registered Nurse #1 stated Resident #5 required such close supervision they could not be brought off the unit to any activities. Resident #5 was an early riser and was always placed in the dayroom before breakfast.An interview was conducted with Registered Nurse #2 on 06/29/2026 at 11:55 AM, who stated they were assigned as the charge nurse on Resident #5's unit on 02/07/2026 when the resident fell in the dayroom. Registered Nurse #2 stated they neglected to create the dayroom assignment at the beginning of their shift and there was no certified nurse aide assigned to watch the dayroom when Resident #5 fell. Registered Nurse #2 stated they wheeled Resident #2 into the dayroom and sat them at a table in the far-left side of the room. Registered Nurse #2 went to retrieve more residents from the hallway to place them in the dayroom and had to tell Resident #5 to sit down multiple times because the resident kept getting up from their wheelchair. Registered Nurse #2 stated, the last time they left the room, they heard a thud from behind them in the dayroom and Licensed Practical Nurse #1 called out that Resident #5 was on the floor. Resident #5 was observed flat on the floor bleeding from the left side of their face. Registered Nurse #2 stated they were disciplined and suspended following the facility's investigation. Resident #5 was a known fall risk and the interventions to prevent falls at the time included not leaving the resident in the dayroom without staff supervision.On 06/29/2026 at 3:32 PM, the Director of Nursing was interviewed and stated Registered Nurse #2 was in the middle of giving report and neglected to make the assignment for dayroom supervision. Resident #5 was in the corner of the room and got up from their wheelchair, started walking, and then fell in the middle of the room. The Director of Nursing stated if the assignment for dayroom supervision was made sooner, Resident #5's fall would have been avoided. The Director of Nursing stated that staff on the unit were instructed to sit next to Resident #5 once the resident was out of bed because they knew the resident was at high risk for falls prior to this incident. The Director of Nursing stated they could not recall Resident #5 having any other falls in the dayroom prior to 02/07/2026 and stated that other residents may have fallen in the dayroom since 02/07/2026.2) Resident #1 had diagnoses of surgical amputation and muscle weakness.The Minimum Data Set 3.0 dated 02/04/2026 documented Resident #1 was moderately cognitively impaired, had limited range of motion of bilateral upper and lower extremities, and was totally dependent on staff for transfers.The facility Investigation initiated 03/29/2026 and completed 03/31/2026 documented Resident #1 fell when the sling (lift pad) strap broke during mechanical lift transfer from wheelchair to bed while Certified Nurse Aides #2 and #3 assisted in the transfer.The facility Report to the New York State Department of Health dated 04/02/2026 documented Resident #1 fell from a mechanical lift while being transferred from their wheelchair to bed by Certified Nurse Aides #2 and #3 on 03/29/2026 at 3:30 PM. The sling for the lift gave way and Resident #1 fell to the floor, sustaining bleeding from their mouth. Resident #1 was transferred to the hospital and returned from the emergency room with no recommendations and no acute fracture.Certified Nurse Aide #3 was from a third-party staffing agency and was terminated by the facility on 05/21/2026. Attempt to contact Certified Nurse Aide #3 for an interview was unsuccessful.Interviews were conducted on 06/08/2026 at 3:01 PM and 06/24/2026 at 2:43 PM with Certified Nurse Aide #2, who stated they were not assigned to Resident #1 on 03/29/2026 and only assisted Certified Nurse Aide #3 with transferring the resident via mechanical lift from their wheelchair to bed. Certified Nurse Aide #2 stated Certified Nurse Aide #3 was assigned to Resident #1 and had already hooked up the sling to the mechanical lift before Certified Nurse Aide #2 entered the room. Certified Nurse Aide #2 stated they did not recall the state of the hooks or the condition of the sling underneath Resident #1.An interview was conducted on 06/29/2026 at 12:32 PM with Registered Nurse #1 who stated they were getting ready to end their shift on 03/29/2026 and were alerted by Certified Nurse Aide #3 that Resident #1 had fallen from the mechanical lift during transfer. Registered Nurse #1 stated they found Resident #1 on the floor of their room on the left side of their face bleeding from their mouth. The medical team was contacted and 911 was called to transfer Resident #1 to the hospital. Registered Nurse #1 stated they observed the mechanical lift sling hanging with three of the four straps attached to the hooks of the lift. Registered Nurse #1 stated they could not recall the condition of the sling. Registered Nurse #1 stated Certified Nurse Aide #3 reported to them at the time that the lift sling broke.An interview was conducted on 06/29/2026 at 3:32 PM with the Director of Nursing revealed they personally inspected the lift sling involved in Resident #1's fall on 03/29/2026 and discovered the stitching attaching the strap to the sling corner was completely unraveled and the canvas material was not ripped nor had the strap broke or snapped. The Director of Nursing stated the aides were responsible for checking the mechanical lifts and the slings to ensure they were in good condition prior to transferring residents. The Director of Nursing stated they believed the nurse aide should have seen the seam coming undone and unraveling because there was a long piece of string hanging from the strap seam and this would have been visible to the nurse aide. All the mechanical lift slings were checked following the incident.3) Resident #12 had diagnoses of dementia and repeated falls.The Minimum Data Set 3.0 dated 05/18/2026 documented Resident #12 was severely cognitively impaired, had trouble sleeping, and displayed no inappropriate behavior.The Comprehensive Care Plan related to disturbed sleeping patterns initiated 05/28/2026 documented Resident #12 verbalized difficulty sleeping and would be provided a quiet and comfortable atmosphere to sleep.The Comprehensive Care Plan related to skin integrity initiated 06/10/2026 documented Resident #12 had fragile skin and tended to sleep on their side on the table as evidenced by ecchymosis to the left forehead, left peri-orbital (around the eye) area, and left chin. Interventions included handling Resident #12 gently while providing care.The facility Incident Investigation dated 06/10/2026 documented Resident #12 was noted with ecchymosis to the left temporal area and left jawline. Resident #12 was confused and unable to provide an account of any occurrence. A statement from Certified Nurse Aide #2 documented they observed blue discoloration to Resident #12's face in the morning. Resident #12 received anticoagulant medication and had fragile skin. Resident #12 frequently rested their head on the dining table in the dayroom. Corrective action included educating staff on the side effects of anticoagulant medication.On 06/23/2026 at 3:05 PM, Resident #12 was observed in the 4th floor dayroom seated in their wheelchair in between two other residents at the dining room table. Resident #12 had the left side of their face lying flat on the table in front of them.On 06/28/2026 at 8:27 AM, Resident #12 was observed in bed with dark purple and faded green and yellow ecchymotic areas to the left side of their peri-orbital area and jawline. There was no documented evidence Resident #12 was provided with interventions to prevent further ecchymotic areas to their face while resting their head on the table in the dayroom.An interview was conducted on 06/29/2026 at 12:32 PM with Registered Nurse #1, who stated they were the daytime charge nurse of the 4th floor. Registered Nurse #1 stated they noticed Resident #12 had left facial discoloration the morning of 06/10/2026 because they were assisting the aide to weigh the resident. The assigned aide was unable to explain what happened to Resident #12 and an investigation was conducted to determine the origin of the resident's discoloration. Registered Nurse #2 stated Resident #12 liked to lay their head down on the dining room table after breakfast and could have pressed on their glasses and the aides were instructed to remove the resident's glasses while the resident rested.An interview on 06/29/2026 at 3:32 PM with the Director of Nursing revealed they were made aware Resident #12 had a left facial discoloration on 06/10/2026 and determined Resident #12 had fragile skin and a behavior of laying their head on the table. The Director of Nursing stated they instructed staff to ensure Resident #12 had a pillow under their head if they laid their head down.There was no documented evidence that placing a pillow under Resident #12's head when it was down was implemented as an intervention.An interview conducted on 07/02/2026 at 1:00 PM with the Medical Director revealed they were involved in the facility fall committee meetings that discussed residents who recently had falls or who were frequently falling once a week or every other week. The facility's population was changing and there appeared to be more residents at high risk for falls being admitted , on average. The dayroom was always staffed to ensure residents received adequate supervision. The Medical Director stated they reviewed all facility incident investigations and was under the impression staff were present and witnessed Resident #5's fall in the dayroom on 02/07/2026. The Medical Director stated Resident #5 was at high risk for falls and should not have been left alone. The Medical Director stated they also reviewed the facility investigation regarding Resident #1 falling from the mechanical lift on 03/29/2026. The Medical Director stated this was a freak occurrence and unavoidable. The Medical Director stated there were times that new machines broke down and the administration was responsible for ensuring equipment was maintained in good working conditions.An interview conducted on 07/03/2026 at 11:24 AM with the Administrator, revealed Resident #5 was at high risk for falls and falling in the dayroom was not a common occurrence. The Administrator stated they did not recall if Resident #5 had more than one fall in the dayroom. The Administrator stated the Director of Nursing was responsible for conducting the investigation into Resident #1's fall from the mechanical lift and looking at the lift sling. The Maintenance Department was responsible for checking the mechanical lift machines and slings daily to ensure there were no defective or worn/torn equipment. 10 NYCRR 415.12(h)(2)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents. This was evident for two (Residents #1 and #11) of three residents reviewed for staff competency. Specifically, 1) Certified Nurse Aides #2 and #3 did not properly inspect a transfer sling prior to transferring Resident #1 with a mechanical lift. During the transfer, the sling broke, causing Resident #1 to fall on the floor and sustain swelling and bruising to the left side of their face, and 2) Certified Nurse Aide #10 and Certified Nurse Aide #4 were observed transferring Resident #11 with a mechanical lift on [DATE] . Staff did not check to be sure the color-coded transfer sling was attached appropriately and that the mechanical lift charge indicator had adequate power to transfer the resident. During the observation, the mechanical lift lost power during the transfer and staff had to manually maneuver the resident for a safe transfer back to bed. The findings are:The facility policy titled Mechanical Lift dated 12/2025 documented staff were to attach the sling to the hooks of the lifter with the proper amount of staff present. Before each use, slings were checked for wear, tears, and loose stitching.1) Resident #1 had diagnoses of surgical amputation and muscle weakness.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 was moderately cognitively impaired, had limited range of motion of bilateral upper and lower extremities, and was totally dependent on staff for transfers.The facility Investigation initiated [DATE] and completed [DATE] documented Resident #1 fell when the sling (lift pad) strap broke during mechanical lift transfer from wheelchair to bed when Certified Nurse Aides #2 and #3 assisted in the transfer.The facility Report to the New York State Department of Health dated [DATE] documented Resident #1 fell from a mechanical lift while being transferred from their wheelchair to bed by Certified Nurse Aides #2 and #3 on [DATE] at 3:30 PM. The sling for the lift gave way and Resident #1 fell to the floor, sustaining bleeding from their mouth. Resident #1 was transferred to the hospital and returned from the emergency room with no recommendations and no acute fracture.The facility terminated Certified Nurse Aide #3 on [DATE] from a third-party staffing agency and was unable to be contacted for interview.Interviews were conducted on [DATE] at 3:01 PM and [DATE] at 2:43 PM with Certified Nurse Aide #2 who stated they were not assigned to Resident #1 on [DATE] and only assisted Certified Nurse Aide #3 on transferring the resident via mechanical lift from their wheelchair to bed. Certified Nurse Aide #2 stated Certified Nurse Aide #3 was assigned to Resident #1 and had already hooked up the sling to the mechanical lift before Certified Nurse Aide #2 entered the room. Certified Nurse Aide #2 stated they did not recall the state of the hooks or the condition of the sling underneath Resident #1.An interview was conducted on [DATE] at 12:32 PM with Registered Nurse #1 who stated they were getting ready to end their shift on [DATE] when they were alerted by Certified Nurse Aide #3 that Resident #1 had fallen from the mechanical lift during transfer. Registered Nurse #2 stated they found Resident #1 on the floor of their room on the left side of their face bleeding from their mouth. The medical team was contacted and 911 was called to transfer Resident #1 to the hospital. Registered Nurse #1 stated they observed the mechanical lift sling hanging with three of four of the straps attached to the hooks of the lift. Registered Nurse #1 stated they could not recall the condition of the sling. Registered Nurse #1 stated Certified Nurse Aide #3 reported to them at the time that the lift sling broke.2) Resident #11 had diagnoses of chronic obstructive pulmonary disease and dementia.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #11 was severely cognitively impaired, had functional impairment of bilateral upper and lower extremities, and was totally dependent on staff for transfers in and out of bed.The Comprehensive Care Plan related to activity of daily living dated [DATE] documented Resident #11 was totally dependent on staff for transfers in and out of bed.Physician Orders dated [DATE] documented Resident #11 be transferred out of bed via mechanical lift with the assistance of two people.Staff Education dated [DATE] and [DATE] documented nursing staff were educated on mechanical lift use. There was no documented evidence Certified Nurse Aides #4 and #10 received mechanical lift education on [DATE] or [DATE].An interview was conducted on [DATE] at 3:01 PM with Certified Nurse Aide #10 who stated they worked for the facility for approximately three months and floated to different units on the evening shift. Certified Nurse Aide #10 stated their onboarding process included shadowing other senior aides for one to two weeks and having their performance evaluated by a licensed nurse during tasks. Certified Nurse Aide #10 stated they always checked the mechanical lift slings to ensure they were in good condition and attached correctly. They also check the mechanical lift to make sure the machine was functional prior to each resident transfer.On [DATE] at 3:51 PM, Certified Nurse Aide #10 was observed wheeling Resident #11 towards their room for transfer back to bed. The mechanical lift was in Resident #11's room and Certified Nurse Aide #10 hooked the resident's four sling straps (one on each side of the resident's head and one on each side of the resident's legs) to the mechanical lift hooks while Certified Nurse Aide #4 entered the room to assist. Each lift string strap also had four color-coordinated (red, green, blue, and yellow) loops allowing the mechanical lift hooks to attach closer to or farther away from the sling canvas. As Certified Nurse Aide #4 using the lift remote control to hoist the Resident #11's sling was observed hooked to the lifter unevenly with the loop near the resident's left leg hanging more loosely than the other three loops. Certified Nurse Aide #10 was asked during transfer whether Resident #11 was hooked properly to the mechanical lift and the aide did not reply and continued to lift the resident from their wheelchair. Certified Nurse Aide #4 was positioned behind the lift with the remote control in hand. As Resident #11 was placed into their bed, the lift lost power and would not rise off the resident. Certified Nurse Aides #4 stated the mechanical lift battery was dead and they did not know if there was a way to maneuver the lift manually. Hoyer lift died during transfer. Certified Nurse Aides #11 and #4 both repositioned Resident #11 in bed and slid the lift off the top of the resident. The mechanical lift was rolled out of the room by Certified Nurse Aide #4 and left unplugged in the hallway.An interview was conducted on [DATE] at 4:30 PM with Certified Nurse Aide #4 who stated they usually work the night shift and have not received training or in-service from the facility because the facility provided trainings during the day and did not ensure the night shift were included. Certified Nurse Aide #4 stated the mechanical lift is supposed to be plugged in after each use and they did not check the mechanical lift battery during Resident #11's transfer. Certified Nurse Aide #4 stated the aide assigned to the resident was responsible for hooking the resident's sling to the lift. Certified Nurse Aide #4 stated they did not know what the color-coded loops were for and made sure to only use the loop closest to sling canvas to ensure the resident was hooked as close to the lift as possible.An interview was conducted on [DATE] at 1:44 PM with Certified Nurse Aide #9 who stated the transfer sling loops should be hooked evenly to the mechanical lift to distribute the resident's weight evenly. Certified Nurse Aide #9 stated the mechanical lift should always be plugged in after each use to ensure the battery remained charged. Certified Nurse Aide #9 stated the digital screen on the lift flashed an indicator when the battery was running low. An interview was conducted on [DATE] at 3:32 PM with the Director of Nursing revealed they personally inspected the lift sling involved in Resident #1's fall on [DATE] and discovered the stitching attaching the strap to the sling corner was completely unraveled and the canvas material was not ripped nor had the strap broke or snapped. The Director of Nursing stated the aides were responsible for checking the mechanical lifts and the slings to ensure they were in good condition prior to transferring residents. The Director of Nursing stated they believed the nurse aide should have seen the seam coming undone and unraveling because there was a long piece of string hanging from the strap seam and this would have been visible to the nurse aide. All the mechanical lift slings were checked following the incident. The Director of Nursing stated all units had backup batteries for the mechanical lifts and the aides should check the lift prior to transfer to ensure it does not run out of power. The Director of Nursing stated residents should have their transfer sling loops evenly hooked to the lift to ensure the resident's weight was balanced during transfer. The Director of Nursing stated they did not know what the color-coding on the transfer slings meant or the reason there were four different loops to choose from when hooking the resident's sling to the mechanical lift.10 NYCRR 415.26(c)(1)(iv)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure a resident was free from restraints for one (Residents #12) of 3 residents sampled for restraints. Specifically, Resident #12, an ambulatory resident at risk for falls, was observed with another resident's recliner and a chair positioned to prevent the resident from getting out of bed on 06/28/2026. Resident #12 was observed unable to move freely. The findings are:The facility policy titled Resident Rights dated 2022 documented residents have the right to be free from restraints.Resident #12 had diagnoses of dementia and repeated falls.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #12 was severely cognitively impaired, had trouble sleeping, and displayed no inappropriate behavior.The Comprehensive Care Plan related to disturbed sleeping patterns initiated 05/28/2026 documented Resident #12 verbalized difficulty sleeping and would be provided a quiet and comfortable atmosphere to sleep.The Comprehensive Care Plan related to skin integrity initiated 06/10/2026 documented Resident #12 had fragile skin and tended to sleep on their side on the table as evidenced by ecchymosis to the left forehead, left peri-orbital (around the eye) area, and left chin. Interventions included handling Resident #12 gently while providing care.On 06/28/2026 at 8:27 AM, Resident #12 was observed in bed with their head positioned lower than their legs preventing the resident from sitting up. Resident #12 attempted to sit up and could not do so. A recliner labeled with Resident #7's name (who resided in a private room across the hall) was positioned horizontally up against the right side of Resident #12's bed, blocking the resident from being able to freely move on that side. The left side of Resident #12's bed had a bedside dresser and the back of a large chair up against the upper half of the bed, blocking the resident from freely moving on that side.An interview was conducted on 06/28/2026 at 9:05 AM with Certified Nurse Aide #8 who stated they were assigned to Resident #12 and did not know the reason another resident's recliner was in Resident #12's room up against the right side of the bed. Certified Nurse Aide #8 stated they did their rounds when they came in to work at 7AM this morning and did not notice that Resident #12 had the back of a chair blocking their left side and another resident's recliner blocking their right side. Certified Nurse Aide #8 stated no devices should be used to block the side of any resident's bed to block them or restrain them. The facility did not use restraints.An interview was conducted on 06/28/2026 at 10:18 AM with Registered Nurse #4 who stated they were assigned as the unit charge nurse and made visual rounds on residents this morning Registered Nurse #4 stated they observed the recliner in Resident #12's room this morning and should have removed it. Registered Nurse #4 stated Resident #12 was at risk for falls and staff may have placed the recliner in front of Resident #12's bed to prevent a fall but, even if inconvenient, resident rooms should remain clutter free. Registered Nurse #4 stated the large sitting chairs are for visitors and should not be placed with their backs against any resident bed. Resident #12 was unable to sit up in the chairs that were at their bedside, and the chairs should not be there.An interview was conducted on 06/29/2026 at 3:32 PM with the Director of Nursing who stated they made visual rounds on the units often and have not identified any concerns with devices and equipment being used inappropriately as restraints by preventing residents from getting out of their bed. The Director of Nursing stated the facility did not use restraints.A telephone interview was conducted on 07/03/2026 at 11:24 AM with the Administrator who stated they were not aware of any staff using devices inappropriately as restraints to prevent residents from getting out of bed. The Administrator stated the facility did not use restraints.10 NYCRR 415.4(a)(2-7)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 1 resident (Resident #95) reviewed for dignity that care was provided in a manner to maintain dignity. Specifically, Resident #95's urinary (Foley) catheter tubing and drainage collection bag were not concealed to prevent direct observation by other residents and their families to maintain dignity and privacy. The findings are: Resident #95 had diagnoses and conditions including subdural hemorrhage, hemiplegia, and urinary retention. The Significant Change Minimum Data Set (MDS; a resident assessment and screening tool) dated 4/1/24 documented Resident #95 had moderately impaired cognition; and had an indwelling urinary catheter in place. On 5/07/24 at 9:55 AM Resident #95 was observed lying in bed with catheter bag laying in the bed next to him with no privacy bag over it and was visible hallway. On 5/07/24 at 11:58 AM Resident #95 was observed in wheelchair in room waiting for lunch, catheter bag attached to their wheelchair, no privacy bag over it and was visible from hallway. The Urinary Catheter Care Plan last revised 3/23/24 had no documented evidence of any intervention to provide a privacy bag over the catheter bag. When interviewed on 5/10/24 at 1:47 PM, Staff #4 (certified nurse aide) stated they were the resident's assigned certified nurse aide on 5/7/24. Staff #4 acknowledged they did not put the a privacy bag over the catheter bag and stated they were now aware they need to put the privacy bag over the catheter bag. 10 NYCRR 415.5 (a)

Based on observations, record review and interviews, during the recertification survey conducted from 5/7/24 to 5/14/24, the facility did not ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner for 2 of 4 residents reviewed for accidents. Specifically, (1) Resident #7 had an unwitnessed fall on 3/9/24 and the Fall Care Plan was not updated to reflect new interventions to prevent a fall; (2) Resident #215 had an unwitnessed fall on 4/18/24 and the Fall Care Plan was not updated to reflect new interventions to prevent a fall. The findings are: 1. Resident #7 was admitted to the facility 11/26/23 with a diagnoses including cancer, congestive heart failure, diabetes and lack of coordination. The Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 3/3/24, documented the resident's cognition was moderately impaired. It further documented the resident was dependent on staff for transfers and the resident had a fall without injury since admission or reentry. The Fall/Injury Care Plan created 11/26/23, documented the resident fell in the last 31-180 days, date: 1/1/24 and 3/9/24. The interventions included the following: Anticipate needs of resident; encourage resident to seek assistance as needed; maintain safe environment free of any hazards; monitor activities of resident; and physical therapy evaluation for transfer/ambulation status as needed. There was no further documented evidence the Fall/Injury Care plan was revised with new interventions after the falls on 1/1/24 and 3/9/24. According to facility Accident/Incident Reports, Resident #7 had an unwitnessed fall with injury on 3/9/24. The corrective action was to monitor resident's activity and visual monitoring every hour. Hospital Discharge Papers dated 3/11/24 documented the resident was admitted for fall and an x-ray showed a left tibia (lower leg) fracture, a splint was placed. When interviewed on 5/13/24 at 2:30 PM, Staff #6 (Registered Nurse) stated they were supervising the night of the incident. Staff #6 stated after a fall they update care plan and do an Accident and Incident Report. Staff #6 stated the interventions on the care plan needed to correlate with the date of the fall when updating. Staff #6 reviewed the care plan with the surveyor and acknowledged there were no new interventions put in place following each fall and had no explanation as to why. When interviewed on 5/13/24 at 2:49 PM, the Director of Nursing stated it was the practice of the facility to just update the monitoring notes and progress notes and have tried to reeducate the nurses on proper way to update the care plans with new interventions following a fall or incident. The Director of Nursing stated they recently provided education to the nurses about updating the interventions on the care plans. 2. Resident #215 admitted to facility 2/25/22 with diagnoses of cerebrovascular accident, diabetes, and other lack of coordination. The Admission Minimum Data Set (MDS; a resident assessment tool) dated 2/12/24 noted the resident had a BIMS (Brief Interview for Mental Status; a test used to measure memory, recall and orientation) score of 13 indicating that the resident had modified independence in cognition and it further documented Resident #215 was dependent in transfer and had 1 fall in the last month and had a fall within the last 2-6 months. The Fall/Injury Care Plan created 9/20/23 documented the resident fell in past 30 days (4/18/24); and had a history of falls on 8/8/23 and 10/4/23. The interventions included the following: Anticipate needs of resident; encourage resident to seek assistance as needed; keep personal items within reach; maintain safe environment free of any hazards; make sure assistive devices are in good working condition; monitor activities of resident; and physical therapy evaluation for transfer/ambulation status as needed. There was no further documented evidence the Fall/Injury Care Plan was revised with new interventions following the fall on 4/18/24. When interviewed on 5/13/24 at 3:43 PM, Staff #2 (Registered Nurse) stated they had to update the care plans following a fall. Staff #2 stated the supervisor updated the care plans, and they completed the incident report and assessed the resident. While reviewing the electronic medical record with the surveyor, Staff #2 stated they were the person who updated the monitoring note in the resident's care plan and stated they did not put in any new interventions. When interviewed on 5/13/24 at 4:06 PM, Staff #7 (Registered Nurse) stated after a fall they did an assessment and updated care plans. Staff #7 reviewed the care plan and stated they did not update the care plan with new interventions, and they just wrote a monitoring note. 10 NYCRR 415.11(c)(1)

Based on observation record review and interviews during the recertification survey conducted from 5/7/24 to 5/14/24, the facility did not ensure treatment and care were provided in accordance with professional standards to meet the needs of one of three residents (Resident #55) reviewed for skin conditions. Specifically, for Resident #55 skin impairments were not identified or reported. The findings include: The facility policy for Certified Nurse Aide Competency Checklist: Bed Bath policy, effective November 2023, documented Certified Nurse Aides check, clean and clip nails as necessary, and document on Certified Nurse Aide accountability record; and note any reddened or broken skin areas to a nurse. Resident #55 had diagnoses including history of cerebral infarction (stroke), local infection of the skin and subcutaneous tissue, and adult failure to thrive. The Minimum Data Set quarterly assessment dated [DATE] documented the resident had severely impaired cognition and was dependent on staff for all activities of daily living. The Resident Nursing Instructions (instructions for direct care staff), dated 12/8/22, documented weekly skin check every Monday and as needed; and to apply Vitamin A&D ointment to bilateral upper extremities and lower extremities every shift and as needed during care as skin protectant. The comprehensive care plan, updated on 4/8/23, documented Skin Integrity-Impaired related to skin fragility. Interventions included to monitor skin during daily care and provide protective/preventive skin care. The record review of Nursing Progress notes from 01/01/2024 to 05/12/2024 did not document any issues regarding the resident's skin condition. Review of the February 2024 through May 13, 2024 Treatment Administration Record revealed that no skin treatment was administered. The Certified Nurse Aide documentation, dated 3/20/24 to 5/14/24, documented Skin Check/ Care was signed for as performed every shift. During an observation on 05/08/24 at 10:51 AM, Resident #55 was in bed with their legs uncovered. The resident had a dry skin, the left knee had excoriated (scraped) areas and scratch marks, the left anterior foot had dry scabs, the right shin had scratch marks, and the right ankle had dry scabs. During an observation and interview on 05/13/24 at 04:39 PM, the resident was in bed with their legs uncovered. Staff #8 (Register Nurse) looked at the resident's legs and stated they were not aware of the scratch marks and excoriated area. Staff #8 stated the skin looked very dry and it looked as if the resident had long nails and scratched themselves. Staff #8 said that currently they did not have orders to apply anything to the resident's skin. They said the Certified Nurse Aide was responsible for keeping the resident's nails short by filing them and they expected to be informed of skin impairments. Following the interview with the nurse in the resident's room the conversation continued at the nursing station in front of the computer where the nurse was asked to show a record on skin assessment. The only report Staff #8 was able to find was the nursing admission skin assessment dated [DATE]. During an interview on 05/14/24 at 11:36 AM Staff #9 (Certified Nurse Aide) stated that the nurses clipped and filed nails for the residents. Staff #9 stated filing the resident's naifs was not on their task assignment. During an interview on 05/14/24 at 12:47 PM, the Director of Nursing stated that Certified Nurse Aides clipped and filed residents' nails, as well as check the residents skin condition and report to a nurse any abnormal findings. They stated the task was in the policy for Skin Care and on the Resident Nursing Instructions which showed their assignments, and the Certified Nurse Aides documented in the Certified Nurse Aide Documentation. 10 NYCRR 415.12

Based on observation, record review and interviews during the recertification and abbreviated surveys (NY00328628) conducted from 5/7/24 to 5/14/24, the facility did not ensure residents were provided timely dental services for one of one resident (Resident #13) reviewed for dental services. Specifically, Resident #13's dentures were discovered lost on 6/28/2023, and the resident did not get their dentures replaced until 12/6/2023, six months later. The findings include: Resident #13 had diagnoses including diabetes, dysphagia (difficulty swallowing), and hepatocellular carcinoma (liver cancer). The Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition, and required minimal assistance with eating and oral hygiene. The Comprehensive Care Plan for Potential Oral Dental Problems, last dated 10/29/2022, documented interventions for a dental consult annually as needed, and ensuring dentures were worn daily. A Complaint Investigation form, dated 6/28/2023, documented Resident #13's family member reported the resident's dentures were missing. A search was conducted and the dentures were not found. The corrective actions was the facility would pay for the resident's dentures and the form was signed off on 7/3/24 A Speech-language pathologist progress note dated 7/6/2023 documented the resident's upper dentures was missing and caused difficulty masticating (chewing). New recommendations were made to change from a regular-consistency solids to a chopped diet. A Registered Dietician progress note dated 9/19/2023 documented the resident had a significant undesirable weight loss possibly secondary to loss of dentures. Replacement dentures were in the works, with food texture modifications in place and tolerating well. Review of dental progress notes documented the resident was seen: - on 10/6/23 for bite registration (taking an impression of the teeth ). - on 10/30/23 for try-on and retook bite. - on 12/6/23 the denture was delivered. There were no dental progress between the date of the complaint, 6/28/23, until the resident was seen on 10/6/23. During observations on 5/7/2024 at noon, 5/9/2024 at 8:00 AM, and 5/9/2024 at 12:15 PM, Resident # 13 had their dentures in place and ate a chopped diet unassisted. During an interview on 5/9/2024 at 9:13 AM, the resident family member stated that the resident's dentures had been lost twice while at the faciity and the last time it took a long time to replace them. During an interview on 5/14/2024 at 9:00 AM, Staff #2 (Registered Nurse Unit Manager) stated they did not remember why it took so long for the resident's dentures to be made. They stated they made a consult sometime in July 2023 and notified the dental office. During an interview on 5/14/2024 at 9:22 AM, the Registered dietician stated that it took about six months for the resident to finally receive the dentures because there were several fittings, and the resident had many complaints. The resident did not lose weight because his diet was downgraded, and supplements were added. During an interview on 5/14/2024 at 9:34 AM, the Director of Nursing stated it took six months because there were many fittings. During an interview on 5/13/2024 at 1:00 PM, the dentist stated this was the second set of dentures, and sometimes they waited for one month to see if the dentures showed up. The dentist stated it usually takes 2-3 months for residents to get dentures and it should not take six months. 10 NYCRR 415.17

Based on observations and interviews during the recertification survey conducted from [DATE] to [DATE], the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, 1) opened perishable food was not covered properly; and 2) expired food was not discarded. The findings are: The facility policy and procedure titled Food Storage Policy, last revised ,d+[DATE], documented that all food will be stored in the refrigeration units either wrapped or in closed storage containers and be clearly dated and labeled. All expired food items will be discarded. The initial tour of the kitchen on [DATE] at 09:21 AM was conducted with the Dietary Supervisor. The following were observed: 1. In the freezer for meat products, there were two cardboard boxes of frozen vegetables on the shelf with inner plastic wrap that was opened and frozen vegetables were exposed to the air, the boxes were dated [DATE]. 2. In the dry storage room, there was a box of [NAME] Honey Dijon sauce with an expiration date [DATE]. During an interview on [DATE] at 10:02 AM the Dietary Supervisor stated that all boxes need to be kept closed with inner plastic wrap between uses of the product. The Dietary Supervisor also stated the box of Honey Dijon sauce had small print for the expiration date, and was overlooked. 10 NYCRR 415.14 (h)

Based on record reviews and interviews during an abbreviated survey (NY00311874), the facility did not ensure that 1 of 3 residents (Resident #1) reviewed for constipation were provided the necessary care to maintain bowel regularity. Specifically, Resident #1's bowel movements were not consistently monitored, and the necessary interventions were not implemented in accordance with the care plan and facility bowel management protocol. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Anemia, Hypertension, Chronic Kidney Disease Stage 3, Type 2 Diabetes Mellitus (DM), and Cerebral Ischemia. The resident was discharged to the hospital on 02/21/2023 and returned to the facility on [DATE]. The Facility Policy on Bowel Management created on 10/01/2017, with review date of 10/20/2022, documented to establish/maintain normal patterns of bowel function. To develop bowel management regimen based upon evaluation of resident risk, contributing factors and evidence of a tendency toward constipation. The procedure documented that at the end of each shift, the unit nurse will review all residents accountability logs and note any residents who have not had a bowel movement for nine (9) consecutive shifts. The nurse who takes the 3 days/9th shift of no bowel movement will document residents need for intervention by the next shift nurse on the 24-hour report. The resident is then to be medicated as ordered, or the attending physician is to be notified. The Hospital Discharge Documentation from 02/21/2023 to 02/24/2023 was reviewed. Resident #1 had constipation for which they got enema, manual disimpaction (unsuccessful) moved their bowel after reinforcement of bowel regimen with golytely (electrolyte used to clean out the intestines before certain bowel exam procedures such as colonoscopy or barium enema X-rays). Computed Tomography (CT) of chest, abdomen, and pelvis result documented esophageal thickening, and stool burden with dilation. One of the new medications ordered was Bisacodyl 10 mg rectal suppository every day as needed for Constipation. Review of Resident #1's Alteration in Bowel Elimination Care Plan initiated on 11/03/2022 documented a potential risk for constipation related to decreased mobility, poor oral intake, and psychotropic drug use, as evidenced by bowel incontinence and constipation. The goal documented to have a soft formed stool at least every 3 days for 90 days and have no fecal impaction for 90 days. Interventions included to monitor for bowel movement daily. The Physician Order and the Medication Administration Record (MAR) from 02/01/2023 to 02/20/2023 was reviewed. Resident #1 was administered the following medications as ordered: Increase oral hydration 400 mL QID (9 AM, 1 PM, 5 PM 9 PM) which started on 01/30/2023, the order was changed to 450 mL QID on 02/02/2023; Polyethylene Glycol 3350 17 gm/dose oral powder by oral route daily at 9 AM (Protocol: mix with 8 oz water, juice, soda, coffee, or tea) for Constipation which started on 11/25/2022; Senna 8.6 mg tablet 2 tablets by oral route once daily for Constipation which started on 11/25/2022. Review of the Resident Certified Nursing Assistant (CNA) Documentation Record from 02/01/2023 to 02/21/2023 documented Resident #1 did not have a bowel movement (BM) for all 3 shifts on 14 of 21 days (02/01/2023, 02/02/2023, 02/03/2023, 02/04/2023, 02/07/2023, 02/08/2023, 02/09/2023, 02/11/2023, 02/12/2023, 02/13/2023, 02/14/2023, 02/16/2023, 02/17/2023, 02/18/2023). Resident #1 had a BM on the following days/shift: 02/05/2023 at 10 PM 1 loose medium BM; 02/06/2023 at 12 PM 1 formed large BM; 02/06/2023 at 2 PM 1 formed large BM; 02/10/2023 at 10 AM 1 soft small BM; 02/15/2023 at 12 AM 1 loose small BM; 02/19/2023 at 2 AM 1 loose small BM; 02/19/2023 at 6 PM 1 soft medium BM. There was no documented evidence the resident received any new medication order for constipation, or physician notification, during the days/shifts that the resident did not have a bowel movement. During interviews conducted with CNA's #1, #2 and #3 on 03/06/2023, all revealed they documented in the Electronic Medical Record (EMR) the number of times a resident had a BM and included the type of BM, if it was formed, loose, or soft; and the size of the BM such as small, medium, or large. The CNAs also stated they informed the nurses when a resident did not have a BM during their work shift. During an interview conducted with the Registered Nursing (RN) Supervisor on 03/06/2023 at 11:50 AM, the RN Supervisor stated the nurses called the physician for a new order, like a fleet enema, on the 3rd day (9th shift) without a bowel movement. A follow up interview with the RN Supervisor on 03/06/2023 at 3:15 PM revealed the CNAs had no way of knowing thru the EMR if a resident did not have a BM for 3 days. The CNAs were trained to report to the nurse when a resident did not have a BM during their work shift. The RN Supervisor stated the nurses could look back in the EMR and review the residents BM's. Aside from calling the physician for new order of medication when a resident had no BM for 3 days, the nurse also would report to the RN Supervisor on duty, and the resident would be placed on the 24-hour report (shift to shift communication) until the resident had a BM. The RN Supervisor stated they reviewed the 24-hour report and Resident #1 was not on it for the month of February. During an interview conducted with the RN #2 on 03/06/2023 at 3:20 PM. RN #2 stated the CNAs were trained and very good at reporting to the nurses when a resident did not have a BM. RN #2 stated that nurses could look back and review in the EMR when a resident had no BM. RN #2 stated when a resident had no BM for 3 days, they would do the following: check the MAR to see if the resident had any PRN (as needed) medication order for constipation; if there was no order, they would check the resident's bowel sounds and call the physician for further orders. RN #2 stated the bowel assessment, physician notification and orders would be documented in the progress notes. RN #2 also stated they would report all of this to the RN Supervisor. 415.2

Based on interview and record review conducted during an abbreviated survey (NY 617), the comprehensive person-centered care plan for toilet use and transferring was not implemented for one of three residents reviewed for accidents (Resident #1). Specifically, Resident #1 had a care plan for assistance of two people for toilet use and transferring. The resident was assisted by one person and fell resulting in a fall with injury. The findings are: Resident #1 was admitted to the facility on [DATE] with a history of falls and total hip replacement. The comprehensive care plan for Activities of Daily Living; toilet use and transfer, effective 5/11/18, and Resident Nursing Instructions dated 5/11/18, revealed that Resident #1 required extensive physical assistance of two persons for toilet use and transferring. According to the Accident Report, dated 6/14/18 and signed by the RN charge nurse, on 6/14/18 at 8:25AM, the resident was being assisted by CNA #1 for toileting. The resident was turning around to sit on the toilet when she felt dizzy, started leaning to the side and fell to the bathroom floor. CNA #1was unable to reach her to get a good hold to break her fall. The nurse responded immediately and observed resident on her right side on the floor. The resident was noted with contusion to the right side of her head and pinpoint opening with minimal bleeding to the same area. The resident was transferred to the hospital and was admitted with [DIAGNOSES REDACTED]. The facility summary of investigation signed by the Director of Nursing (DON) revealed that CNA #1 who was assigned to Resident #1 stated that while she was performing ADL care, she assisted Resident #1 to the toilet without assistance of another person. The CNA Accountability Record and comprehensive care plans were reviewed and revealed that Resident #1 required the assistance of two persons. CNA #1 failed to follow the plan of care. CNA #1 was interviewed on 3/6/19 and 5/24/19 and stated that she assisted the resident with toileting and transfer without assistance on 6/14/18. She stated that the resident needed two people to assist was before but, by the time of the 6/14/18 incident, the resident was already training to walk with the walker and CNA #1 felt comfortable enough to do one on one assistance because the resident had improved a lot. 415.11(c)(1)

Based on observation, record review and interview conducted during an abbreviated survey (NY # 0), the facility did not ensure that CNAs (Certified Nurse Aides) demonstrated competency to provide safe care and respond to individual needs as identified in the assessment and care plan for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, Resident #1 was not able to stand and required the assistance of two persons to transfer with the use of a mechanical device (Hoyer lift). The Hoyer lift was not working, and the nurses' aides transferred the resident without the use of the Hoyer lift without notifying the nurse or seeking guidance for how to safely transfer the resident. The findings are: Resident #1 has [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set, a resident assessment and screening tool) dated 11/11/18 revealed that resident was severely cognitively impaired, required extensive assistance of two persons with transfer and used a wheelchair. The comprehensive care plan (CCP) on ADLs (Activities of Daily Living), specifically for transfer, was initiated on 11/17/14. The CCP had interventions to assist the resident with transfers, ensure devices are in good working order, transfer aids: Hoyer lift. According to the Accident/Incident Report Form that was signed by the Director of Nursing (DON), and the facility summary of investigation, the resident reported that on 12/29/18, on the evening shift around 6PM, she was transferred back to bed by three CNAs without use of the Hoyer lift. The resident stated she felt pain in her shoulder at the time of the transfer. The resident was assessed to have no new bruises or evidence of acute injury. The resident has a history of chronic shoulder pain due to history of severe left shoulder erosive arthritis, a history of right scapular fracture and left clavicle fracture in 2017. X-rays of both shoulders were ordered and showed osteopenia and [MEDICAL CONDITION] and no dislocations. CNA #1 was interviewed on 5/15/19 at 12:32PM. She stated that she observed CNA #2 and CNA #3 transfer Resident #1 manually without the mechanical lift from the wheelchair to bed. She further stated that after the transfer, CNA #2 and CNA #3 left the room and she left after them because she put a special quilt cover on Resident #1. CNA #2 was interviewed on 5/17/19 at 9:30AM. She stated that CNA #3 asked her to help transfer Resident #1 from the wheelchair to bed. CNA #3 told her that there was no Hoyer lift on the floor. CNA #1 came and Resident #1 knew her. She reassured Resident #1 that everything was okay. She did not remember the detail on how they transferred the resident to bed and did not remember if CNA #1 participated with the transfer. She was not aware if CNA #2 told the nurse that there was no Hoyer lift to use for her transfer. CNA #3 was interviewed on 5/17/19 at 10AM. She stated that she was assigned to Resident #1 on 12/29/18 on the 3-11 shift. Resident #1 wanted to go to bed and something was wrong with the Hoyer lift. She was told it was broken and couldn't find it. She stated she told the nurse. Somebody called CNA #1 as the resident was afraid and mad about transferring without the Hoyer lift. CNA #1 came and told Resident #1 that everything was okay. She, CNA #1 and CNA #2 transferred Resident #1 from the wheelchair to bed. LPN #1 was interviewed on 5/20/19 at 11:06PM. He stated that, on 12/29/18, he was doing rounds at 10 o'clock. When he went into Resident #1's room she complained that they did not use the Hoyer lift when the three CNAs came and put her to bed. She did not complain of pain at that time. LPN #1 asked CNA #3 why she didn't use the Hoyer lift. CNA #3 stated that the Hoyer lift was not used because it was not working. He checked the Hoyer lift and it was being charged. No CNA informed him that they were going to transfer Resident #1 to bed without the Hoyer lift. 415.26(c)(1)(iv)

Based on observation and interview conducted during the recertification survey, the facility did not ensure proper preparation, storage and service of food in accordance with professional standards for food safety. Specifically, perishable foods were not labeled and/or dated, and thermometers used to monitor food temperatures were not properly sanitized. The findings are: 1. Observations and interviews conducted during the initial tour of the kitchen on 2/11/19 at 9:40 AM revealed: The following unlabeled and/or undated foods were stored in the walk-in refrigerator: -Two (2) opened, undated, and partially used loaves of bologna. -One (1) ten-pound, unlabeled, undated, defrosted package (not solid frozen to touch) of ground turkey. -One (1) ten-pound unlabeled, undated, defrosted package (not solid frozen to touch) of ground beef. The Food Service Director (FSD) was interviewed at that time and reported the bologna should have been dated when opened and discarded within 7 days after opening. The FSD further stated the ground beef and ground turkey should have been labeled and dated when pulled from the freezer and that both items should be used within 7 days after being pulled from the freezer. An undated facility policy entitled Thawing Meat and Poultry Safely documented thawed ground meat should be cooked within 1-2 days. The policy did not provide guidance for labeling and dating frozen foods pulled for defrosting. 2. Observation and interview conducted during a follow up tour of the kitchen on 2/14/19 at 11:30 am revealed: During an observation of food temperature monitoring prior to lunch meal service, the cook was observed dipping the thermometer probe into a cup of water, wiping the probe with a disposable paper towel and placing the probe into a cooked, pureed food held for service. The cook proceeded to repeat this action to monitor the temperature of an additional cooked food item held for service. The cook was interviewed at that time and reported he usually uses an alcohol wipe to sanitize the thermometer probe. 415.14(h)

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, the trash compactor area was not maintained in sanitary condition. The finding is: An inspection of the trash compactor area was conducted on 2/14/19 at approximately 12:00 PM with the Director of Maintenance (DOM) and Food Service Director (FSD) and revealed a visually estimated two (2) yard by three (3) yard area behind the trash compactor littered with debris. This included pieces of various vegetables, paper and plastic food and beverage containers, utensils, plates, cardboard, and disposable gloves. The DOM was interviewed at that time and reported both the dietary and the maintenance departments are responsible to maintain the compactor area and further stated that maintenance checks the compactor area in the morning and in the afternoon. The DOM was asked if the compacter area had been checked this morning and he stated it had not. At that time the FSD was interviewed and asked when the debris behind the trash compactor was disposed of. The FSD stated that the debris appeared to have been disposed of the previous night as the labels on the food containers had yesterday's date on them. A facility policy and procedure for Disposal of Garbage and Refuse dated (MONTH) 24, 2010 documented: Policy: to properly maintain the garbage and refuse collection area located outside the building in a clean, sanitary and odor free condition. Procedure documented: Any spills on the floor/ground must be immediately swept and properly disposed. 415.14(h)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that one resident (Resident #72) reviewed for urinary incontinence received the necessary care and services to maintain urinary continence. Specifically, urinary incontinence was not identified and a plan of care was not developed to restore bladder continence. The finding is: Resident # 72 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) dated 1/24/19 documented the resident had moderately impaired cognitive skills for decision making; required extensive assist of two people for transfer and toilet use and was always continent of bowel and bladder. A subsequent MDS dated [DATE] documented the resident required extensive assist of two persons for transfer and toilet use and was always continent of bowel and bladder. The person-centered care plan for continence of bowel and bladder dated 1/17/19 documented the resident was continent of bladder. The goal was to maintain continence of bladder for 90 days and the interventions included encourage independence, instruct resident to call for assistance, report need to use bathroom and to provide appropriate assistance for toileting. The person-centered Activities of Daily Living (ADL)/Rehabilitation Potential care plan dated 1/17/19 documented the resident had a self-care deficit related to diagnoses/condition and weakness from hospitalization ; toilet use: extensive assist of one person. Goal: remain clean, neat, odor free and dressed appropriately each day. Interventions documented: assist with ADL as indicated; encourage participation in ADL care; monitor ADL performance. Observe for any deterioration in ability. Refer to Occupational therapy (OT) /Physical Therapy (PT) as needed. The 5-day Review note dated 1/24/19 documented extensive assist of two for transfers and toileting. The 14-day Review note dated 1/31/19 documented extensive assist of two for transfers and toileting. The medical History and Physical dated 1/17/19 documented the resident was continent of bladder. The Nursing Admission assessment dated [DATE] documented the resident was continent of bladder. The Certified Nursing Aide (CNA) documentation history for toilet use dated 1/17/19 to 1/31/19 documented toilet type as: pull-ups (1 shift) incontinence brief (19 shifts); and bedpan/incontinence brief (1 shift). The remaining shifts documented toilet type as toilet or not applicable. The initial resident interview was conducted on 2/13/19 at 9:45 AM and revealed the resident asks for the bedpan to urinate but staff leave her on it for 30-45 min and it hurts her bottom, so she asked for a diaper and she urinates in the diaper and then asks to be changed. The resident further revealed that staff toilet her for bowel movement and she is not incontinent of bowel. When asked if she would use the toilet to urinate if offered, the resident responded no because it takes staff too long to get to her and she would urinate in her diaper. The Unit Manager (UM) was interviewed on 2/15/19 at 12:35 PM and reported the resident is continent and asks to be toileted. The staff transfer her to the toilet and the resident does not like the bedpan as it is hard for her and it causes pain related to surgery. She further stated the resident wears a pull up because she did not bring her own underwear when first admitted and further stated she was told by the night shift that the resident prefers to wear a pull up. When asked if she discussed this issue with the resident, the UM responded that she discussed it with the resident and her daughter and they both told her the pull up was adequate. When asked if the resident is ever incontinent of bladder, the UM reported not that she knows of. When asked how she would know if the resident had a decline in bladder continence the UM reported the CNAs would tell her and they have not reported a change in bladder status. CNA #1 responsible for resident care on the day shift was interviewed on 2/15/19 at 1:05 PM and reported the resident uses a pull up because she does not have her own underwear, the resident is continent and will use the toilet when out of bed and in the morning if she is still in bed she sometimes is incontinent of bladder in the pull-up. The MDS coordinator -Registered Nurse (RN) was interviewed on 2/15/19 at 2:06 PM and revealed the CNA would need to report to the charge nurse if there is a change in resident continence. The RN stated she had not seen documentation or been informed that the resident had a change in bladder continence. A follow up interview with the resident was conducted on 2/15/19 in the afternoon with the UM in attendance. At that time the resident reported she wears a diaper because when she rings the call bell at night, the staff answer and tell her they will be back, then do not come back for about an hour and further stated she cannot wait that long so the urine comes down. A follow up interview with the resident was conducted with the Director of Nursing (DON) in attendance on 2/15/19 at about 3:30 PM. At that time, the resident reported that at night when she rings the call bell to go to the bathroom and staff answer, they don't come back until as much as an hour later, and by that time it is too late as she has already urinated in the diaper. The DON was interviewed on 2/19/19 at 10:10 AM and revealed that the current CNA documentation in the Electronic Medical Record (EMR) for resident bowel and bladder care does not indicate if the resident was incontinent of bladder in the incontinence brief. The DON further revealed she has spoken to the provider of the EMR program and has requested a change to the CNA bowel and bladder care documentation to identify and document episodes of incontinence. 415.12(d)(2)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that the Office of the Long Term Care Ombudsman (OLTCO) was given written notice of the transfer or discharge of residents. This was evident for 2 of 4 residents ( residents #32, #71) reviewed for hospitalization . The findings are: Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/19/19 at 10:30 am the resident experienced a change in medical status and the physician ordered that the resident be transferred to the emergency room for evaluation. In an interview with the facility social worker (SW) on 02/19/19 at 3:30pm she was asked to provide evidence that the OLTCO was informed of the transfer. This proof of notification was not provided. Resident #71 was admitted with [DIAGNOSES REDACTED]. On 2/7/19 he experienced a change in mental status and as a result was transferred to the hospital. In an interview with the SW on 02/14/19 at 12:54 pm she stated that the Director of SW or nursing notifies resident's families of hospital transfers. The SW also stated that the ombudsman was updated weekly of all discharge summaries. An interview was conducted on 02/14/19 at 12:59 pm with the facility administrator and he stated that resident's families are notified of the transfer and bed hold policy on admission. The administrator was unable to locate documentation that the ombudsman had been notified of the resident's transfers to the hospital. 415.3(h)(1)(iii)(a-c)

Based on record review and interview, conducted during an abbreviated survey (NY 2), the facility did not implement the protection component of the abuse prohibition protocol for 1 of 3 residents (Resident #1) reviewed for allegation of resident abuse. During a conduct of an investigation of an allegation of physical abuse by a Certified Nursing Aide (CNA) reported by the Director of Nursing (DON), the CNA was permitted to be assigned on same unit where Resident #1 resides and performed resident care duties to other residents, potentially promoting continuation of the physical abuse. The facility policy on Abuse Prevention dated 12/01/16 stated under the investigation component that employees of this facility who have been accused of or involved in an investigation for suspected resident abuse may be reassigned to nonresident care duties or suspended from duty pending the results of the investigation. The protection component of this policy and procedure stated that should the employee be reassigned to nonresident care duties such assignment will not be in any part of the building which the resident frequents. The findings are: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) dated 8/18/17 revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15 which suggested that resident had severely impaired cognitive skills for daily decision making; required limited assistance with walking in room and corridor, eating and personal hygiene; required extensive assistance of 1 person with bed mobility, transfer, dressing and toilet use; always continent of bowel and bladder; had trouble falling or staying asleep, or sleeping too much; was feeling tired or having little energy; was feeling bad about herself ; had trouble concentrating on things, such as reading the newspaper or watching television; and received antipsychotic medication during the last 7 days of the assessment period. According to the Abuse Hotline Intake Information dated 10/19/18, the Director of Nursing (DON) reported an allegation of resident abuse an initiated an investigation. The summary of investigation report dated 10/19/17 documented that on Friday, 10/13/17 at 11:45 AM, a CNA (#2) was observed putting a resident onto a chair in the dayroom with force and roughness. Resident was assessed and no visible injury was noted. Resident was reported to be agitated earlier during the day and was combative during care. The assigned CNA #1 asked CNA #2 to help her in changing the resident and assisted resident to the day room. Resident was resistive and refusing to sit. A receptionist witnessed CNA #2 forcibly directed and held resident down into the chair and reported her observation to a supervisor. DON concluded that CNA #1 was rough and forcibly sat and held down the resident into the chair. The receptionist was interviewed on 6/4/18 at 11:12 AM and she stated that she was in the elevator and when the elevator door opened, she witnessed CNA #2 pushed her hand down on the resident. She stated she reported this incident immediately to her supervisor (Customer Service Manager - CSM). CNA #2 was interviewed on 6/4/18 at 2:15 PM. She stated that she wasn't assigned to the resident. The resident was combative so she went to help CNA #1 to get the residents cleaned up and dressed. She then took the resident by the hand to the dining room, pulled a chair by the table and resident immediately stood up and she put her hand on the resident's shoulder and told the resident to sit down. She further stated that the facility had her work for 2 days after the incident (10/14 - Saturday and 10/16 - Monday) on the same floor where the resident resides and performed care duties. The DON was interviewed on 6/4/18 at 2:54 PM. She stated that the incident occurred on 10/13/18, Friday, late in the afternoon. It was religious holiday and only the administrator and the CEO knew how to review the tape. It was not until Monday, 10/16/18 that the video tape was reviewed and decided to suspend CNA #2. The Daily Staffing Sheet dated 10/14/17 and 10/16/17 revealed that CNA #2 worked on the Third Floor where the resident resides and took care of other residents. CNA #2's timesheets revealed that on 10/14/17 and 10/16/17, she worked on the resident unit performing care duties. The Administrator was interviewed on 6/4/18 at 3:27 PM and he stated that he was made aware of the allegation on Monday, 10/16/17. He stated that it was a religious holiday and he couldn't pick up the phone. He stated that the videotape was reviewed that Monday and felt that CNA #2 had to be removed from the schedule. He further said that he didn't know that CNA #2 was on the schedule. The CSM was interviewed on 6/4/18 at 3:35 PM and she stated that she informed the DON of the observation made by the receptionist regarding the incident. She was told by the receptionist that CNA #2 pushed Resident #1 down by her shoulders back into the chair to keep her on the chair. The CSM then informed the DON the same day of the incident. CNA #2 was interviewed further on 10/18/18 at 1:10 PM and she stated that on 10/14/17, she worked on the Third Floor. She had her regular assignment, took care of 10 or more residents on the unit; gave morning care to residents, gave showers, did ambulation, and feeding. On Monday, 10/16/17, she reported back to work on the same unit and did the same assignment. The administrator and the DON called her down around 2 PM on 10/16/18 and she was interviewed about the incident that occurred on 10/13/17. 415.4(b)(1)(ii)

Based on record review and interview, the facility failed to refer 6 of 8 sampled residents (Resident (R)1, R2, R3, R4, R7, and R8), with a new [DIAGNOSES REDACTED]. The affected residents, therefore, did not have a PASARR Level II assessment to determine the appropriate setting for each and recommendations of any specialized services and/or rehabilitative services needed following a newly documented [DIAGNOSES REDACTED]. Findings Include: The (MONTH) 2009 New York State Department of Health's Instruction Manual for SCREEN Form documented, The SCREEN currently serves two purposes. The first purpose of the SCREEN is to determine the person's potential to be appropriately cared for in a setting other than a Residential Health Care Facility (RHCF). The second purpose of the SCREEN is to assess persons being recommended for RHCF placement for possible mental illness (MI) . If the Level I Review identifies a person suspected of having serious MI . the next step is a Level II PASRR (Pre-Admission Screen Resident Review) . A Level II Referral can also be required in certain situations for those currently residing in a RHCF. This is referred to as a Resident Review (RR of PASRR). The Level II Evaluation will determine if specialized services are required and will provide a treatment recommendation. Each state is responsible for administering its own PASRR program. The New York State Department of Health (NYSDOH) oversees the PASRR process and reviews compliance with the PASRR requirements to ensure that appropriate assessments are being conducted and that necessary services are being delivered . A screen is needed . If a RHCF resident is newly diagnosed with [REDACTED]. The facility's 03/05/2008 policy addressing PASARR completion documented, If there is no significant change as defined by MDS trigger of such of mental status, the resident is not reviewed again. However, if there is a significant change of mental status in subsequent years as defined by MDS 3.0, the resident will be rescreened . All residents with mental illness or mental [MEDICAL CONDITION], regardless of whether they were first screened under the preadmission screening or annual resident review requirements, are reviewed annually. If there is no significant change as determined by MDS trigger or such, the resident is not reviewed again. On 03/01/2018 at 10:45 a.m., the Administrator stated his understanding, and the facility policy, indicated a new PASARR was required only if a significant change MDS assessment was completed. When asked why the facility policy was in conflict with the NYDOH and Federal regulatory requirements, the Administrator stated he believed the policy met the State and Federal requirements. The Administrator stated he would provide the reference he used in generating the facility's policy. On 03/01/2018 at 12:00 p.m., the Administrator provided an undated reference titled, PASRR in Plain English | PASRR Technical Assistance Center printed from the website http://www.pasrrassist.org/resources/federal-regulations/pasrr-plain-english. The reference documented, A resident review (RR) is triggered whenever an individual undergoes a significant change in status and that change has a material impact on their functioning as it relates to their (mental illness) status. The notion of 'significant change' is defined by responses to the Minimum Data Set (MDS). 1. Per the 02/28/2018 Resident Face Sheet, R7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 02/17/2016 admission Minimum Data Set MDS documented R7 had a psychiatric [DIAGNOSES REDACTED]. The 03/09/2017 quarterly MDS documented R7 had psychiatric [DIAGNOSES REDACTED]. This was the first assessment where [MEDICAL CONDITION] was indicated as an active diagnosis. The current MDS assessment, dated 12/27/2017, also indicated the psychiatric [DIAGNOSES REDACTED]. The 02/05/2016 Pre-Admission Screening and Resident Review (PASARR) level 1 screen form documented R7 had dementia, and there was no evidence or indicator R7 had a serious mental illness. On 02/27/2018 at 12:05 PM, the MDS Licensed Practical Nurse (MDS2) stated she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. An updated PASARR, reflecting the [DIAGNOSES REDACTED]. On 02/28/2018 at 10:30 AM, the Director of Social Work (DSW) stated she was responsible for ensuring PASARR screens were completed for every resident. She stated she was not aware that a new PASARR Level 1 Screen needed to be completed upon a newly diagnosed major mental illness; however, she was educated reading this need by the NS this morning. The DSW stated she was not aware R7 had been coded with a [DIAGNOSES REDACTED]. 2. Per the 02/28/2018 Resident Face Sheet, R8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/01/2017 5-day MDS documented R8 had a psychiatric [DIAGNOSES REDACTED]. The 11/11/2017 admission MDS documented R8 had psychiatric [DIAGNOSES REDACTED]. This was the first assessment where [MEDICAL CONDITION] was indicated as an active diagnosis. The current MDS, dated [DATE], also indicated the psychiatric [DIAGNOSES REDACTED]. The 10/25/2017 Pre-Admission Screening and Resident Review (PASARR) level 1 screen form documented R8 had dementia, and there was no evidence or indicator R8 had a serious mental illness. On 02/27/2018 at 12:05 PM, MDS2 stated she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. An updated PASARR, reflecting the [DIAGNOSES REDACTED]. that there was no updated PASARR completed for R8. On 02/28/2018 at 10:30 AM, the DSW stated she was not aware R8 had been coded with a [DIAGNOSES REDACTED]. 3. R1's Face Sheet dated 02/28/2018 included [DIAGNOSES REDACTED]. The face sheet reflected that R1 was admitted to the facility on [DATE]. The current quarterly MDS (a federal mandated assessment tool completed by the facility for care planning purposes) dated 11/22/2017, Section I regarding active diagnoses, reflected a psychiatric [DIAGNOSES REDACTED]. Review of a quarterly MDS Section I for Active [DIAGNOSES REDACTED]. On 02/27/2018 at 12:00 PM, the MDS coordinator (MDS1) stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A PASARR provided by the facility dated 06/02/2016 reflected that R1 had dementia and qualified for convalescent care. The PASARR reflected that R1 was not a danger to herself or others and there was no recommendation to complete a level II evaluation. There was no other PASARR provided by the facility. On 02/28/2018 at 10:35 AM, an interview with the DSW revealed that she had not completed a new PASARR for R1. The DSW was not aware of a new [DIAGNOSES REDACTED]. The DSW stated that she completed Section E of the MDS regarding behavior but she had not reviewed Section I of the MDS regarding active diagnoses. 4. R2's Face Sheet dated 02/28/2018 reflected the following diagnoses, Unspecified dementia without behavioral disturbance, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or know physiological condition, and major [MEDICAL CONDITION]. According to the face sheet, R2 was admitted to the facility on [DATE]. A current quarterly MDS dated [DATE] section I, regarding Active [DIAGNOSES REDACTED]. An annual MDS dated [DATE] section I, regarding Psychiatric and mood disorder, reflected a [DIAGNOSES REDACTED]. On 02/27/2018 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A PASARR evaluation provided by the facility dated 07/16/2017, reflected that R2 had dementia and did not have a serious mental condition. The PASARR did not have a recommendation for a level II evaluation. There was no other PASARR provided by the facility. On 02/28/2018 at 10:35 AM, an interview with the DSW revealed that she had not completed a new PASARR for R2. The DSW was not aware of a new [DIAGNOSES REDACTED]. The DSW stated that she completed Section E of the MDS regarding behavior but she had not reviewed Section I of the MDS regarding active diagnoses. 5. R3's Face Sheet dated 02/28/2018 included the following diagnoses, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, and unspecified dementia. R3 was admitted to the facility on [DATE]. A current 14-day MDS dated [DATE], under section I for Active diagnoses, reflected [MEDICAL CONDITION]. A quarterly MDS dated [DATE] section I reflected [MEDICAL CONDITION]. Section E of the MDS regarding behavior reflected that R3 had no indicators of [MEDICAL CONDITION] such as hallucinations or delusions. Section E reflected that R3 had no behaviors directed toward others. On 2/27/18 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A PASARR evaluation dated 03/31/2016 provided by the facility, reflected that R3 had dementia and did not have a serious mental illness. The PASARR reflected that R3 was not a danger to herself or others and a level II PASARR was not recommended. There was no other PASARR provided by the facility for review. On 02/28/2018 at 10:35 AM, an interview with the DSW revealed that she had not completed a new PASARR for R3. The DSW was not aware of a new [DIAGNOSES REDACTED]. The DSW stated that she completed Section E of the MDS regarding behavior but she had not reviewed Section I of the MDS regarding active diagnoses. 6. R4's Face Sheet dated 02/28/2018 reflected the following diagnoses, Unspecified mood disorder, major [MEDICAL CONDITIONS], and unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. R4 was admitted to the facility on [DATE]. A current quarterly MDS dated [DATE], under section I regarding Active diagnosis, reflected [MEDICAL CONDITION]. A quarterly MDS dated [DATE], under section I, reflected [MEDICAL CONDITION] had been added to the active [DIAGNOSES REDACTED]. On 02/27/2018 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. A PASARR evaluation dated 01/31/2014 provided by the facility, reflected that R4 had dementia and did not have a serious mental illness. The PASARR reflected that R4 was not a danger to herself or others and a level II PASARR was not recommended. There was no other PASARR provided by the facility for review. On 02/28/2018 at 10:35 AM, an interview with the DSW revealed that she had not completed a new PASARR for R4. The DSW was not aware of a new [DIAGNOSES REDACTED]. The DSW stated that she completed Section E of the MDS regarding behavior but she had not reviewed Section I of the MDS regarding active diagnoses.

Based on interview and record review, the facility failed to complete Section I of the Minimum Data Set (MDS) accurately for six of eight sampled residents (Resident (R)1, R2, R3, R4, R7, and R8). Specifically, the facility added the [DIAGNOSES REDACTED]. Findings Include: According to DSM-V, The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), [MEDICAL CONDITION] has characteristic symptoms of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, a reduction in speech, and a lack of motivation or interest. According to the DSM-V, this severe mental disorder is typically developed between the ages of 16 and 30 and it would be rare to have an individual over the age of 75 develop [MEDICAL CONDITION]. According to the DSM-V, the individual needs to have at least two characteristic symptoms of [MEDICAL CONDITION] for more than six months with no substance abuse, pharmacological, or clinical [DIAGNOSES REDACTED]. Review of the ICD-10 (International Classification of Diseases-Medical [DIAGNOSES REDACTED]. ICD-10 coding reference: F-20 - F-29 [MEDICAL CONDITION], schizotypal, delusional, and other non-mood [MEDICAL CONDITION] F20 [MEDICAL CONDITION] F21 Schizotypal disorder F22 Delusional disorders F23 Brief [MEDICAL CONDITION] F24 Shared [MEDICAL CONDITION] F25 [MEDICAL CONDITION] disorder F28 Other [MEDICAL CONDITION] not due to a substance or known physiological condition F29 Unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. The facility was unable to provide a policy and/or procedure for the completion of the MDS Section I specifically related to [MEDICAL CONDITION]. 1. R1's Face Sheet dated 02/28/2018 included [DIAGNOSES REDACTED]. The face sheet reflected that R1 had resided at the facility since (MONTH) of (YEAR). Review of the 11/22/2017 quarterly MDS (a Federally mandated assessment tool completed by the facility for care planning purposes), under Section I regarding active diagnoses, reflected a psychiatric [DIAGNOSES REDACTED]. Review of the 06/8/2017 quarterly MDS, under Section I for Active Diagnoses, revealed the [DIAGNOSES REDACTED]. Section E of the MDS regarding Behavior reflected that R1 had no indicators of [MEDICAL CONDITION] such as hallucinations or delusions. According to Section E of the MDS, there were no verbal or physical behaviors directed toward others, no Rejection of care, no behavioral symptoms of hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at others, disrobing in public, screaming, disruptive sounds, or wandering. The previous quarterly MDS dated [DATE], under Section I, did not list [MEDICAL CONDITION] as an active diagnosis. On 02/27/2018 at 12:00 PM, the MDS coordinator (MDS1) stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS1 stated, I review hospital admission records, progress notes and what the psychiatrist writes. MDS1 reviewed the Psychiatry Consultation Request form dated 05/15/2017 and stated, The psychiatrist wrote the [DIAGNOSES REDACTED]. I was told by our corporate MDS case manager to add the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. We use the ICD-10 coding system. MDS1 confirmed that she had not seen the [DIAGNOSES REDACTED]. MDS1 stated that she had not verified the [DIAGNOSES REDACTED]. On 02/28/2018 at 3:45 PM, the Psychiatrist for R1 stated, I did not diagnose this resident with [MEDICAL CONDITION]. This code of F-29 is not [MEDICAL CONDITION]. When I started consulting to this facility about a year and a half ago, the coding was an issue that was verbalized from staff. I spoke to the Acting Director of Nursing at that time and educated the staff. I explained the [DIAGNOSES REDACTED]. This patient has [MEDICAL CONDITION] disorder and dementia and she is stable. On 03/1/2018 at 12:00 PM, an interview with the Director of Case Management for the MDS process (DCM) revealed that she had directed the MDS nurses to use the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The DCM stated that she had not communicated with the psychiatrist before directing the MDS nurses to add the diagnosis. 2. R2's 02/28/2018 Face Sheet reflected the following diagnoses, Unspecified dementia without behavioral disturbance, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, and major [MEDICAL CONDITION]. According to the face sheet, R2 had resided at the facility since (MONTH) of (YEAR). The 12/31/2017 quarterly MDS, under section I regarding Active Diagnosis, reflected a psychiatric [DIAGNOSES REDACTED]. The 07/30/2017 annual MDS, under section I regarding Psychiatric and mood disorder, reflected a [DIAGNOSES REDACTED]. R2 had no physical behaviors directed toward others. The behaviors identified had no impact on R2 for significant risk for physical illness or injury, and did not put others at significant risk for physical injury. The previous quarterly MDS dated [DATE], under Section I, did not list [MEDICAL CONDITION] as an active diagnosis. On 02/27/2018 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS1 stated, I review hospital admission records, progress notes and what the psychiatrist writes. MDS1 reviewed the Psychiatry Consultation Request form dated 07/29/2017 and stated, The psychiatrist wrote the [DIAGNOSES REDACTED]. I was told by our corporate MDS case manager to add the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. We use the ICD-10 coding system. MDS1 confirmed that she had not seen the [DIAGNOSES REDACTED]. MDS1 stated that she had not verified the [DIAGNOSES REDACTED]. On 02/28/2018 at 3:48 PM, the Psychiatrist for R2 stated, I did not diagnose this resident with [MEDICAL CONDITION]. This code of F-29 is not [MEDICAL CONDITION]. He has been in and out of the hospital. I recommended a reduction of his [MEDICATION NAME] because he had not shown any signs of [MEDICAL CONDITION] earlier. This consult report (referring to the report dated 07/29/2017) was to evaluate his medications. He had no hallucinations or delusions, that's indicated on the report. He is stable on his current medication. I wrote F-29 on my report, this is unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. 3. R3's 02/28/2018 Face Sheet included the following diagnoses, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, and unspecified dementia. R3 was admitted to the facility on [DATE]. The 02/01/2018 14-day MDS, under section I for Active diagnoses, reflected [MEDICAL CONDITION]. The 3/20/2017 quarterly MDS, under section I reflected the [DIAGNOSES REDACTED]. Section I of the previous MDS dated [DATE] did not list [MEDICAL CONDITION] as an active diagnosis. On 02/27/2018 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS1 stated that she had not verified the [DIAGNOSES REDACTED]. On 02/28/2018 at 3:48 PM, the Psychiatrist for R3 stated, I did not diagnose this resident with [MEDICAL CONDITION]. This code of F-29 is not [MEDICAL CONDITION]. She is on [MEDICATION NAME] because she mumbles and she is pre-occupied. 4. R4's 02/28/2018 Face Sheet reflected the following diagnoses, Unspecified mood disorder, major [MEDICAL CONDITIONS], and unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. R4 was admitted to the facility on [DATE]. The 12/08/2017 quarterly MDS, under section I regarding Active diagnosis. reflected [MEDICAL CONDITION]. The 12/18/2017 quarterly MDS, under section I reflected [MEDICAL CONDITION] had been added to the active [DIAGNOSES REDACTED]. On 02/27/2018 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS1 stated that she had not verified the [DIAGNOSES REDACTED]. On 2/28/2018 at 3:48 PM, the Psychiatrist for R4 stated, I did not diagnose this resident with [MEDICAL CONDITION]. This code of F-29 is not [MEDICAL CONDITION]. She is delusional and talks to herself. She has [MEDICAL CONDITION] and a history of depression. 5. Per the 02/28/2018 Resident Face Sheet, R7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 02/17/2016 admission MDS assessment documented R7 had a psychiatric [DIAGNOSES REDACTED]. The 03/09/2017 quarterly MDS assessment documented R7 had psychiatric [DIAGNOSES REDACTED]. This was the first assessment where [MEDICAL CONDITION] was indicated as an active diagnosis. The current MDS assessment, dated 12/27/2017, also indicated the psychiatric [DIAGNOSES REDACTED]. Review of R7's complete medical record revealed no documentation by a physician, psychiatrist, or any other entity of a [DIAGNOSES REDACTED]. On 02/27/2018 at 12:05 PM, the MDS Licensed Practical Nurse (MDS2) stated she was responsible for coding of [DIAGNOSES REDACTED]. She stated she would glean the information regarding active [DIAGNOSES REDACTED]. MDS2 stated she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS2 confirmed that she had not seen the [DIAGNOSES REDACTED]. On 02/27/2018 at 1:52 PM, when informed R7 was coded on the MDS assessment as having a [DIAGNOSES REDACTED]. He added, I wouldn't code a [DIAGNOSES REDACTED]. It's not the same as [MEDICAL CONDITION]. On 02/28/2018 at 3:26 PM, the psychiatrist stated R7 did not have a [DIAGNOSES REDACTED]. '[MEDICAL CONDITION] spectrum disorder.' The psychiatrist stated she had never intended for R7 to be given a [DIAGNOSES REDACTED]. 6. Per the 02/28/2018 Resident Face Sheet, R8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/1/2017 5-day MDS assessment documented R8 had a psychiatric [DIAGNOSES REDACTED]. The 11/11/2017 admission MDS documented R8 had psychiatric [DIAGNOSES REDACTED]. This was the first assessment where [MEDICAL CONDITION] was indicated as an active diagnosis. The current MDS assessment, dated 02/07/2018, also indicated the psychiatric [DIAGNOSES REDACTED]. Review of R8's complete medical record revealed no documentation by a physician, psychiatrist, or any other entity of a [DIAGNOSES REDACTED]. On 02/27/2018 at 12:05 PM, MDS2 stated she was responsible for coding of [DIAGNOSES REDACTED]. She stated she would glean the information regarding active [DIAGNOSES REDACTED]. MDS2 stated she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS2 confirmed that she had not seen the [DIAGNOSES REDACTED]. MDS2 stated that she had not verified the [DIAGNOSES REDACTED]. On 02/27/2018 at 1:52 PM, when informed R8 was coded on the MDS assessment as having a [DIAGNOSES REDACTED]. He added, I wouldn't code a [DIAGNOSES REDACTED]. It's not the same as [MEDICAL CONDITION]. On 02/28/2018 at 3:26 PM, the psychiatrist stated R8 did not have a [DIAGNOSES REDACTED]. '[MEDICAL CONDITION] spectrum disorder.' The psychiatrist stated she had never intended for R8 to be given a [DIAGNOSES REDACTED]. 7. Follow-Up Interviews On 02/27/2018 at 3:54 PM, the Director of Case Management (DCM) and Administrator were interviewed concurrently. The DCM stated she would code the [DIAGNOSES REDACTED]. She stated a [DIAGNOSES REDACTED]. The Administrator stated because the word [MEDICAL CONDITION] was in the [DIAGNOSES REDACTED]. The DCM then changed her response, and stated she would code a [DIAGNOSES REDACTED]. On 02/28/2018 at 9:45 AM, MDS2 stated she was told by the DCM that a [DIAGNOSES REDACTED]. She stated, We just started doing the codes this way about a year ago when the new psychiatrist started writing the (ICD-10-CM) code F-29 (unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition) in her notes because we didn't understand what those codes were. Prior to using the codes, the [DIAGNOSES REDACTED]. only code [MEDICAL CONDITION] and not [MEDICAL CONDITION] (on the MDS assessment). On 02/28/2018 at 3:26 PM, the psychiatrist stated the diagnostic coding had been recently changed for a [DIAGNOSES REDACTED]. She stated the [DIAGNOSES REDACTED]. The psychiatrist stated this change in wording caused confusion among the staff. She stated a [DIAGNOSES REDACTED]. The psychiatrist explained that she conducted education with the staff regarding the differentiation between a [DIAGNOSES REDACTED]. '[MEDICAL CONDITION] spectrum disorder.' The psychiatrist stated she had never intended for residents diagnosed with [REDACTED]. On 02/28/2018 at 4:28 PM, the Administrator stated, Certainly we're aware a [DIAGNOSES REDACTED]. But there are two components: one is the actual [DIAGNOSES REDACTED]. Clearly the language in the (ICD-10-CM) code says '[MEDICAL CONDITION] spectrum.' That's why we are operating that way (coding as [MEDICAL CONDITION] on the MDS). The Administrator added he was not aware of any education provided to the staff by the psychiatrist clarifying the [DIAGNOSES REDACTED]. On 03/01/2018 at 11:53 AM, the DCM stated she followed instructions in the Resident Assessment Instrument (RAI) Manual when coding the [DIAGNOSES REDACTED]. She stated the [DIAGNOSES REDACTED]. the definition, so she was required to code that as a [DIAGNOSES REDACTED]. The DCM stated she was confused by the psychiatrist's documentation of the [DIAGNOSES REDACTED]. Some sort of incentive or something like that. I did not understand. The DCM stated the facility did not have a specific policy addressing coding on the MDS assessment; the facility followed the Resident Assessment Instrument (RAI) Manual. According to the (MONTH) (YEAR) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.15, Section I: Active Diagnoses, Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. In Section I, the [DIAGNOSES REDACTED].g., [MEDICAL CONDITION] and schizophreniform disorders), and [MEDICAL CONDITION].

Based on record review and interview, the facility failed to revise the comprehensive care plan for four of eight sampled residents (Resident (R)2, R3, R7, and R8), when the [DIAGNOSES REDACTED]. Findings Include: The facility's undated policy titled, Care Planning: Interdisciplinary indicated, Problems will be identified from the MDS 3.0 triggers, as well as from resident assessment, interview, and direct observation . Problems, goals, and approaches will be entered on admission, readmission, or whenever a new problem is identified or changed. 1. R2's Face Sheet dated 02/28/2018 reflected the following diagnoses, Unspecified dementia without behavioral disturbance, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, and major [MEDICAL CONDITION]. A current quarterly MDS dated [DATE], under section I regarding Active Diagnosis, reflected a psychiatric [DIAGNOSES REDACTED]. An annual MDS dated [DATE] section I, regarding Psychiatric and mood disorder, reflected the [DIAGNOSES REDACTED]. The quarterly MDS prior to that, dated 04/30/2017, did not list the [DIAGNOSES REDACTED]. On 02/27/2018 at 12:10 PM, MDS1 (the MDS Coordinator) stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS1 stated the social worker was responsible for completing the care plans related to behavior and psychosocial issues. MDS1 stated that she had not informed the social worker of the new [DIAGNOSES REDACTED]. On 02/28/2018 at 10:35 AM, an interview with the Director of Social Work (DSW) revealed that she was not aware of a new [DIAGNOSES REDACTED]. The DSW stated that she completed Section E of the MDS regarding behavior, but she had not reviewed Section I of the MDS regarding active diagnoses. The DSW stated that she was responsible for completion of the care plans when it was related to behaviors and psychosocial well-being. The DSW stated she could not recall any new behavioral symptoms for R2 and stated that she had not revised the care plan related to the new [DIAGNOSES REDACTED]. On 02/28/2018 at 2:00 PM, the DSW provided copies of the comprehensive care plan for R2. The care plan was dated Effective 7/20/16. The focus of the care plan was Behavioral Symptoms. The care plan form was electronically developed and a check list was included. The print date on the care plan was 2/27/18 at 4:56 PM. The care plan reflected, Resident has hallucinations as evidenced by: (underlined blank space). This area of the form was left blank and not checked. Resident has delusions as evidence by: (underlined blank space). This area of the form was left blank and was not checked. The care plan did not address the [DIAGNOSES REDACTED]. 2. R3's Face Sheet dated 02/28/2018 included the following diagnoses, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, and unspecified dementia. R3 was admitted to the facility on [DATE]. A current 14-day MDS dated [DATE], under section I for Active diagnoses, reflected [MEDICAL CONDITION]. A quarterly MDS dated [DATE] section I reflected [MEDICAL CONDITION]. Section I of the prior quarterly MDS dated [DATE] did not list the [DIAGNOSES REDACTED]. On 02/27/2018 at 12:10 PM, MDS1 stated that she added the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. MDS1 stated that she had not notified the social worker about the new diagnosis. MDS1 stated that the care plans for behavior and mental health [DIAGNOSES REDACTED]. On 02/28/2018 at 10:35 AM, an interview with the Director of Social Work (DSW) revealed that she was not aware of a new [DIAGNOSES REDACTED]. The DSW stated that she completed Section E of the MDS regarding behavior but she had not reviewed Section I of the MDS regarding active diagnoses. The DSW stated that she was responsible for completion of the care plans when it was related to behaviors and psychosocial well-being. The DSW stated she could not recall any new behavioral symptoms for R3. On 02/28/2018 at 2:00 PM, the DSW provided copies of the comprehensive care plan for R3. The care plan was dated Effective 8/12/16. The focus of the care plan was Behavioral Symptoms. The care plan form was electronically developed and a check list was included. The print date on the care plan was 2/27/18 at 5:17 p.m. The care plan reflected, Resident has hallucinations as evidenced by: (underlined blank space). This area of the form was left blank and not checked. Resident has delusions as evidence by: (underlined blank space). This area of the form was left blank and was not checked. The comprehensive care plan was not revised to address the new [DIAGNOSES REDACTED]. 3. Per the 02/28/2018 Resident Face Sheet, R7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 02/17/2016 admission MDS assessment documented R7 had a psychiatric [DIAGNOSES REDACTED]. The 03/09/2017 quarterly MDS assessment documented R7 had psychiatric [DIAGNOSES REDACTED]. This was the first assessment where [MEDICAL CONDITION] was indicated as an active diagnosis. The current MDS assessment, dated 12/27/2017, also indicated the psychiatric [DIAGNOSES REDACTED]. R7's (MONTH) (YEAR) physician's orders [REDACTED]. The 01/20/2018 to 02/22/2018 Resident CNA (Certified Nurse Aide) Documentation History Detail report indicated [REDACTED]. She also wandered on 16 of the 34 days included in the report. R7's comprehensive Care Plan included individual plans addressing [MEDICAL CONDITION] drug use, implemented on 02/12/2016; mood, implemented 02/13/2017; and psychosocial well-being, implemented 02/11/2016. There was no plan to address behavioral symptoms. The [MEDICAL CONDITION] drug use, mood, and psychosocial well-being plans did not document any targeted behavioral symptoms. R7's care plan was not updated to reflect the newly assigned [DIAGNOSES REDACTED]. R7's comprehensive Care Plan included individual plans addressing [MEDICAL CONDITION] drug use, implemented on 02/12/2016; mood, implemented 02/13/2017; and psychosocial well-being, implemented 02/11/2016. There was no plan to address behavioral symptoms. The [MEDICAL CONDITION] drug use, mood, and psychosocial well-being plans did not document any targeted behavioral symptoms, were left incomplete, and were not individualized to R7's needs. The individual plan addressing psychosocial well-being documented R7's preferred name and an issue with confusion and behaviors of a family member. The documented goal was, Resident will exhibit a sense of well-being as evidenced by: (underlined blank space) x (times) 90 days. The intervention was, Assist resident in identification of support systems/strengths and determine level of involvement. The goal was not completed and the care plan intervention was not individualized for R7's specific needs. The individual plan addressing mood issues was in checklist form, and the items, Resident has mood issues based on: Resident Interview and Feeling or appearing down, depressed, or hopeless were checked. The documented goal was Resident will show an improvement in mood AEB (as evidenced by) (underlined blank space) x 90 days. The intervention was, Assess and monitor to determine onset of mood problem: (environmental, health status, relationship change, people, noise levels, situations). The goal was not completed and the care plan intervention was not individualized for R7's specific needs. The individual plan addressing [MEDICAL CONDITION] drug use documented R7 used an antipsychotic for a [DIAGNOSES REDACTED]. The care planned goal was to be free of side effects from [MEDICAL CONDITION] medication for 90 days. The interventions included: administer medications as ordered, observe for side effects of medications, provide psychiatric and psychological services as needed, monitor frequency of bowel movements, monitor for changes in status, approach the resident in calm manner, monitor for weight change, and educate the resident and/or family on risks and benefits of treatment. There was no documentation of the symptoms the [MEDICATION NAME] was used to treat, the specific risks of the medication, its benefits to R7, or person-centered non-pharmacological approaches. On 02/28/2018 at 10:30 AM, the Director of Social Work (DSW) stated R7 had some confusion due to dementia, but did not exhibit any behavioral symptoms of mental illness. She stated she did not know R7 was coded on the MDS assessment as having a [DIAGNOSES REDACTED]. She stated the team had not discussed behaviors for R7 that she could recall. The DSW stated the team reviewed the progress notes and CNA accountability record (see Resident CNA Documentation History Detail, above) to determine which behaviors should be reflected in the care plan. The DSW stated whenever a new [DIAGNOSES REDACTED]. The team should also discuss possible non-pharmacological approaches to address the symptoms and add to the care plan. 4. Per the 02/28/2018 Resident Face Sheet, R8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/1/2017 5-day MDS assessment documented R8 had a psychiatric [DIAGNOSES REDACTED]. The 11/11/2017 admission MDS assessment documented R8 had psychiatric [DIAGNOSES REDACTED]. This was the first assessment where [MEDICAL CONDITION] was indicated as an active diagnosis. The current MDS assessment, dated 02/07/2018, also indicated the psychiatric [DIAGNOSES REDACTED]. The 01/20/2018 to 02/22/2018 Resident CNA Documentation History Detail report indicated [REDACTED]. She also exhibited tearfulness on 12 of the 34 days included in the report. The report did not indicate R8 exhibited behavioral symptoms of a mental illness which put R8 or other residents in danger or severely impacted their quality of life. R8's comprehensive Care Plan included individual plans addressing [MEDICAL CONDITION] drug use, implemented on 11/29/2017; mood, implemented 02/05/2018; psychosocial well-being, implemented 11/06/2017; and behaviors, implemented 11/06/2017. The [MEDICAL CONDITION] drug use, mood, and psychosocial well-being plans did not document any targeted behavioral symptoms used in determining the effectiveness of the antipsychotic medication. The individual plan focused on Behaviors was electronically developed and included a generic checklist. The print date on the care plan was 2/27/18 at 5:37 p.m. The care plan reflected, Resident has hallucinations as evidenced by: (underlined blank space). This area of the form was left blank and not checked. Resident has delusions as evidence by: (underlined blank space). This area of the form was left blank and was not checked. Multiple possible behavioral symptoms, under the headings physical behaviors directed toward others, physical behaviors not directed toward others, and verbal behaviors directed toward others, were listed on the form but none were check-marked. The care plan goal reflected, Resident will have improved behavior as evidenced by a decrease in: non-compliance in requires assistance for care/ambulation as evidenced by observation and documentation in the medical chart X (Times) 90 days. The area to document R8's actual behavioral symptoms was left blank. On 02/28/2018 at 10:30 AM, the DSW stated R8 had some confusion due to dementia, but did not exhibit any behavioral symptoms of mental illness. She stated she did not know R8 was coded on the MDS assessment as having a [DIAGNOSES REDACTED]. She stated the team had not discussed behaviors for R8 that she could recall. The DSW stated the team reviewed the progress notes and CNA accountability record (see Resident CNA Documentation History Detail, above) to determine which behaviors should be reflected in the care plan. The DSW stated whenever a new [DIAGNOSES REDACTED]. The team should also discuss possible non-pharmacological approaches to address the symptoms and add to the care plan.