Every finding on record at St Catherine Laboure Health Care Center

Based on observation, interview, and record review conducted during a Standard survey completed on 10/1/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #41) of one resident's reviewed. Specifically, Resident #41 was not provided with a right hand and right elbow splint as planned by Occupational Therapy. Additionally, staff lacked knowledge regarding the correct application of the right elbow splint. The finding is: The policy and procedure titled Community Based Care: Contractures with effective date 4/2/24 documented that a plan of care would be developed regarding contracture management. Approaches to prevent or treat contractures may include positioning, range of motion, ambulation, application of a splint/brace, and /or therapy treatment programs. The policy and procedure titled Community Based Care: Minimum Data Set, Comprehensive Care Planning, and Kardex Utilization with effective date 11/30/21 documented that prior to providing hands on care, staff will review the content of the Kardex and will then provide care in accordance with Kardex guidelines/instructions. Resident #41 had diagnoses of cerebral infarction with right sided hemiplegia (stroke with paralysis on one side of body), contracture to right elbow (loss of joint mobility), and aphasia (absence or difficulty with speech). The Minimum Data Set (MDS - an assessment tool) dated 9/6/24 documented Resident #41 had severe cognitive impairment, was rarely understood, and rarely understands, dependent on staff for all activities of daily living, and had no refusals care. The comprehensive care plan revised on 10/18/23 documented that Resident #41 had ADL self-care performance deficit related to weakness. Interventions included a right resting hand splint and right elbow extension splint to be donned (put on) by the certified nursing assistant after morning care, and doffed (to take off) before evening care. Review of the Visual/Bedside Kardex Report (a guide used by staff to provide care) dated 9/27/24 documented under dressing/splint care Resident #41 was to have right resting hand splint and right elbow extension splint to be donned by the certified nursing assistant after morning care, doffed before evening care. Review of the occupational therapy note dated 6/13/22 documented that occupational therapy educated certified nursing assistants on proper donning technique for Resident #41's right elbow and resting hand splint. The Occupational Therapist updated Resident #41's care plan to include: right resting hand splint and right elbow extension splint to be donned by Certified Nurse Assistant after morning care, doffed before evening care. Review of the nursing progress notes dated 9/1/24 - 9/30/24 revealed there was no documented evidence that Resident #41 had refused application of the right hand and right elbow splints. During an observation on 9/25/24 at 9:57 AM, Resident #41 was lying in bed, there were no splints visualized to their right hand and right elbow. Resident #41's right thumb was touching their right index finger, and their pinky finger was bent towards the palm of the hand. During an observation on 9/25/24 at 2:53 PM, Resident #41 was observed lying in bed without their right resting hand splint or right elbow extension splint in place. Resident #41's right arm was resting to their side in a bent position. During an observation of morning care on 9/27/24 at 9:26 AM, Certified Nursing Assistant #1 provided morning care to Resident #41. Certified Nursing Assistant #1 completed care, gathered soiled items, and exited the room without applying Resident #41 splints to their right hand and elbow. During an observation and interview on 9/27/24 at 9:45 AM, Certified Nursing Assistant #1 stated Resident #41 does not get out of bed, morning care had been completed, and the resident did not need anything additional for care to be completed. Certified Nursing Assistant #1 re-entered Resident #41's room to review the closet care plan (Kardex - guide used by staff to provide care) and stated Resident #41 was to have splints on their right hand and elbow. Certified Nursing Assistant #1 was unable to locate the right-hand splint. Certified Nursing Assistant #1 attempted to apply the right elbow splint, and stated they were unsure how to properly apply the splint and would have to get the nurse. During an observation and interview on 9/27/24 at 9:50 AM, Licensed Practical Nurse #2 entered Resident #41's room and brought in a right-hand splint. Licensed Practical Nurse #2 assisted Certified Nursing Assistant #1 with Resident #41's right elbow extension splint. Licensed Practical Nurse #2 stated they believed the elbow splint was applied correctly. Licensed Practical Nurse #2 then applied the resident's right hand splint. They stated they had not received any education on splint application. Licensed Practical Nurse #2 stated the Certified Nursing Assistant providing care to Resident #41 would be responsible for applying splints. Licensed Practical Nurse #2 stated if certified nursing assistants needed help, they would notify them, and they would assist. During an observation and interview on 9/27/24 at 10:03 AM, the Director of Rehabilitation stated Resident #41's right elbow splint had been incorrectly applied and was backwards. The Director of Rehabilitation took the elbow splint off and reapplied the splint without any difficulty. They stated Resident #41 would not get the full benefit of the splint without it being applied correctly. The Director of Rehabilitation stated Resident #41 utilized the right hand and elbow splints due to a spastic arm (stiff or rigid muscles) and the resident was at risk for further decline due to the lack of mobility. They stated the splints were utilized to reduce the risk of decline. The Director of Rehabilitation stated the nurses and certified nursing assistants were trained by therapy staff when a resident was issued a new splint/device and that annual mandatory in-services were completed. They stated the certified nursing assistants would be responsible for splint application. During an interview on 9/27/24 at 2:52 PM, Licensed Practical Nurse Manager #1 stated that Resident #41 was dependent on staff for all care needs and was unable to their make needs known. They stated the resident has had both splits for approximately two years, and they would expect that staff knew how to apply the devices correctly. Licensed Practical Nurse Manager #1 stated it was the certified nursing assistant and restorative nursing aides' responsibility to apply splints. The nurses were responsible to ensure sure the splints were on, and the care plan was followed. They stated there were no physician orders for splint application, splints were listed on the care plan, and they expected staff would follow the care plan. During an interview on 9/30/24 at 12:24 PM, the Director of Nursing stated the certified nursing assistants and licensed practical nurses were responsible for putting on splints and that the restorative nursing aides could assist if working on the floor. They stated all splints were listed on the closet care plan/Kardex, and they would expect staff to review their closet care plan before providing care. The Director of Nursing stated if certified nursing assistants were unsure how to apply splints they should ask the nurse for assistance. They stated that both the nurses and certified nursing assistants received training on splint application when a new splint was ordered and would expect staff to contact therapy for additional training if needed. They stated they would have expected staff to follow the care plan and apply devices/splints per plan of care. During an interview on 9/30/24 at 2:50 PM, Certified Nursing Assistant #2 stated splints would be listed on the resident's care plan and they would review the plan prior to providing care. They stated they had not received education on applying splints. During an interview on 9/30/24 at 3:24 PM, Certified Nursing Assistant #3 stated the restorative nursing aides applied Resident #41's splints and the nurse would remove them in the evening. Certified Nursing Assistant #3 stated they would notify the nurse or therapy if a resident did not have their splints on and was unsure how to apply them. They stated they have not received any training on splint application. During an interview on 9/30/24 at 3:46 PM, Licensed Practical Nurse #4 stated the nurse team leaders and supervisors were responsible to ensure certified nursing assistants were following the care plan and applying splints. They stated that the nurses and therapy department should make sure splints were applied correctly. Licensed Practical Nurse #4 stated they would contact therapy or their supervisor if they were unsure how to apply a splint/device. During an interview on 10/1/24 at 9:01 AM, the Administrator stated that they would expect staff to visualize and read the care plan before providing care. They stated they would expect staff to review all details of the care plan to provide safe care, they would expect staff to follow the care plan and report any discrepancies. 10 NYCRR 415.12 (e)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain personal hygiene for one (Resident #14) of four residents reviewed for ADLs. Specifically, the lack of timely toileting/changing of an incontinent resident. The finding is: The facility policy and procedure (P&P) titled ADL Care effective 7/19/22 documented the purpose was to ensure a resident who is unable to care out ADL's receives the necessary services to maintain good nutrition, grooming, and personal hygiene. ADL's include elimination/toileting. The resident's care plan (CP) will be updated as needed (PRN) in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that address the identified limitations in their ability to perform ADL's. Facility P&P titled Perineal/Incontinence Care in Subacute/LTC effective 2/25/22 documented the purpose was to provide guidelines for the performance of incontinence care. The goal being to maintain patient comfort and dignity and improve skin care status/integrity. Perineal care should be performed daily but not limited to; as part of daily bathing, after use of the bed pan and following any episode of urinary and/or fecal incontinence. All residents with incontinence will receive perineal care as per agency guidelines to promote maintenance of skin integrity and help prevent urinary tract, bladder, and kidney infections. 1. Resident #14 had diagnoses including dementia, repeated falls, and diabetes. The Minimum Data Set (MDS-a resident assessment tool) dated 12/12/22 documented the resident had severe cognitive impairment, required extensive assistance of one staff for transfer and toileting and was always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) documented the following: -On 3/8/21, had a history of urinary tract infection r/t history of incontinence, diabetes, dementia. Interventions included the nurse and Certified Nurse Aide (CNA) were to check on the resident q (every) 2 hrs (hours), turn and position (T&P) and provide incontinent care. -On 3/8/21, the resident had a history of actual impairment to skin integrity r/t fragile skin, diabetes, and incontinence. Interventions included to keep skin clean and dry. - On 3/8/21, the resident had urinary incontinence r/t dementia. Interventions included check and change for incontinence q2hrs and PRN. The Visual/Bedside Kardex Report (guide used by staff to provide care) dated 2/14/23 and identified as current by the Assistant Director of Nursing/Infection Preventionist (ADON/IP), documented the nurse and CNA were to check on resident q2hrs, turn and position (T&P) and provide incontinent care. During a continuous observation of Resident #14 on 2/13/23 between 8:30 AM and 2:05 PM the following was observed: -2/13/23 at 8:30 AM, Licensed Practical Nurse (LPN) #2 came out of a room with the resident. The resident sat in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. Dressed and well groomed. -2/13/23 at 8:45 AM, the resident was leaning forward trying to scoot in their chair but stopped and leaned back into chair. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. -2/13/23 from 9:47 AM to 11:41 AM, the resident sat near nurse's station in the broda chair, rested with their eyes closed at times. -2/13/23 at 11:42 AM, the resident was wheeled in their broda chair by staff to the unit dining room for lunch. The resident was not offered toileting or incontinent care. -2/13/23 at 11:53 AM, LPN #1 placed a clothing protector on the resident. -2/13/23 at 12:10 PM, Registered Nurse (RN) #4 MDS Coordinator sat next to the resident, assisted them with lunch. -2/13/23 at 12:41 PM, the resident was wheeled back into the hall next to the nurse's station. -2/13/23 at 12:44 PM, the resident was fidgeting with the seat belt buckle, and called out non sensical words to staff walking by and other residents sitting nearby. -2/13/23 at 12:48 PM, CNA #2 stopped and asked the resident if they were cold. The CNA came out of the resident's room with a blanket and placed it on the resident's lap. The resident was not offered toileting or incontinent care. -2/13/23 from 12:49 PM to 2:05 PM, the resident was sitting at the nurse's station in their broda chair. The resident was not toileted or provided incontinent care during this continuous observation. During an interview on 2/13/23 at 1:57 PM, CNA #1 stated they were familiar with Resident #14 and their Kardex. Resident #14 should be checked for incontinence and/or toileted/changed q2hrs. CNA #1 stated they had not had a chance to check for incontinence and/or toilet the resident since getting them OOB this morning, but they would have, or wanted to, but they were short staffed today. CNA #1 stated they had not told anyone that they were unable to check the resident for incontinence or toilet the resident since they got the resident OOB after morning care. During observation on 2/13/23 at 3:00 PM, Resident #14 was sitting in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around Resident #14 waist. During interview on 2/13/23 at 3:01 PM, LPN #6 stated the nurse was responsible for making sure Resident #14 was checked and provided incontinent care q2hrs to prevent skin breakdown because they are signing it off on the Medication/Treatment Administration Record (MAR/TAR). LPN #6 stated CNA #1 didn't tell them that they were unable to get it (their work) done. During interview on 2/13/23 at 3:10 PM, the ADON/IP reviewed Resident #14 CCP and Kardex in the electronic medical record (EMR) and stated the nurse and CNA were to check on the resident q2hrs, turn and position (T&P) and provide incontinent care. The ADON/IP stated they were not aware that Resident #14 had not been toileted. The ADON/IP stated they expected that the plan of care be followed and if staff were unable, would expect them to let someone know so they could get some help. During an observation on 2/13/23 at 3:36 PM, CNA #3 took Resident #14 to their room. At 3:42 PM, the CNA #3 transferred Resident #14 to their bed using the sit to stand lift. While they were removing Resident #14 pants the CNA #3 stated Oh, (Resident #14) pants are wet and placed them in the hamper. The resident's brief was noted to be heavily saturated with urine, from front to back, and a small amount of brown stool was noted in the brief. CNA #3 stated they had just come in for second shift, today, but the resident should be toileted, per their Kardex, q2hrs. During an interview on 2/14/23 at 10:00 AM, LPN #7 stated the CNAs were expected to toilet incontinent residents. LPN #7 stated they would expect the CNAs to release the seat belt and offer toileting/incontinent care q2hrs. At least three times per shift. During an interview on 2/14/23 at 10:08 AM, RN #5 Unit Manager (UM) stated they were not aware toileting or incontinent care was not offered to Resident #14 for greater than 6 hours on 2/13/23. RN #5 UM stated CNAs were responsible and would expect staff to follow physician orders and the resident's plan of care, to toilet the resident at least two to three times per shift. During an interview on 2/14/23 at 12:11 PM, the Director of Nursing (DON) reviewed the camera footage at the nurse's station from 2/13/23 of Resident #14 as per the continuous observation documented above. The DON stated staff should be toileting the resident q2hrs as ordered and per the plan of care and that was not done on 2/13/23. On follow up interview 2/14/23 at 1:40 PM, in the presence of the facility Administrator, the DON stated they had completed reviewing the camera footage from 2/13/23 from 2:00 PM until 3:36 PM and Resident #14 did not have release of seat buckle, toileting or PROM performed by staff q2hrs as ordered by the physician and per the plan of care. The DON stated they would have expected all of that to be done. 10 NYCRR 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that the resident is free from physical restraints for the purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms when the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Specifically, for one (Resident #14) of one resident reviewed, staff did not release the seat belt restraint every 2 hours and perform passive range of motion (PROM- exercises performed on the resident by nursing staff) to bilateral extremities on 2/13/23 as ordered by the physician and per the plan of care. The finding is: The facility policy and procedure (P&P) titled Community Based Care: Restraints effective 11/18/21, documented the purpose was to provide restraint free care while protecting resident safety, comfort, and well-being. Restraints will only be used when all other interventions have been exhausted and the patient/resident posed harm to self and/or others. If restraints are used, they must be the least restrictive for the least amount of time, and an on-going evaluation of need for use will occur. If a resident is restrained, resident status and ongoing evaluation of need will be conducted and documented every (q) two (2) hours (hr). The State Operations Manual issued 10/21/22 defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body and cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to their body. Examples of the facility practices that mean the definition of physical restraint include but not limited to using devices in conjunction with a chair, such as belts, that the resident cannot remove and prevents the resident from rising. 1. Resident #14 had diagnoses which included dementia, repeated falls, and diabetes. The Minimum Data Set (MDS-a resident assessment tool) dated 12/12/22 documented the resident had severe cognitive impairment, required extensive assistance of one staff for transfer and toileting and had no falls since the prior assessment. The MDS was not coded for restraint use during the look back period. The Comprehensive Care Plan (CCP) documented the following: -On 12/16/21, the resident was a high risk for falls r/t gait/balance problems. Interventions included do PROM to bilateral lower extremities (BLE) for 10 minutes when releasing the seat belt q2hrs. -On 4/13/22, the resident used physical restraints (seat belt in Broda-a positioning chair that prevents skin breakdown) related to (r/t) wandering, and history of falls with fractures. Interventions included release restraint q2hr and ambulate using walker. The Visual/Bedside Kardex Report (guide used by staff to provide care) dated 2/14/23 and identified as current by the Assistant Director of Nursing/Infection Preventionist (ADON/IP), documented to do PROM to BLE for 10minutes when releasing seat belt q2hrs; keep in broda chair at all times (AATs) when out of bed (OOB), keep at nurses station for monitoring as able with opportunities to ambulate as needed (PRN); release restraint q2hrs and ambulate using a walker, per physical therapy, seat belt when OOB in broda chair, document and release every 2hrs while OOB and for toileting. Review of the physician Order Listing Report documented the following: -1/25/23, Release of restraint q2hrs and as needed. Ambulate 10-15 minutes with release q2hrs for frequent falls. The order was discontinued on 2/8/23. -2/8/23, Release seat belt q2hrs, certified nurse aide (CNA) to perform PROM to BLE x10 minutes each time q2hrs when OOB. During observations on 2/10/23 at 8:56 AM and 11:41 AM, Resident #14 was sitting in their broda chair next to the nurse's station. A black seat belt was attached to the broda chair with the fastened buckle observed around Resident #14's waist. During a continuous observation of Resident #14 on 2/13/23 between 8:30 AM and 2:05 PM the following was observed: -2/13/23 at 8:30 AM, Licensed Practical Nurse (LPN) #2 came out of a room with the resident. The resident sat in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. -2/13/23 at 8:45 AM, the resident was leaning forward trying to scoot in their chair but stopped and leaned back into chair. A black seat belt attached to the broda chair with a fastened buckle was observed around the resident's waist. -2/13/23 from 9:47 AM to 11:41 AM, the resident sat near nurse's station in the broda chair, rested with their eyes closed at times. The seat belt remained intact around their waist. -2/13/23 at 11:42 AM, the resident was wheeled in their broda chair by staff to the unit dining room for lunch. The seat belt remained intact around their waist. -2/13/23 at 11:53 AM, LPN #1 placed a clothing protector on the resident. The seat belt was not released and remained intact around their waist. -2/13/23 at 12:10 PM, Registered Nurse (RN) #4 MDS Coordinator sat next to the resident, assisted them with lunch. The seat belt remained intact around their waist during the lunch meal. -2/13/23 at 12:41 PM, the resident was wheeled back into the hall next to the nurse's station. The seat belt remained intact. -2/13/23 at 12:44 PM, the resident was fidgeting with the seat belt buckle, and called out non sensical words to staff walking by and other residents sitting nearby. -2/13/23 at 12:48 PM, CNA #2 stopped and asked the resident if they were cold. The CNA came out of the resident's room with a blanket and placed it on the resident's lap. -2/13/23 from 12:49 PM to 2:05 PM, the resident was sitting at the nurse's station in their broda chair. The seat belt remained intact around their waist. There was no release of the resident's seat belt buckle, toileting or PROM performed by staff for the resident during this continuous observation. During an interview on 2/13/23 at 1:57 PM, CNA #1 stated they were familiar with Resident #14 and their Kardex. CNA #1 stated Resident #14 CCP was just changed from ambulation to PROM to BLE last week. Resident #14 should have had their seatbelt released and had PROM for 10 minutes q2hrs, additionally they should be checked for incontinence and/or toileted/changed. CNA #1 stated they had not had a chance to release the seat belt, toilet or do PROM, but they would have or wanted to but they were short staffed today and they all just worked together to get everything done. CNA #1 stated they had not told anyone that they were unable to release the belt, toilet or provide PROM to the resident. During an observation on 2/13/23 at 3:00 PM, Resident #14 was sitting in their broda chair next to the nurse's station. A black seat belt attached to the broda chair with a fastened buckle was observed around Resident #14's waist. During interview on 2/13/23 at 3:01 PM, LPN #6 stated the nurse was responsible for making sure Resident #14's seat belt was being released and PROM and/or toileting was being done because they are signing it off on the Medication/Treatment Administration Record (MAR/TAR). LPN #6 stated they asked CNA #1 if the belt was released, and they said yes. LPN #6 stated CNA #1 didn't tell them that they were unable to get it (their work) done. During interview on 2/13/23 at 3:10 PM, the ADON/IP reviewed Resident #14's CCP and Kardex in the electronic medical record (EMR) and stated PROM intervention was the current plan and the responsibility of releasing Resident #14's seat belt and doing PROM for 10 minutes was a group effort. The ADON/IP stated they were not aware that Resident #14 had not had their seal belt released with PROM for 10 minutes to BLE q2hrs, nor been toileted. The ADON/IP stated they expected the CCP be followed and if staff were unable, would expect them to let someone know so they could get some help. During an observation on 2/13/23 at 3:26 PM, the ADON/IP released Resident #14's seat belt and provided PROM to BLE. The ADON/IP asked CNA #3, who was assigned to Resident #14, and if they could toilet the resident. During observation on 2/13/23 at 3:36 PM, CNA #3 took Resident #14 to their room. Resident #14 was unable to unfasten the seat belt buckle on command. During an interview on 2/14/23 at 10:00 AM, LPN #7 stated Resident #14 had a seat belt restraint because they were high risk for falls. LPN #7 stated the CNAs were responsible for releasing the belt and performing PROM. LPN #7 stated they would expect the CNAs to release the seat belt, perform PROM and offer toileting/incontinent care q2hrs, at least three times per shift. During an interview on 2/14/23 at 10:08 AM, RN #5 Unit Manager (UM) stated the resident was trialed without the use of a seat belt for some time. It was going well but then they fell again and it was reordered. RN #5 UM stated they were not aware Resident #14 had not had their seat belt released, PROM or toileting offered for greater than 6 hours on 2/13/23. RN #5 UM stated CNAs would be responsible and they would expect staff to follow the physician orders and the resident's plan of care to release the seatbelt and toilet the resident at least two to three times per shift. During interview on 2/14/23 at 12:11 PM, the Director of Nursing (DON) stated Resident #14 had a history of frequent falls with multiple fractures and had used the restraint on and off. The DON reviewed the camera footage at the nurse's station on 2/13/23 of Resident #14 as per the continuous observation documented above. The DON stated the staff should be releasing the belt and performing PROM as ordered and per the plan of care and that was not done on 2/13/23. During interview on 2/14/23 at 1:10 PM, the Nurse Practitioner (NP) stated Resident #14 had used the seat belt restraint off and on due to history of falls with fractures. The NP stated the expectation was the seat belt should be released per facility protocol and that is what staff should follow. On follow up interview 2/14/23 at 1:40 PM, in the presence of the facility Administrator, the DON stated they had completed reviewing the camera footage from 2/13/23 from 2:00 PM until 3:36 PM and Resident #14 did not have release of seat belt buckle, toileting or PROM performed by staff q2hrs as ordered by the physician and per the plan of care. The DON stated they would have expected all of that to be done. 10 NYCRR 415.4(a)(5)(i)(ii)

Based on interview and record review conducted during a Standard survey completed 2/14/23, the facility did not inform the resident's representative of a need to alter treatment significantly for one (Resident #29) of one resident reviewed for notification of change. Specifically, Resident #29 developed an unstageable pressure ulcer (a skin injury due to pressure where the wound base cannot be visualized due to slough or eschar [dead tissue]) to the coccyx (tail bone) and there is no documented evidence the responsible party was not notified of the development, status or treatment to the wound. Additionally, the resident had an order for an antibiotic medication for the wound and there is no documented evidence the responsible party was notified of the need for the antibiotic use. The finding is: The policy and procedure (P&P) titled Notification of a Significant Change in Condition effective date of 1/2023 documented the resident/responsible party should be informed of provider notification related to a significant change in condition. The P&P documented that communication should be reflected in the medical record and will include date, time, person notified, the time the calls were returned, a description of the information communicated to the provider, and the actions requested by the provider. The P&P further documented that if unable to contact the responsible party this information should be communicated during the hand off and should be documented. 1.Resident #29 had diagnoses including hemiplegia (weakness or paralysis on one side of the body) following a cerebral infraction (a lack of blood supply to the brain), aphasia (disorder affectioning the ability to communicate) and dementia. The Minimum Data Set (MDS-a resident assessment tool) dated 5/10/22 documented Resident #29 was absent of spoken words, rarely/never understood, rarely/never understands and had severe impairment of cognitive skills. The MDS documented that Resident #29 had one unstageable pressure ulcer due to slough or eschar. The Comprehensive Care Plan (CCP) with a revised date of 3/11/22 documented Resident #29 had skin impairment of an unstageable area to the coccyx on 3/10/22. Interventions included that the resident was to have two incontinent pads in bed, administer treatments as per the medical provider's orders, heel booties while in bed, notify the nurse if the dressing to the coccyx was loose or off, keep skin clean and dry, turn and position every 2-4 hours and as needed and place a wedge under back to hold resident to a side laying position. Review of the Daily Wound UDA dated 3/9/22 at 10:14 PM, documented that Resident #29 was noted to have a bleeding, black, gray and white open wound to their sacrum. Review of the Weekly RN (Registered Nurse) Wound notes documented Resident #29 had an unstageable area to their coccyx: -3/10/22 at 4:30 PM, measured 4.0 centimeters (cm) by 5.0 cm by less than 0.1 cm. -4/11/22 at 5:10 PM, measured 5.0 cm by 5.0 cm by less than 0.1 cm. The note documented that the area was larger in size and an antibiotic medication was started. -4/14/22 at 2:27 PM, measured 4.6 cm by 6.8 cm by less than 0.1 cm. The note documented that the Nurse Practitioner (NP) attempted to debride slough. -4/28/22 at 11:29 PM, measured 5.4 cm by 6.5 cm. The notes documented that the area was assessed with the NP present and there was no documented evidence that Resident #29's family was notified of the initial visualization or worsening in the measurements of the wound or the attempted debridement of the wound by the NP. Review of the Medication Administration Record (MAR) documented that Resident #29 had an order for a brand named ointment to that removes dead tissue to coccyx topically every day shift and as needed for wound care from 3/11/22 until 6/15/22. The MAR documented that Clindamycin (an antibiotic medication) 300mg three times a day was ordered from 4/11/22 until 4/16/22 for the unstageable wound. Review of the Progress Notes dated 3/8/22 through 5/3/22 revealed no documented evidence that Resident #29 family was notified of the resident's unstageable pressure ulcer or the need for antibiotic medication. Review of the Medical Provider Notes date 3/10/22 through 5/3/22 revealed no documented evidence that Resident #29's family was notified of the resident's unstageable pressure ulcer or need for antibiotic medication. During a telephone interview on 2/8/23 at 3:11 PM, Resident #29's Health Care Proxy (HCP) stated they were not notified that Resident #29 had a pressure ulcer. The HCP stated that Resident #29 developed a pressure ulcer in March of 2022 and the facility did not notify them. Resident #29 had a pressure ulcer until approximately May or June when they came into town to visit the resident. During a telephone interview on 2/14/23 at 9:17 AM, RN #2, former unit manager of the second floor, stated they could not answer any questions due to that they had not worked at the facility in six months, and they did not have access to any of their nursing notes. During an interview on 2/14/23 at 10:24 AM, RN Care Coordinator (CC) #1 stated that they were responsible for rounding with the NP for skin rounds weekly and as needed. RN CC #1 stated that when a resident had a new or worsening skin wound the residents responsible party would be notified either by the unit manager or themselves. RN CC #1 stated that the conversation with the responsible party should also be documented in the medical record. RN CC #1 stated they had never spoke to Resident #29's HCP on the telephone but they had discussed Resident #29 wound status with the HCP while they were visiting Resident #29 in person. During an interview on 2/14/23 at 10:56 AM, the Director of Nursing (DON) stated that they could not locate any documented evidence that the HCP was notified of the new, worsening or treatment for Resident #29's pressure ulcer. The DON stated that the HCP should have been notified by the nurse manager, RN or NP. The DON stated that the notification should have been documented in the medical record and did not know why it was not. During an interview on 2/14/23 at 1:29 PM, the Administrator stated a new, worsening, improving skin wound or a skin wound that had treatment change would be considered a change in condition. The Administrator stated that if a resident had a change in condition they would expect the family to be notified by supervisor, unit manager or the staff member that discovered the change. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on interview and record review conducted during a Standard survey completed 2/14/23, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #44) of two residents reviewed. Specifically, the facility did not report an injury of unknown origin (fracture of the distal left femur) to the State Agency within the two-hour time frame, as required. The finding is: The policy titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation effective date 11/1/22 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and no not result in serious bodily injury, to the administrator of the facility and to other officials including to the NYS Department of Health (DOH) through established procedures. 1.Resident #44 had diagnoses including fracture of the left lower end of the femur, Alzheimer's disease and chronic ischemic heart disease (narrowed arteries in the heart). The Minimum Data Set (MDS-a resident assessment tool) dated 10/24/22 documented Resident #44 was absent of spoken words, rarely/never understood, rarely/never understands and had severe impairment of cognitive skills. The MDS documented Resident #44 was a total assist of two staff members for bed mobility, transfers, dressing and toileting; a total assist of one staff member for eating and personal hygiene; and was non ambulatory. The Comprehensive Care Plan (CCP) with a revised date of 10/17/22 documented Resident #44 had self-care performance deficit and limited functional mobility related to Alzheimer's and a sacral wound infection. Interventions included that the resident was a total assist of two staff for bathing, dressing and toileting, was a total assist of one staff member for rolling in bed, a total assist of two staff for boosting with a slide sheet in bed, and a mechanical lift of two staff for transfers. Review of the Acute Progress Note dated 10/28/22 at 10:53 AM, the Nurse Practitioner (NP) documented that Resident #44's initial lab work was normal but recent lab work revealed an elevated alkaline phosphatase (enzyme found in the blood indicating if there is damage to the liver or bone). The NP documented that on 10/17/22, Resident #44 had significant edema along with bruising to the left knee. The NP documented an x-ray of the left knee was performed on 10/27/22 and revealed a fracture involving the distal femur and an orthopedic evaluation was recommended. The NP documented they spoke with the MD and NP at the resident's previous nursing facility, and they denied any history of prior recent fall or incidents. Review of the Progress Notes revealed: -On 10/28/22 at 3:25 AM, LPN #5 documented that Resident #44 x-ray report in with the Registered Nurse (RN) supervisor. See results. -On 10/28/22 at 9:25 AM, the Assistant Director of Nursing documented that Resident #44 x-ray result was positive for left distal fracture, the NP was notified, and received a new order to transfer Resident #44 to the emergency room . Review of the NYS DOH Automated Complaint Tracking System (ACTS) Facility Summary revealed that no report from the facility had been filed regarding the injury of unknown origin for Resident #44 on 10/28/22. During an interview on 2/14/23 at 10:41 AM, the Director of Nursing (DON) stated that they were notified of Resident #44's fracture when the x-ray was received. The DON stated that the Administrator was notified, and the fracture was discussed with the interdisciplinary team. The DON stated that they did not know how the fracture occurred to Resident #44 but after their investigation they felt it could have occurred where the resident resided prior to admission. The DON stated that any potential abuse, neglect or mistreatment should be reported to the DOH. The DON stated that they did not suspect abuse, neglect, or mistreatment due to Resident #44 had swelling and bruising to the left leg upon admission. The DON stated Resident #44 had an injury of unknown origin and a fracture would be considered a significant injury and therefore it should have been reported to the DOH. During an interview on 2/14/23 at 1:16 PM, the Administrator stated that they were notified of the Resident #44 facture and an SBAR (Situation-Background-Assessment-Recommendations) was completed as an investigation. The Administrator stated that from the SBAR investigation, Resident #44 was lowered to the floor in another nursing facility where they previously resided. The Administrator stated that the fracture likely was obtained prior to admission. The Administrator stated that if there was an injury of unknow origin they would look at the reporting manual to see if injury needed to be reported to the DOH. The Administrator stated that they did not report the fracture to the DOH because abuse, neglect or mistreatment was not suspected. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during a Standard survey completed 2/14/23, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #44) of two residents reviewed. Specifically, the facility did not complete a thorough investigation of a significant injury of unknown origin (fracture of the left femur) by obtaining statements from staff members who would have transferred or cared for the resident. The finding is: The facility policy and procedure (P&P) titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation with effective date of 11/1/22, documented all cases of suspected or actual abuse, neglect, exploitation, injury of unknown origin and/or misappropriation of resident property will be reported to the immediate supervisor and an investigation will begin immediately. The P&P documented that the Director of Nursing (DON) or designee will coordinate the investigation and is responsible for maintaining and ensuring completion of all investigative documentation, including but not limited to the Occurrence Investigation Summary and Occurrence Investigation Checklist, occurrence reports, assessments, statements, and other supporting documentation. All statements gathered through investigation will be kept confidential and all evidence found during assessment/investigation will be safeguarded. 1.Resident #44 had diagnoses including fracture of the left lower end of the femur, Alzheimer's disease and chronic ischemic heart disease (narrowed arteries in the heart). The Minimum Data Set (MDS-a resident assessment tool) dated 10/24/22 documented Resident #44 was absent of spoken words, rarely/never understood, rarely/never understands and had severe impairment of cognitive skills. The MDS documented Resident #44 was a total assist of two staff members for bed mobility, transfers, dressing and toileting; a total assist of one staff member for eating and personal hygiene; and was non ambulatory. The Comprehensive Care Plan (CCP) with a revised date of 10/17/22 documented Resident #44 had self-care performance deficit and limited functional mobility related to Alzheimer's and a sacral wound infection. Interventions included that the resident was a total assist of two staff for bathing, dressing and toileting, was a total assist of one staff member for rolling in bed, a total assist of two staff for boosting with a slide sheet in bed, and a mechanical lift of two staff for transfers. Review of the Medical Provider Note dated 10/17/22 at 8:35 PM, the Nurse Practitioner (NP) documented that Resident #44 was seen for admission history and physical and had bilateral pitting edema of the lower limbs, a 17-centimeter (cm) surgical scar of the right knee and a 12-centimeter surgical scar of the left knee. Review of the Medical Provider Note dated 10/18/22 at 6:34 PM, the Medical Doctor (MD) documented Resident #44 was seen for admission history and physical and has left knee edema that was not warm to touch. Review of the Acute Progress Note dated 10/28/22 at 10:53 AM, the NP documented that Resident #44's initial lab work was normal but recent lab work revealed an elevated alkaline phosphatase (enzyme found in the blood indicating if there is damage to the liver or bone). The NP documented that on 10/17/22 Resident #44 had significant edema along with bruising to the left knee. The NP documented an x-ray of the left knee was performed on 10/27/22 and revealed a fracture involving the distal femur and an orthopedic evaluation was recommended. The NP documented they spoke with the MD and NP at the resident's previous nursing facility, and they denied any history of prior recent fall or incidents. The previous nursing facility did obtain a venous doppler (diagnostic test to check the circulation in a vein) of the bilateral lower extremities that was negative. Review of the Progress Notes revealed: -on 10/17/22 at 12:13 PM, Register Nurse (RN) #3 documented Resident #44 was transferred from another nursing facility and was nonverbal. RN #3 documented Resident #44 was sitting in a wheelchair in the hallway and had +1 pitting edema (up to 2 millimeter of depression in swelling) to left leg/foot. -on 10/18/22 at 1:41 AM, Licensed Practical Nurse (LPN) #5 documented that Resident #44's left foot had slight pitting edema and left knee appeared greater than the right with lower leg nonpitting edema. At 6:16 AM, LPN #5 documented that Resident #44 left posterior knee and thigh area had dark purple bruises. -on 10/28/22 at 9:25 AM, Assistant Director of Nursing documented that Resident #44's x-ray result was positive for the left distal fracture. The NP was notified and received new order to transfer Resident #44 to the emergency room . The note also documented that the family was notified. Review of the SBAR (Situation-Background-Assessment and Recommendations-the facility's investigation) dated 11/1/22 and signed by the DON, documented that Resident #44's x-ray on 10/27/22 revealed a comminuted and displaced left femur fracture. The SBAR documented that while Resident #44 was at their previous nursing facility their progress notes documented on 10/4/22 that their knees buckled during a transfer and on 10/6/22 a left lower venous doppler was completed due to swelling. The assessment documented that upon admission, assessments by the medical doctor and nursing that Resident #44 left knee was edematous, larger than the right and had dark purple bruising. The recommendations documented that Resident #44 was currently in the hospital. The investigation did not contain any statements/interviews from staff that would have transferred or cared for Resident #44 since their admission to the current nursing facility. During an interview on 2/14/23 at 10:04 AM, RN #3 (Director of Adult Day Care) stated that they did the admission assessment for Resident #44. They stated that they did not transfer Resident #44 and they completed the admission assessment while the resident was sitting in a wheelchair. RN #3 stated their assessment revealed that Resident #44 had +1 pitting edema to their left leg and foot. RN #3 stated that Resident #44 family members were present during the admission assessment, and their family stated that Resident #44 did not have any previous falls. During an interview on 2/14/23 at 10:24 AM, RN Care Coordinator (CC) #1 stated that along with the NP they performed a skin assessment on Resident #44 the evening Resident #44 was admitted to the facility. RN CC #1 stated that Resident #44 was laying in bed upon their assessment, and they did not transfer the resident into bed. RN CC #1 stated that Resident #44 left knee was swollen and larger than their right knee. They stated Resident #44 did not display any nonverbal signs of pain. During an interview on 2/14/23 at 10:41 AM, the DON stated that they were notified of Resident #44 fracture when the x-ray report was received. The DON stated that the Administrator was notified, and the fracture was discussed with the interdisciplinary team. The DON stated Resident #44 had an injury of unknown origin and a fracture would be considered a significant injury. The DON stated they completed an SBAR for the investigation. The DON stated that Resident #44 had been transferred to their facility from another nursing facility and Resident #44 had documented edema of their left leg upon admission. The DON stated that the Director of Therapy had access to the previous nursing facility medical record and noted Resident #44 had an incident at that nursing facility earlier that month. The DON stated that they did not know who performed a transfer for Resident #44 and they did not obtain any interviews or statements of the staff members. The DON stated that they talked to staff in general but did not obtain any staff statements but probably should have obtained statements from staff who had completed care for Resident #44. The DON stated that they concluded that the cause of the fracture was undetermined due to bruising and edema to the left leg and a fall prior to admission. During an interview on 2/14/23 at 11:15 AM, the Director of Therapy stated they were notified of the facture when the x-rays results were received. The Director of Therapy stated that Resident #44 had edema of the left leg since admission and did not have any signs and symptoms of pain during their therapy treatments. The Director of Therapy stated they performed standing exercises to Resident #44 during their therapy treatments. They stated they after review of the previous nursing facility medical record they noted there was an incident at that facility, and they stated they cannot know for sure that the fracture happened at that time. The Director of Therapy stated they talked about Resident #44 fracture as a group but that they did not obtain any statements from the therapy staff. During an interview on 2/14/23 at 1:16 PM, the Administrator stated that they were notified of the Resident #44 facture and an SBAR was completed for investigation. The Administrator stated that there may not be any written staff statement, but the fracture was discussed at morning report. The Administrator stated that from the SBAR results the fracture was likely obtained prior to admission. The Administrator stated that Resident #44 was lowered to the floor at another nursing facility, and it was likely the fracture resulted there. 10 NYCRR 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #15) of three residents reviewed. Specifically, staff did not perform hand hygiene after they completed wound care to the left gluteal (buttock) unstageable (full thickness tissue loss where base of ulcer is covered by slough-yellow, tan, grey, green, or brown tissue and or eschar (black, dead tissue) pressure ulcer with a current methicillin resistant staphylococcus aureus (MRSA- an antibiotic resistant bacteria) infection, then performed wound care to the gluteal cleft unstageable pressure ulcer. Additionally, the staff used their gloved finger, not an applicator, to apply Santyl (sterile ointment to remove dead tissue) to the gluteal cleft (deep groove that lies between the two gluteal regions) pressure ulcer. The finding is: The facility policy and procedure (P&P) titled Community Based Care Handwashing/Hand Hygiene dated 9/9/20 documented a definition to decontaminate hands was to reduce bacterial and viral counts on hands by performing antiseptic hand rub or antiseptic hand wash. Indications for hand washing included after removing gloves or any physical barrier and when moving from a contaminated site to a clean site on the same resident. 1. Resident #15 had diagnoses including neurogenic bladder (bladder with diminished sensation), epilepsy, and hypertension. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 12/6/22 documented Resident #15 was cognitively intact and had four pressure ulcers, including an unstageable pressure ulcer present on admission. The comprehensive care plan dated 11/30/22 documented Resident #15 was at risk for further alteration in skin integrity, had an unstageable pressure ulcer to their left gluteal fold and gluteal cleft (as of 1/30/23). Interventions included to administer treatments per the medical provider's order. The culture report (lab test to confirm a bacterial infection) final result dated 2/7/23 at 6:15 AM, documented the left buttock swab specimen had multiple mixed flora (a community of bacteria that exists on or in the body) including moderate colonies of MRSA and may be an isolation risk. The Order Summary Report dated 2/14/23 documented an order started 2/9/23 to cleanse the unstageable pressure ulcer on the gluteal cleft included with Dakin's (topical antiseptic used to clean infected wounds) dry, apply Santyl and cover with Allevyn (absorbent dressing). An active order dated 2/1/23 for the unstageable pressure ulcer on the left gluteal fold included to cleanse with Dakin's, dry, apply skin prep (topical application that toughens skin and enhances adherence of dressing to border), pack with Dakin's soaked gauze and cover with Allevyn. During an observation on 2/10/23 at 10:25 AM, with Registered Nurse (RN) Care Coordinator (CC) #1 present, Licensed Practical Nurse (LPN) #2 washed their hands and donned (applied) gloves. LPN #2 removed the soiled dressing from the left gluteal pressure ulcer and removed the packing; the ulcer had a moderate amount of bleeding. The LPN removed their gloves, did not perform hand hygiene, donned new gloves, and cleaned the ulcer with Dakin's soaked gauze, skin prepped the skin around the ulcer, placed Dakin's soaked gauze into the ulcer and covered it with Allevyn. The LPN #2 removed their gloves, did not perform hand hygiene, donned new gloves, and removed the dressing from the gluteal cleft ulcer. LPN #2 removed their gloves, did not perform hand hygiene, donned new gloves, cleansed the ulcer with Dakin's, applied Santyl to their gloved fingertip and directly applied the Santyl to the ulcer. LPN #2 then placed the Allevyn to the ulcer. During an interview on 2/10/23 at 10:56 AM, LPN #2 stated the pressure ulcer that was packed (left gluteal fold) had the MRSA infection. LPN #2 stated they performed the left gluteal treatment before the coccyx treatment because it was harder, but it did make sense to start with the cleaner area before the dirtier area. LPN #2 stated the order didn't say to do one treatment prior to the other one. LPN #2 stated they thought as long as they changed their gloves between ulcers it was fine and didn't think they had to wash their hands between sites. During an interview on 2/10/23 at 11:01 AM, RN CC #1 stated the left gluteal fold pressure ulcer had MRSA and that ulcer should have been completed last because you don't want to infect the other ones with MRSA. The RN CC #1 stated LPN #2 should have also washed their hands between ulcer sites and not just change their gloves. During an interview on 2/14/23 at 9:02 AM, the Director of Nursing (DON) stated they would have expected the LPN #2 to wash their hands as well as change their gloves when moving from the ulcer with MRSA to the other site because you never know if there were pinpoint holes in gloves and want to start fresh with every ulcer. The DON stated they would have expected the LPN #2 to use an applicator to apply Santyl to the ulcer and not the glove. During an interview on 2/14/23 at 1:24 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated the LPN #2 should have performed hand hygiene between the two pressure ulcer treatments because they went from a dirty area to a clean area and wouldn't want to contaminate the other ulcer. The ADON/IP stated the nurse should have used a tongue depressor or q- tip, besides their gloved finger to apply the Santyl. 10 NYCRR 415.12 (c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/14/23, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; PRN (as needed) orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for one (Resident #61) of four residents reviewed for antipsychotic (AP) medications. Specifically, PRN Haldol (an AP medication) was ordered longer than 14 days for dementia with behaviors and there was no documentation the practitioner evaluated the resident for appropriateness of the medication used beyond 14 days, there was lack of documented specific behaviors and non-pharmacological interventions attempted prior to the administration of PRN Haldol, and the Seroquel (an AP medication) dose was increased with lack of supporting behavioral documentation and rationale for the increase. Additionally, there was no care plan developed for use of antipsychotic medications to include targeted behaviors and individualized non-pharmacological interventions. The finding is: The facility policy and procedure (P&P) titled Psychotherapeutic Drug Review dated 3/5/19 documented antipsychotic medications may be indicated if multiple non-pharmacological approaches have been attempted, but did not relieve symptoms which present a danger or significant distress, identified target behaviors will be monitored each shift along with individualized interventions as well as supporting documentation in the clinical record, the goals of psychotropic medication and non-pharmacologic approaches will be addressed in the resident's care plan. The care plan will include the type of psychotropic drugs to be monitored for side effects daily. A PRN antipsychotic medication will be limited to 14 days and not renewed unless the provider evaluates the resident for appropriateness of the medication and documents in the medical record. 1. Resident #61 had diagnoses including peripheral vascular disease (PVD-decreased circulation of the lower extremities), chronic obstructive pulmonary disease (COPD), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 12/9/22 documented Resident #61 had moderately impaired cognition, had no behavioral symptoms and received antipsychotic medications on a routine basis. Review of the undated comprehensive care plan, identified as current by the Licensed Practical Nurse Unit Manager (LPN UM) #2, revealed there was no documented evidence Resident #61 used antipsychotic medications. During a morning care observation on 2/10/23 at 7:10 AM, Resident #61 had no behaviors and was cooperative with care. a. Review of the Clinical Physician Orders revealed an order for Haldol 5mg (milligrams)/mL (milliliter) inject 5mg intramuscularly (IM) every 8 hours PRN for restlessness/agitation started on 12/26/22 and ended on 1/9/23. An order or Haldol 5mg IM every 8 hours PRN for agitation and restlessness started on 1/11/23 and ended on 1/25/23. Review of the Medication Administration Record (MAR) revealed the following: -From 12/1/22-12/31/22 Resident #61 received Haldol IM on 12/29/22 at 10:55 PM -From 1/1/23-1/31/23 Resident #61 received Haldol IM on 1/11/23 at 7:36 PM, 1/12/23 at 8:19 PM, 1/17/23 at 5:57 PM, 1/22/23 at 2:02 AM, 1/23/23 at 1:30 AM and 10:46 PM, and 1/25/23 at 5:57 PM. Review of medical provider Progress Notes revealed the following: - 12/19/22 at 12:03 PM, there was no documentation about AP drug use or behaviors - 12/28/22 at 9:38 PM, there was no documentation about AP drug use or behaviors - 1/2/23 at 9:48 PM, there was no documentation about AP drug use or behaviors - 1/11/23 at 4:40 PM, there was no documentation about AP drug use or behaviors There was no documentation a medical provider evaluated Resident #61 for the appropriateness of the PRN AP medication when it was started on 12/26/22 or when it was renewed 1/11/23. Review of the nursing Progress Notes for Resident #61 revealed the following: - 12/29/22, there was no documentation of behaviors or that PRN Haldol was administered - 1/11/23 at 7:17 PM, LPN #4 documented the resident had increased agitation with self-transfer, attempted to hit another resident, difficulty to give care to, notified the RN supervisor, will monitor. - 1/12/23 at 9:39 PM, LPN #4 documented difficult to give care, restless, agitation self-transfer risk fall, Haldol PRN with effect. - 1/17/23 at 7:42 PM, LPN #4 documented resident was restless with agitation, self-transfer out of wheelchair, risk for fall, Haldol PRN with positive effect - 1/22/23 at 3:41 AM, LPN #4 documented the resident was restless with agitation, several times attempted to self-transfer out of bed, risk for fall, Haldol PRN with positive effect - 1/23/23 at 4:26 AM, LPN #4 documented the resident self-transferred out of bed, risk for falls, restless with agitation, rude to the staff, Haldol PRN with positive effect. - 1/25/23 at 4:56 PM, LPN #4 documented at 4:30 PM the resident attempted to self-transfer out of the wheelchair, risk for falls, refused care, resident took their shirt off, wanted to go home and was verbally abusive. There was no documentation of non-pharmacological interventions attempted prior to the administration of the PRN Haldol. Review of 24-Hour Reports dated 1/12/23, 1/17/23, 1/22/23, 1/23/23, and 1/25/23 revealed there was no documented non- pharmacological interventions attempted prior to the administration of PRN Haldol. b. Review of the Clinical Physician Orders revealed an order for Seroquel 25mg 1 tablet at bedtime started on 10/13/22 and was discontinued on 12/15/22, Seroquel 25mg give 2 tablets (50mg) in the evening was started 12/16/22 and discontinued on 1/20/23. Review of the MAR dated 12/1/22-12/31/22 revealed Resident #61 received Seroquel 25mg from 12/1/22 until 12/14/22 and received Seroquel 50mg in the evening from 12/16/22 to 12/31/22. The MAR dated 1/1/23-1/31/23 revealed the resident received Seroquel 50mg in the evening from 1/1/23 to 1/19/23. Review of the Psychotropic Drug Review dated 11/13/22 revealed Resident #61 received Seroquel 25mg at bedtime for dementia with behaviors, was on the medication since admission and had a GDR on 8/11/22. The reason for using the AP drug was sleep induction, depression, and organic mental syndrome (i.e., dementia and other cognitive disorders with associated psychotic and/or agitated behaviors. Symptom description included restlessness and self-transfers. There was no documentation whether the behaviors were persistent, caused by preventable reasons or if the behaviors were causing the resident to present danger to themselves or others. The Psychotropic Drug Review dated 12/20/22 revealed the resident received Seroquel 50mg in the evening for dementia with behaviors, which was increased on 12/16/22. The reason for using the AP drug was sleep induction, agitation, and organic mental syndrome. The behavior section documented no concerns reported or noted. Review of medical provider Progress Notes for Resident #61 revealed the following: - 12/12/22 at 10:07 PM, no documentation about AP drug use or behaviors - 12/19/22 at 12:03 PM, no documentation about AP drug use or behaviors There was no documentation of a rationale for the increase in Seroquel medication. Review of the nursing Progress Notes for Resident #61 revealed the following: - From 12/15/22 to 12/31/22 there was no documentation about the increase in Seroquel dose and no documentation of any behaviors. Review of the Consultant Pharmacist Review: Nursing Communication dated 1/9/23 documented Resident #61 was on Seroquel 50mg daily and was recently increased to the current dose. Recommended to monitor and document their mood/behavior with changes to the medication regimen for 14 days. During a telephone interview on 2/10/23 at 4:25 PM, LPN #4 stated Resident #61 was ok during the day but in the evening their behavior changed. Sometimes it was hard to provide care. LPN #4 stated they didn't like to use Haldol but for the resident's and caregivers' safety they had to use it. LPN #4 stated the resident's behaviors were agitation, was verbally abusive, tried to hit and kick staff when they gave care. LPN #4 stated they would try to toilet the resident, give food or drinks, and call family. The LPN #4 stated maybe their documentation didn't include all their actions they tried for the resident, and they should document more. During an interview on 2/13/23 at 9:52 AM, the LPN UM #2 stated Resident #61 was admitted on AP medication for depression and anxiety, and dementia with behavior concerns that happened more at nighttime with hands on care. LPN UM #2 stated staff should always reapproach the resident or try more therapeutic things like one on one before they used AP medication. LPN UM #2 reviewed progress notes in the EMR (electronic medical record) and stated they only saw wound treatment notes documented by the medical provider in December when the Seroquel was increased. LPN UM #2 stated usually the nurse practitioner (NP) documented about medication changes, on 12/14/22 it was documented the resident self-transferred, but AP medication shouldn't be used for self-transfers. LPN UM #2 stated they didn't see anything in the care plan about use of AP medications and usually the Director of Nursing (DON) deals with the care planning. The LPN UM #2 stated staff should be documenting specific interventions they tried prior to giving the PRN AP medication and the behaviors that required using the medications. During an interview on 2/13/23 at 1:08 PM, the Nurse Practitioner (NP) stated Resident #61 became irate in the evening, combative with hands on care mostly. The NP stated they order Haldol when residents are a risk to themselves or others, if striking at other residents or trying to harm themselves by getting out of their wheelchair and walk. Also stated orders for PRN AP medications were limited to 14 days and they physically examine the resident in the 14 days. The NP stated after 14 days the PRN AP wouldn't get reordered unless behaviors were escalating. The NP stated they were in the facility daily including evenings and had witnessed the resident's behaviors and the staff interventions. The NP stated they knew they needed to document better. During an interview on 2/13/23 at 1:17 PM, the Consultant Pharmacist stated the resident was on Seroquel for dementia with behaviors including combativeness with hands on care. They had reviewed the resident monthly in BMARC (behavior modification assessment record committee) and had reduced other psychoactive medications that were ordered, recently ordered a different AP medication and were trying to figure out the best medication regimen. During an interview on 2/14/23 at 9:07 AM, the DON stated they would expect staff to document the specific behaviors a resident had prior to giving a PRN AP medication. The DON stated non-pharmacological interventions vary depending on the resident. Resident #61 was very combative with care for a while, has since calmed down and sometimes it was hard for staff to try other things for a resident prior to giving Haldol because they were uncontrollable. The DON stated they would expect the NP to document the reason for extending any 14-day PRN AP medication. The DON stated would expect the care plan to address AP medication use and interventions should include monitoring for side effects. The DON stated the December BMARC documented no concerns because the medication was working for the resident. During further interview on 2/14/23 at 12:40 PM, the Consultant Pharmacist stated they recommended behavior charting because of the increased dose of Seroquel in December and wanted to make sure if the resident had behaviors they were documented. The Consultant Pharmacist stated the NP did see the resident during the medication changes, however notes were mostly about their wound. The Consultant Pharmacist stated they review so many residents at the BMARC meetings, especially focusing on AP use, that the notes of those meetings weren't very complete, and they were trying to streamline that process. 10 NYCRR 415.12(l)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/10/21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #9) of one resident reviewed. Specifically, there were no physician's orders for [CONDITION(S)] (an opening in the neck to put a tube into a person's windpipe allowing air to enter the lungs) care. The finding is: The facility policy titled Community Based Care/TLC Resident [CONDITION(S)] Care dated 10/2020 documented a physician's order was necessary to perform [CONDITION(S)] care. 1. Resident #9 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/28/21 documented Resident #9 was cognitively impaired and totally dependent with care needs. The Comprehensive Care Plan (CCP) dated 1/15/21 documented Resident #9 had a [CONDITION(S)] related to chronic respiratory failure with [CONDITION(S)]. Interventions included to provide [CONDITION(S)] care as ordered. Review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARs) for Resident #9 from 1/15/2021 to 9/9/2021 revealed no there were no physician's orders for [CONDITION(S)] care. Review of an Order Listing Report for active, completed, and discontinued orders showed there were no active orders for [CONDITION(S)] care since 1/15/2021. During an observation and interview on 9/10/2021 at 9:02 AM, Licensed Practical Nurse (LPN) #1 was observed providing [CONDITION(S)] care to Resident #9. LPN #1 stated that Resident #9 received [CONDITION(S)] care daily and they knew this because they have worked with Resident #9 before. LPN #1 stated once [CONDITION(S)] care was completed it was signed out on the TAR. LPN #1 stated there was no [CONDITION(S)] care order on the TAR or MAR and there should be an order. During an interview on 9/10/21 at 9:29 AM, LPN #2 stated [CONDITION(S)] care was done every shift. LPN #2 stated, they knew [CONDITION(S)] care had to be done on Resident #9 because the resident had a [CONDITION(S)] and I just automatically do [CONDITION(S)] care if a resident has a [CONDITION(S)]. After looking at MARS, TARS and standing orders LPN #2 stated, I don't understand why there isn't an order. During an interview on 9/10/21 at 9:37 AM, Registered Nurse (RN) Unit Manager (UM) stated [CONDITION(S)] care should be completed with an order. [CONDITION(S)] care was usually ordered every shift and as needed for excess secretions. RN UM stated, I don't know why there isn't an order. During an interview on 9/10/21 at 9:49 AM, the Director of Nursing (DON) stated an order should have been in place for basic [CONDITION(S)] care. The order would have been on the TAR in the electronic medical record (EMR). If there was not an order, then the nurses would not know that [CONDITION(S)] care needed to be provided. The DON, also stated that the facility utilizes float and agency nurses. During a follow up interview on 9/10/21 at 1:21 PM, the DON stated the nurse manager should have reviewed the physician's orders to ensure the proper orders were in place. During an interview on 9/10/21 at 1:12 PM, Nurse Practitioner (NP) stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was the responsibility of the provider who sees that resident to review orders every month to ensure medical orders were correct and current. This was important so the staff caring for the residents were aware of the care to provide. 415.12 (k)(4)

Based on interview and record review conducted during the Standard survey completed on 5/13/19, the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Two (Residents #16, 35) of two residents reviewed for abuse did not have complete and thorough investigations of incidents of alleged resident abuse (#16) and bruises of unknown origin (#35). The findings are: Review of a facility policy entitled Investigation, Prevention, Investigation and Reporting of Potential Abuse, Neglect or Exploitation dated 2/14/17 revealed it is the policy of the facility to prohibit any form of patient/resident abuse, neglect or exploitation while the patient/resident is under the supervision/care of the facility. All cases of suspected or actual abuse, neglect, exploitation, injury of unknown origin, and/or misappropriation of patient/resident property will be reported to the immediate supervisor/manager and an investigation will begin immediately. An Occurrence Report will be completed. Statements will be obtained from the patient/resident, staff, family member, visitor, and/or anyone involved. The facility Administrator/ Designee and the Director of Nursing will be notified of the incident. The Occurrence Investigation Summary will be initiated and the Occurrence Investigation Checklist will be utilized as an investigative resource. The Director of Nursing or designee will coordinate the investigation and is responsible for maintaining and ensuring completion of all investigative documentation. 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 2/4/19 documented the resident was cognitively intact and exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). a.) During an interview on 5/6/19 at 11:08 AM, the resident stated that she was hit in the eye twice by a staff member (approximately two weeks ago) and reported the incident to the Resident Financial Liaison. During an interview on 5/8/19 at 10:44 AM, the Resident Financial Liaison stated the resident reported she was hit in the head (a few weeks ago). The Resident Financial Liaison stated she reported the incident to the Administrator. During an interview on 5/8/19 at 10:54 AM, the Director of Nursing (DON) stated Resident #16 had reported about a month ago that someone had poked the resident in the eye. The DON stated, if we are told of an incident we do an investigation. She did not recall whether an investigation was completed and stated that the resident makes a lot of accusations, not mentally stable. Review of a Progress Note, written by the DON, dated 5/9/19 revealed a late note: (MONTH) 9th. I was informed that resident said someone hit her on the face a month ago. I went in to see her after supper and asked her how everything was going for her and she said fine. I asked Resident if all her needs are being met and she said yes. I also asked her if she had any concerns with any staff and she replied no. We spoke a little while about her daughter. I observed her face and there wasn't any changes, redness, or bruising noted. I spoke to several staff who were working, and they said they had not heard any comments or concerns made about this allegation. This allegation was discussed at report the next morning by the ID (interdisciplinary) team. Several staff members, including managers, have met with resident since (MONTH) 9th and she has not indicated any concerns or issues about this allegation. The facility was unable to provide an Occurrence Report; statements from the resident or staff; an Occurrence Investigation Summary; or an Occurrence Investigation Checklist for the reported allegation. During an interview on 5/8/19 at 11:18 AM, the Administrator stated he did not recall the Financial Liaison reporting an incident involving Resident #16 to him and the expectation for any abuse allegation would be an investigation with a summary of events. b.) During the interview on 5/6/19 at 11:08 AM, the resident stated last Monday (4/28/19) the 11-7 (11:00 PM to 7:00 AM) Supervisor twisted my wrist because I was ringing the call light incessantly; she twisted my wrist and it's still sore. The resident stated she had reported the incident to the Resident Financial Liaison. During an interview on 5/8/19 at 10:44 AM, the Resident Financial Liaison denied the resident had reported the incident. The Department of Health (DOH) Surveyor reported the allegation of abuse to the DON on 5/6/19 at 11:06 AM. The DON stated nothing was ever reported to her regarding the alleged incident. Review of a Report of Concern, completed by the DON, included the following: Person Reporting Concern: DOH Surveyor Date of Event: 4/28/19 Time: 11:00 PM to 7:00 AM shift Date concern reported: 5/8/19 Time: 12:00 PM During an interview on 5/10/19 at 10:46 AM, the 11:00 PM to 7:00 AM Registered Nurse (RN #3) Supervisor stated resident (#16) attention seeks, is on the call light all night, and wants stuff immediately. A week or so ago, one of the CNAs (certified nurse aide) and an agency nurse told me the resident had made an accusation that I twisted her arm. I would never twist a resident's arm. She had been on the call light all night and when she fell asleep I went in there to turn to the call light off. I reported this to the Unit Manager (RN #2) and the DON that morning when I gave report. During an interview on 5/10/19 at 10:59 AM, the RN (#2) Unit Manager stated, a week or two ago, RN #3 was giving report to the DON and myself when RN #3 reported the resident accused RN #3 of twisting her arm. There was no documented evidence of an investigation into the resident's allegation that her arm was twisted. The allegation was reported to multiple staff. 2. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severe cognitive impairment, was usually understood, and usually understands. Review of a Resident/Patient Occurrence Report dated 11/4/18 at 6:00 PM revealed the following: - Nature of Occurrence: Res (resident) often self-transfers and ambulates, possibly bumped into furniture causing bruises. - Assessment: 7 cm (centimeter) x 6 cm reddish purple bruise to left hip and a 5 cm x 2 cm bruise to left side of waist. - Employee Statement: While toileting resident, she complained of pain to her back. After she finished, the resident walked to her bed and stated she felt like she was hit by a train. While putting on her pajamas, I noticed a bruise on her left side directly above her hip. - Interdisciplinary Team Review/Recommendations: Res ambulates, impulsive, may have walked into something. No evidence abuse, neglect, or mistreatment occurred. - The Report did not include an investigation of events that preceded the discovery of the bruises, interviews with staff who cared for the resident or interviews with other residents. Review of a Resident/Patient Occurrence Report dated 3/8/19 at 11:08 PM revealed the following: - Nature of Occurrence: Bruise 7 x 4 cm found on right elbow with hematoma (collection of blood under the skin). - Assessment: Bruise with hematoma found on right elbow. Pt (patient) complained of pain when touched. - Employee Statement: I noticed her door was closed, so I went in to check on her. She was lying in door bed and I noticed there was a bruise on her elbow - flinches in pain with palpation. - Interdisciplinary Team Review/ Recommendations: Res is restless, swings arms, legs. - The Report did not include an investigation of events that preceeded the discovery of the bruises, interviews with staff who cared for the resident or interviews with other residents. During an interview on 5/10/19 at 10:05 AM, the DON stated an investigation would be initiated for bruises of unknown origin that includes a review of camera footage, an interview with the resident, interviews with other residents, and statements from staff who worked the 24 to 48 hours prior to the discovery of the bruise. The DON stated abuse was ruled out because the resident (#35) has a history of walking into items, therefore no staff were interviewed to rule out abuse for the 11/4/18 and 3/8/19 bruises of unknown origin. There was no review of camera footage or interviews with other residents. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/13/19, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain grooming and personal hygiene. Specifically, one (Resident #57) of three residents dependent on staff for ADL's, had long, dirty fingernails and was observed consuming finger foods. The finding is: Review of a policy and procedure (P&P) entitled Activities of Daily Living (ADL) Care dated 7/17/18 revealed the purpose of the P&P is to ensure patients/residents who are unable to carry out ADL's receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The P&P further documented ADL's include but are not limited to bathing, dressing, grooming and oral care. 1. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/18/19 revealed the resident had severe cognitive impairment, was understood, understands, and required extensive assistance of one person for all ADL's except eating, which requires supervision with set up of one person. The MDS did not document that the resident rejected care. Review of the Comprehensive Care Plan (CCP) for Preferences dated 4/11/19 revealed the resident prefers a shower two times a week on Sundays and Wednesdays with a plan to check skin and nails. The CCP did not document that the resident rejects/refuses hands on care. Review of an undated Order Summary Report revealed an order initiated on 12/26/18 to check the resident's skin and nail length on Sundays 6:00 AM to 2:00 PM and Wednesdays 2:00 PM to 10:00 PM, trim and clean on bath day as necessary and report any changes. Review of Treatment Administration Records (TARs) dated 4/1/19 to 5/8/19 revealed staff initials and the number 9 were documented on the following dates regarding checking the resident's skin and nail length, clean and trim on bath day: - 4/3/19, 4/7/19, 4/10/19, 4/17/19, 4/21/19, 4/24/19 - 5/1/19, 5/5/19, 5/8/19 Review of the Progress Notes for the 2:00 PM to 10:00 shift dated 4/3/19 to 4/24/19 and 5/1/19 to 5/8/19 revealed no documented evidence the resident refused nail care. Observation from 5/7/19 to 5/9/19 revealed the resident had long, jagged fingernails approximately 3/4 of an inch long on both hands with brown debris under the nails as follows: - 5/7/19 at 10:11 AM - The resident was sitting, fully dressed at the Nurses' Station after morning care was provided by staff. - 5/8/19 at 8:05 AM - The resident was in the dining room, fully dressed, for breakfast after morning care was provided by staff. The resident was using her fingers to move food around on her breakfast plate and using her fingers to eat toast with jelly. - 5/8/19 at 12:26 PM - The resident was in the dining room for lunch. - 5/9/19 at 10:06 AM - The resident was sitting in her wheelchair, fully dressed, at the Nurses' Station sleeping. Interview with a Certified Nurse Aide (CNA #1) on 5/9/19 at 2:36 PM revealed the resident refused her shower yesterday, she always refuses. The CNA stated she does not cut or clean the resident's nails; the nurse does because she has diabetes mellitus. Interview with a Licensed Practical Nurse (LPN #2) on 5/9/19 at 3:18 PM revealed a 9 entered on the TARs means that the resident refused. LPN #2 further revealed she does not document that the resident refused nail care in the progress notes, but the resident did refuse nail care yesterday. During an interview with the Registered Nurse (RN #2) Nurse Manager on 5/10/19 at 7:39 AM revealed residents' nails are cleaned and cut on bath days. A 9 in the electronic medical record (EMR) for nurses means see progress notes. It does not necessary mean refused, they should document something in the note. Observation on 5/10/19 at 8:01 AM revealed the resident was in the dining room. Her finger nails remained long with brown debris under them and the resident was eating toast with her fingers. When interviewed on 5/10/19 at 10:02 AM, the Assistant Director of Nursing (ADON) stated if the nurse picks the code number 9 in the EMR, it means see progress notes and they should have documented something. It does not mean the resident refused. The nurse should have documented if the resident refused. 415.12(a)(3)

Based on observation, record review, and interview during the Standard survey completed 1/10/18, the facility did not provide, based on the comprehensive assessment and care plan, an ongoing activities program to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. One (Resident #22) of two residents observed for activities was not provided sensory stimulation and group activities as planned. The finding is: 1. Resident #22 was admitted [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/8/17 revealed the resident is in a persistent vegetative state and is dependent on staff for all activities of daily living. Review of an Activities Quarterly Participation Review (assessment) dated 11/16/17 revealed the resident is provided with 1:1 in-room visitation including sensory programming such as reading and playing music and she continues to be included in larger group programming including socials, special events and musical entertainment when out of bed and as able. The Quarterly Participation Review documented that the Resident's activity goals were met. Review of the comprehensive care plan (CCP), last reviewed 11/21/17, revealed the resident is non-verbal and unable to make her needs known. The CCP documented a goal for the resident to attend group activities as needed and be provided with 1:1 visits, music, and linked senior activities for sensory stimulation. CCP interventions include providing the resident with sensory stimulation and encouraging her to make eye contact with staff during 1:1 visits. The current Bedside Kardex Report printed 1/5/18 documented that the resident is provided with 1:1 visitation including sensory stimulation programs such as reading and playing music and will be included in larger group programming including socials, special events and entertainment when out of bed as tolerated and able. Intermittent observations of the resident on 1/4/18, 1/5/18, and 1/8/18 between the hours of 8:30 AM and 3:40 AM and 1/9/18 from 8:17 AM to 11:26 AM revealed the resident was either lying in bed or sitting in a Broda (specialized) wheelchair in her room. There was a television and a portable radio/tape player in the resident's room, however neither one was turned on during the observations. Review of the January 2018 Activities Calendar revealed that three to four group activities were schedule daily between 10:00 AM and 2:30 PM. Review of the Unit 2 Activity Attendance records for November 2017 and 2018 revealed the resident attended one Special Event/ Entertainment on 11/1/17. Further review of the January 2018 Activity Attendance record dated 1/4/18 to 1/8/18 revealed documentation that T (television) and V (short social visit) were provided daily. Interview with the Director of Life Enhancement (Activities Director) on 1/9/18 at 10:13 AM revealed there is no Activity Attendance sheet available for December 2017. During the interview, the Director stated that the Activity Aide would be responsible to turn the resident's television on every day. The Director stated that the goal is to coordinate and work with nursing and get the resident's out of bed schedule. Interview with the Registered Nurse (RN #1) Unit Manager (UM) on 1/9/18 at 3:34 PM revealed that nursing will do a better job of letting activities know when the resident is out of bed and that she assumed that activities would take the resident to group activities when she is out of bed, sitting in the hallway. The RN UM stated that she was not aware of a goal to provide Activities with an out of bed schedule for Resident #22. Interview with the Activities Aide (#1) on 1/10/18 at 9:35 AM revealed the activities department passes out the Chronicle (activities schedule/ newsletter) daily and that is indicated by a V on the attendance record. The Activities Aide stated When we pass them out, everyone gets a Chronicle. Either I or someone will turn the (resident's) TV on, it's usually on. It became automatic to put a T on the sheet. If she is out of bed, either the aide or I will take her to an activity. It is my responsibility. Interview with the Director of Life Enhancement on 1/10/18 at 12:45 PM revealed that she checked the cassette player in Resident #22's room and it was not set to the repeat cycle and was stopped. 415.5(f)(1)(ii)

Based on record review and interview during the Standard survey completed 1/10/18, the facility did not ensure that each resident's drug regime is free from unnecessary drugs, when used without adequate monitoring. One (Resident #65) of five residents reviewed for unnecessary medications received daily insulin without obtaining a blood glucose level per physician order. The finding is: 1. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/17 revealed the resident has moderate cognitive impairment, understands, is understood and receives daily insulin. Review of physician's orders [REDACTED].< (under) 120. Review of Medication Administration Records (MARs) dated 12/4/17 to 1/9/18 revealed the seven units of [MEDICATION NAME] was transcribed according to the 12/4/17 and 1/2/18 physician's orders [REDACTED]. Additional review of the 12/2017 and 1/2018 MARs and the 12/2017 and 1/2018 Treatment Administration Records dated 12/2017 and 1/2018 revealed no documented evidence that a blood glucose level was obtained prior to administration of the daily [MEDICATION NAME] at HS. Review of the entire medical record, including Nursing Progress Notes and Laboratory Reports revealed no documented evidence that blood glucose levels were obtained daily at HS. Interview with the Licensed Practical Nurse (LPN #2) on 1/10/18 at 11:05 AM revealed she was unable to find any HS blood glucose checks results in the computer and she stated that the resident does not currently have an order for [REDACTED]. Interview with the Registered Nurse (RN #1) Unit Manager (UM) on 1/10/18 at 11:10 AM revealed the resident had a BMP (basic metabolic profile - blood test) drawn on 1/3/18 at 7:45 AM and the resident's blood glucose was 181 (normal 74 - 100). Further interview with the RN UM on 1/10/18 at 11:52 AM revealed she spoke to the PA (Physician Assistant) and new orders were obtained to check the resident's blood glucose level before meals twice a week. 415.12(l)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18, the facility did not establish and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, one (Unit 2) of two resident units observed for infection control practices during blood glucose monitoring; nursing staff did not properly clean and disinfect shared glucose meters between resident use in accordance with the manufacture's guidelines. Residents #39 was involved. The finding is: Review of the facility's policy and procedure (P&P) entitled Glucometer use, cleaning and control testing dated 12/2017 revealed that cleaning the glucometer shall take place following each use of the device; the procedure for cleaning the device shall follow manufacturer's directions and must us only an EPA (Environmental Protection Agency) registered germicidal disinfectant product approved by the glucometer manufacturer. Observation on 1/4/18 at 1:26 PM revealed Licensed Practical Nurse (LPN #3) completed a glucose meter test on resident #39 with a Medline Evencare G2 blood glucose meter. When LPN #3 was finished she placed the glucose meter in her gloved hand and walked down the hall to the medication cart and placed the glucose meter in a zippered bag without cleaning or disinfecting the glucose meter. During an interview on 1/4/18 1:40 PM, LPN #3 stated that Unit 2 only has one glucose meter for multiple residents and stated that the glucose meter was stored in the bag because that was the last glucose reading she had to complete for her shift. During an interview on 1/4/18 at 3:57 PM, the Registered Nurse (RN) Nurse Manager (NM) stated that Unit 2 has one glucose meter which is used for at least seven diabetic residents who receive daily finger sticks. The RN NM stated that the facility policy directs cleansing the glucose meter with Clorox wipes, the meter is to stay wet for one minute after use; the policy does not direct cleansing before use. Review of the CDC (Center for Disease Control) Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings revealed Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instruction, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Review of the manufacturer's instructions for cleaning the EvenCare G2 blood glucose meter, used to test blood glucose levels in the facility, revealed the EvenCare G2 Meter cleaning and disinfecting is very important in the prevention of infectious disease and lists several EPA registered disinfecting wipes recommended for cleaning and disinfecting the meter. 415.19(a)(1)(b)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18 the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. One (Resident #66) of nineteen residents reviewed for dignity was dressed in a soiled abdominal binder, was exposed with the door wide open and the privacy curtain not drawn and was in dressed in a hospital gown throughout the entire survey. The findings are: 1. Resident #66 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/27/17 revealed that the resident is cognitively intact and is understood and understands. a. Observations of the resident in bed in a hospital gown were as follows: - 1/4/18 at 2:56 PM, Resident he was lying bed dressed in a hospital gown, during an interview. - 1/5/18 at 11:30 AM, Resident was in hospital gown. - 1/8/18 at 8:39 AM, Resident in bed with hospital gown on. - 1/8/18 at 1:45 PM, Resident in bed with a hospital gown on. - 1/9/18 at 9:45 AM, Resident still in bed and in hospital gown. - 1/9/18 at 2:00 PM, Resident in bed in a hospital gown. - 1/10/18 at 9:00 AM, Resident was in bed in hospital gown. Review of Care Plan on 1/9/18 revealed there were no documented preferences regarding the resident's clothing. b. Observation on 1/9/18 at 7:24 AM revealed Certified Nursing Aide (CNA #3) and CNA #2 entered the resident's room to complete morning care. CNA #3 removed a [MEDICATION NAME]/abdominal binder the resident was wearing. The binder was heavily soiled with dried brown debris from top to bottom and observed on the outside and inside. The resident's [MEDICAL CONDITION], nor tube feeding was leaking. c. Observation on 1/9/17 at 3:41 PM revealed a Licensed Practical Nurse (LPN #4) removed leg braces from the resident's legs. Resident #66 was in bed by the doorway which was open to the common resident hall and the roommate and a visitor were in the room sitting approximately four feet from the resident; the privacy curtain between the residents was not drawn closed. The resident was only wearing a hospital gown without briefs and was exposed up to the hip. During an interview on 1/9/18 at 3:41 PM, LPN #4 stated he was only removing the leg braces from the resident's leg. During an interview on 1/9/18 at 2:00 PM the resident was in his bed in a hospital gown. When asked why he was in the gown and not dressed he stated he did not know and that he always wears a hospital gown. When asked if he preferred this he shrugged his shoulders. He stated he didn't mind wearing the hospital gown, but wouldn't mind wearing other clothes but didn't think he had any. During an interview on 1/10/18 at 8:17 AM, the Registered Nurse (RN#1) Unit Manager stated this resident doesn't get out of bed and we normally do not get the residents who stay in bed dressed. They stay in a hospital gown. The resident has a [MEDICAL CONDITION] and a catheter and being in regular clothes would be uncomfortable and the hospital gown is more comfortable. I never really thought about him always wearing a hospital gown. I do not really know if he prefers to be dressed. I never asked. I will go ask him his preference. I do not know if he has any other clothes to wear, I will check with him about this and maybe his mother will bring some in for him. During an interview on 1/10/18 at 8:51 AM, RN#1 Unit Manger stated she spoke with the resident regarding the hospital gown. He stated he doesn't mind wearing the hospital gown as he wore it at home, but wouldn't mind wearing his own pajamas but wasn't sure if his mother would bring some in for him. I called his mother and she will be bringing in some pajamas for him to wear. Review of a document entitled Rights as a Nursing Home Resident dated 2016 revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life. Recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The resident has a right to be treated with respect and dignity, including: the right to retain and use personal possessions, including clothing. 415.3(c)(1)(i)

Based on observation, interview and record review during the Standard survey completed 1/10/18, the facility did not ensure that the resident has a right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care and make choices about aspects of his or her life in the facility that are significant to the resident. One (Resident #65) of two residents reviewed for choices was not provided a choice regarding whether to receive a bath or shower; the resident's plan of care did not identify the resident's preference; and the resident did not receive showers in the facility in accordance with her wishes. The finding is: 1. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/17 revealed the resident has moderate cognitive impairment, understands, and is understood. The MDS documented that it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of an Activities Initial Review dated 12/7/17 revealed it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Additional review revealed the follow-up questions regarding the type and frequency of bathing were blank. Additional review of the Activities Initial Review revealed it was completed with the resident as the primary respondent. Review of the current comprehensive care plan (CCP) last reviewed 12/19/17 and the Bedside Kardex Report printed 1/5/18 revealed the section for Bathing documented Bathing/Showering: The resident will require total assist. The CCP documented that the resident has [MEDICAL CONDITION] over her entire body and complains of pruritic (itching) of her back, chest, and arms. Additional review revealed the resident is non-ambulatory and is transferred with the assistance of two staff using a mechanical lift. Review of computerized Point of Care (P(NAME)) documentation, completed by certified nurse aide (CNA) staff dated 1/2018 revealed the ADL (activities of daily living) section for Bathing did not specify the resident's preference. During an interview on 1/4/18 at 9:54 AM, the resident stated that she just asked the physician and got permission for a shower last week. The resident stated that she had not received a shower since she was admitted to the facility. Observation on 1/8/18 from 10:57 AM to 11:22 AM revealed the resident received a bed bath provided by a Certified Nurse Aide (CNA #1 who was assigned to the resident) with the assistance of the Assistant Director of Nursing (ADON). Observation on 1/9/18 at 10:28 AM revealed the resident was lying in bed. During an interview at the time of the observation, the resident stated she had just received a bed bath and Yes, I would like to take a shower. During an interview on 1/9/18 at 10:59 AM, CNA #1 stated that she has not given the resident any showers and she was told the resident could not have a shower. Interview with the Physician Assistant (PA) on 1/9/18 at 11:14 AM revealed there was no reason that the resident can't be out of bed and that it is okay for her to receive a shower as long as staff wrap her left arm IV (intravenous) site. Review of Nursing Progress Notes and Treatment Administration Records (TARs) dated 12/5/17 to 1/8/18 revealed no documented evidence that the resident refused a shower. 415.5(b)(1,3)

Based on observation, interview and record review completed during the standard survey completed on 1/10/18 the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Two (Residents #65, 66) of five residents observed for ADL's had issues. Specifically, Resident #66 had long toe nails and a foul body odor. Resident #65 was not provided with complete perineal care and did not attend activities due to lack of personal clothing. The findings are: 1. Resident #66 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 12/12/17 revealed that the resident is cognitively intact, understands and is understood. In addition, the MDS documents the resident requires extensive staff assistance for personal hygiene. The MDS indicated the resident has a [MEDICAL CONDITION] and a Foley catheter. Review of the Bedside Kardex Report used by certified nurse aides (CNAs) to provide care, dated 1/5/18 revealed the resident requires the extensive assistance of one staff for personal hygiene. Review of the computerized Comprehensive Care Plan (initiated on 9/13/17) revealed the resident has an ADL self-care deficit related to his advance [MEDICAL CONDITION], wounds and osteo[DIAGNOSES REDACTED]. With planned interventions for the resident to complete upper body extremities and total staff dependence for lower body ADL's. Observation on 1/9/18 at 7:24 AM revealed Certified Nursing Aide (CNA #3) and CNA #2 entered the room to perform morning care for the resident. CNA #3 removed a [MEDICATION NAME]/ abdominal binder the resident was wearing which was heavily soiled with dried brown debris. The resident's toenails were elongated about ½ - ¾ past the ends of the toes. When CNA #2 positioned the resident to complete personal care, a foul odor was detected when the resident's legs were spread. CNA #2 washed the resident's groin using four washcloths, two on each side, and each wipe the washcloth surface was observed soiled with a large amount of brownish/grey discolored debris. CNA #2 then washed each groin with soap again and rinsed until the debris was no longer visible on the washcloths. During an interview on 1/9/18 at 7:59 AM, CNA #2 stated she is the primary aide for the resident. During an interview on 1/9/18 at 4:08 PM, the Registered Nurse (RN #1) Nurse Manager NM stated that staff can obtain clean abdominal binders from the central supply in the hospital at any time. The resident is planned to receive two showers a week and is not incontinent so the resident's groin should not have had large amounts of debris with daily cleansing which he is planned to receive. Additional interview with the RN NM revealed that the podiatrist who cuts toenails has not completed services for this resident since admission in September. 2. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands, and is understood. The MDS documented that the resident is non-ambulatory and dependent on staff for all activities of daily living. Review of a hospital discharge summary dated 12/1/17 and updated 12/4/17 revealed the resident's discharge [DIAGNOSES REDACTED]. Review of an Admit Visit Note, written by a Physician Assistant (PA) dated 12/5/17 revealed the resident was admitted with a Foley catheter (tube inserted into the bladder to drain urine) which will be discontinued with plans to monitor for voiding to limit the risk of recurrent infection. Review of the current CCP last reviewed 12/19/17 and the Bedside Kardex Report, used by certified nurse aides (CNAs) to provide care, printed 1/5/18 revealed the following interventions: - The resident is non-ambulatory and is transferred using a mechanical lift with the assistance of two staff - When out of bed, utilize a Pedal Broda chair (specialized positioning wheelchair) in the tilt position - Extensive assistance by two staff to turn and reposition in bed - Total staff assistance for personal hygiene, bathing/showering, and dressing - The resident is incontinent of bowel and bladder; the Foley catheter was discontinued on 12/5/17 and requires total assistance for bowel and urine a.) Observation on 1/8/18 at 10:57 AM revealed CNA #1 provided morning care to the resident while in bed, with the assistance of the Assistant Director of Nursing (ADON). The CNA was observed to wash, then rinse and dry the resident's bilateral groin and pubic area. The CNA then carried the basin to the bathroom and dumped the water into the toilet. The CNA did not visualize or cleanse the female genitalia while providing perineal care. Interview with CNA #1 on 1/9/18 at 1:19 PM revealed when providing perineal care, I wash across the pubic area, down each groin and then down the middle. Some women do not like when we spread the inner (genitalia) and it gives me shivers now. Interview with CNA #1 on 1/10/18 at 10:00 AM revealed that Resident #65 was incontinent of urine prior to the provision of morning care on 1/8/18. Review of a facility policy and procedure (P&P) entitled Incontinent Care for a female resident dated 2/1/09 revealed the following: Using a wet washcloth with soap/periwash, nursing staff are to open labia (female genitalia) and washing downward cleansing the center of the perineum and passing over the meatus (external opening that urine passes through) - wash downward cleansing the inner labia farthest from you - wash downward cleansing the inner labia closest to you - wash downward cleansing the outer labia farthest from you - wash downward cleansing the outer labia closest to you - rinse and dry all areas in the same manner with a clean cloth b.) Intermittent observations on 1/4/18, 1/5/18, 1/8/18 and 1/9/18, between the hours of 8:30 AM and 3:00 PM revealed the resident was wearing a hospital gown and lying in her bed. The resident was not observed out of bed and there was no Broda chair in the resident's room. During an interview on 1/4/18 at 10:04 AM, the resident stated that she does not get out of bed to go to activities because she does not have any clothes. The resident stated that she has been at the facility for a month and staff are aware that she did not have any clothes. Observations of the resident's room on 1/5/18 at 10:22 AM and 1/8/18 at 7:30 AM revealed there were no clothes in the resident's dresser, closet or bedside table. During an interview on 1/8/18 at 7:30 AM, the resident stated that she is agreeable to getting out of bed. Interview with the Certified Nurse Aide (CNA #1) assigned to the resident, on 1/9/18 at 10:59 AM revealed she probably hasn't asked the resident is she wants to get out of bed and she hasn't seen a chair to use. Observation at the time of the interview revealed the CNA looked at several Geri-chairs located in the hallway near the resident's room and stated, maybe it's this one while pointing to a pink tilting chair at the end of the hall. A Physical Therapy Progress Note dated 12/28/17 at 8:53 AM documented that the resident was issued a Pedal Broda for OOB (out of bed) use. Recommend tilt position when OOB for improved stability and safety. Care plan updated. Interview with the Director of Rehabilitation Services on 1/9/18 at 11:39 AM revealed therapy issued the resident a Pedal Broda chair which is up on the unit. Observation on 1/9/18 at 11:59 AM revealed the Director pointed out the resident's Broda chair, located in the hallway near the resident's room, on the nursing unit. The Broda chair was a low, grey vinyl chair that had the resident's name written on an attached label. Interview with the resident on 1/9/18 at 10:26 AM revealed she would like to go to group activities if she had clothes, particularly religious activities. During an interview in the presence of the Registered Nurse (RN #1) Unit Manager UM) on 1/9/18 at 12:45 PM, the resident stated that she was agreeable to getting out of bed. Interview with the Physician Assistant (PA) on 1/9/18 at 11:14 AM revealed there was no reason that the resident can't be out of bed. Interview with the RN UM on 1/9/18 at 3:40 PM revealed she was not aware that the resident did not have any clothes. Interview with the Social Worker on 1/10/18 at 9:20 AM revealed she was not aware that the resident did not have any clothes. Interview with CNA #1 on 1/10/18 at 11:31 AM revealed she was aware that the resident did not have any clothes and that the dresser drawers were empty. When asked if she told anyone that the resident did not have clothes, the CNA stated Yes, everyone knew. 415.12 (a)(3)

Based on observation, interview and record review completed during the Standard survey completed on 1/10/18 the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Two (Residents #65 & 66) of three residents observed for pressure ulcers had issues. Specifically, Resident #66 had a new pressure area develop which went unreported by the Certified Nursing Assistant (CNA) which delayed treatment and Resident #65 had a pressure treatment which was not in place for two hours. In addition, the lack of barrier cream applied after perineal care (#65, 66). The findings are: 1. Resident #66 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 12/12/17 revealed that the resident is cognitively intact, understands and is understood. In addition, the MDS documented the resident required extensive staff assistance for personal hygiene and that the resident has two Stage IV pressure ulcers and one unstageable pressure ulcer, which were all present on admission. Review of the computerized comprehensive care plan (CCP) initiated on 9/12/17 revealed the resident was admitted with pressure ulcers of the right and left buttock, right heel, left ankle and second toe with planned interventions for the use of an alternating air mattress administer treatments as ordered, turn and position every two hours. Observation on 1/9/18 at 7:24 AM revealed Certified Nursing Aide (CNA #3) and CNA #2 entered the room to perform morning care for the resident. CNA #2 washed the buttocks and hips and the surveyor noted the Allevyn (absorbent dressing) dressing dated 1/8/18 was intact on the right buttock; however, the left buttock had multiple areas of excoriations and two-three large scabs; CNA #2 did not apply any barrier cream when the cleansing and drying of the buttocks was completed. During an interview on 1/9/18 at 3:26 PM the Licensed Practical Nurse (LPN #4) Team Leader stated that the day LPN #3 Team Leader did not report any new concerns or skin issues for the resident to him. Additional observation on 1/9/18 at 4:08 PM with the Registered Nurse (RN #1) Nurse Manger revealed the areas of skin breakdown on the left buttock were new and were not there when she completed the last weekly skin assessment one week ago. The RN NM stated during the observation that the CNA should have informed the LPN Team Leader, who should have informed her. 2. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands, is understood and was identified at risk of developing pressure ulcers. Review of the CCP updated 1/4/18 revealed the resident had a Stage III pressure ulcer on the sacrum (area above the tail bone on the right and left buttocks). CCP interventions include plan to apply barrier cream with incontinent care and to provide treatment as ordered to skin impairments. Review of a Skin/ Wound Note, written by the Registered Nurse (RN #1) Unit Manager (UM) dated 1/5/18 revealed the wound on the resident's sacrum measured 5.0 centimeters (cm) long by 1.5 cm wide with 0.2 cm depth. The RN UM documented that the wound is now a full thickness wound with 10 % (percent) yellow slough (soft, moist dead tissue) and 90 % pink tissue. Review of Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) dated 1/2018 revealed the 1/4/18 physician's orders [REDACTED]. Observation on 1/8/18 at 11:25 AM revealed two CNAs #1 and 4 provided fecal incontinence care during after the completion of a bed bath. When the resident was rolled to her right side, the resident was noted to be oozing soft brown stool and the sacral pressure ulcer was observed without a dressing. The resident continued to be positioned side to side by the two CNAs to place a slide sheet under the resident; the resident was boosted up in bed; pillows were place under the resident's arms; and CNA #1 combed her hair. Barrier cream was not applied to the resident after incontinent care and the sacral dressing remained off. Continued intermittent observation on 1/8/18 from 11:57 AM to 1:13 PM revealed the resident remained in bed. During an interview on 1/8/18 at 1:13 PM, LPN #1 Medication/Treatment Nurse was asked to provide the resident's sacral pressure ulcer treatment. The LPN stated that she had asked CNA #1 if the resident's dressing was okay and the CNA stated Yes. Observation on 1/8/18 at 1:48 PM revealed the sacral dressing remained off and LPN #1 cleansed the sacral pressure ulcer and provided the Santyl ointment treatment as ordered by the physician. Interview with CNA #1 on 1/9/18 at 10:59 AM revealed that she was aware that Resident #65's pressure ulcer dressing was off after morning care on 1/8/18 and that she told LPN #1 that the dressing was off. The CNA stated that she did not apply the barrier cream to the resident's skin after incontinent care because the nurse was supposed to do the treatment. 415.12(c)(2)

Based on observation, record review, and interview completed during the Standard survey completed 1/10/18, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. One (Resident #65) of one resident observed for range of motion (ROM) services received incomplete range of motion and ROM was not provided as planned. The finding is: 1. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/17 revealed the resident has moderate cognitive impairment, understands, and is understood. The MDS documented that the resident had functional limitations in range of motion of both the upper and lower extremities. Review of the current comprehensive care plan (CCP) last reviewed 12/19/17 and the Bedside Kardex Report, used by certified nurse aides (CNAs to provide care) printed 1/5/18 revealed the resident has limited physical mobility related to a history [MEDICAL CONDITION] (severe blood infection), acute UTI (urinary tract infection), B AKA, and limited ROM. CCP and Kardex interventions include the provision of PROM (passive ROM - exercises performed on the resident by nursing staff) to BUE (bilateral upper extremities) three times per week and AAROM (active assisted ROM - the resident performs the exercises with assistance from staff) to B hips three times per week. The CCP documented goals for the resident to maintain her highest level of functional mobility, maintain upper extremity ROM, and remain free of complications related to immobility, including contractures (loss of joint mobility). Additional review of the CCP revealed the resident was admitted to the facility for short term and the plan is for her to go home with her son and services when able. Interview with the Director of Rehabilitation Services on 1/9/18 at 11:38 AM revealed that Resident #65 has good range of motion of her elbows, however both of her shoulders are very limited. The resident is not a good candidate for rehab (rehabilitation) and the current plan is to provide ROM which is provide by CNA (certified nurse aide) staff. Observation on 1/10/18 at 10:16 AM revealed a Certified Nurse Aide (CNA #1) provided ROM services to the resident while she was lying in bed. The CNA was observed to provide PROM including flexion and extension to the resident's bilateral shoulders, elbows, wrists, and fingers. The CNA did not provide abduction (movement away from the body) and adduction (movement towards the body) or internal or external rotation to the resident's shoulders. Further observation revealed the CNA provided PROM to the resident's lower extremities, including flexion, extension, abduction, and adduction to the resident's hips. During the observation, the CNA passively moved the resident's legs and did not encourage the resident to initiate the movements on her own. During an interview on 1/10/18 at 10:26 AM, CNA #1 states that the resident's lower extremities are passive, you assist her, sometimes she moves her legs. The CNA stated that she doesn't do abduction or adduction to the resident's arms and never did. Interview with the Occupational Therapist on 1/10/18 at 11:19 AM revealed that she expects shoulder internal and external rotation and abduction and adduction to be done during ROM. PROM is done by the helper and AAROM means that the individual is encouraged to help with the exercise to the best of their ability and is assisted by the helper. 415.12(e)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18, the facility did not ensure the each resident medical record was maintained in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and Systematically organized. Three (Residents # 22, 39, 65) of 22 medical records reviewed had issues. Specifically, Residents #65 & 22 lacked documentation of activity involvement for December 2017, Resident #22 had inaccurate documentation of Activity involvement in January 2018, Resident #39 had a witnessed episode of respiratory distress which was not documented in the medical record. The findings include but are not limited to: 1. Resident #22 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/8/17 revealed the resident is in a persistent vegetative state and is dependent on staff for all activities of daily living. Review of an Activities Quarterly Participation Review (assessment) dated 11/16/17 revealed the resident is provided with 1:1 in-room visitation including sensory programming such as reading and playing music and she continues to be included in larger group programming including socials, special events and musical entertainment when out of bed and as able. The Quarterly Participation Review documented that the Resident's activity goals were met. Review of the comprehensive care plan (CCP), last reviewed 11/21/17, revealed the resident is non-verbal and unable to make her needs known. The CCP documented a goal for the resident to attend group activities as needed and be provided with 1:1 visits, music, and linked senior activities for sensory stimulation. CCP interventions include providing the resident with sensory stimulation and encouraging her to make eye contact with staff during 1:1 visits. The current Bedside Kardex Report printed 1/5/18 documented that the resident is provided with 1:1 visitation including sensory stimulation programs such as reading and playing music and will be included in larger group programming including socials, special events and entertainment when out of bed as tolerated and able. Intermittent observations of the resident on 1/4/18, 1/5/18, and 1/8/18 between the hours of 8:30 AM and 3:40 AM and 1/9/18 from 8:17 AM to 11:26 AM revealed the resident was either lying in bed or sitting in a Broda (specialized) wheelchair in her room. There was a television and a portable radio/tape player in the resident's room, however neither one was turned on during the observations. Review of the Unit 2 Activity Attendance records for November 2017 and 2018 revealed the resident attended one Special Event/ Entertainment on 11/1/17. Further review of the January 2018 Activity Attendance record dated 1/4/18 to 1/8/18 revealed documentation that T (television) and V (short social visit) were provided daily. Interview with the Director of Life Enhancement (Activities Director) on 1/9/18 at 10:13 AM revealed there was no Activity Attendance sheet available for December 2017. The Director stated that the monthly attendance record for December 2018 was misplaced and staff were unable to locate it. The Director stated that she had checked the attendance sheets on a daily basis and is sure that residents' activity attendance was being documented, however there is no documentation available at this time. During an interview on 1/10/18 at 9:35 AM, the Activities Aide (#1) stated either I or someone will turn the (resident's) TV on, it's usually on. It became automatic to put a T on the sheet. 2. Resident #39 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact understands and is understood. Review of the CCP initiated on 12/13/17 revealed the resident has altered respiratory status and difficulty breathing related to anxiety, end stage [MEDICAL CONDITION], respiratory arrest and sleep apnea. With planned interventions to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. In addition, to report to the physician increased respirations, decreased pulse oximetry, accessory muscle usage, purse-lip breathing. During the initial tour on 1/4/18 at 8:31 AM, the resident was sitting in bed in a semi-fowlers position wearing nasal oxygen (O2) and was markedly short of breath, with a respiratory rate of 30 per minute, using accessory muscles and pursed-lip breathing. During the observation, the resident told the surveyor the nurse knows she is having breathing difficulties and Licensed Practical Nurse (LPN #3) was outside the resident's door with the medication cart. Additional observation on 1/4/18 at 8:51 AM revealed the resident was receiving a breathing treatment with slower respirations and the resident appeared calm sitting in bed. During an interview on 1/4/18 at 1:23 PM, the resident stated she was recently hospitalized with an upper respiratory infection and pneumonia three weeks ago. Review of the Nursing Progress Note dated 1/4/18 revealed LPN #2 revealed the provider was in and ordered [MEDICATION NAME] (used to treat anxiety disorders) 5 milligrams (mg) twice a day, [MEDICATION NAME] (used to treat anxiety and nervousness) 2 mg four times a day, and increased fluid restrictions to two liters a day. There is no documentation form LPN #3 regarding the resident's respiratory distress, witnessed by the surveyor. During an interview on 1/10/18 at 12:29 PM, the Registered Nurse (RN) Nurse manager (NM) stated that the resident has unstable [MEDICAL CONDITION] with symptoms and that staff are expected to monitor, report and document episodes of respiratory distress. During the interview, the RN NM reviewed the 24-hour report for the day shift on 1/4/18 and stated that the resident had no documentation on the 24-hour report. 415.22 (a)(1,2)