Every finding on record at Tarrytown Hall Care Center

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00352594, NY00352648, NY00348708) from 9/24/24 to 9/28/24, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule from August 22, 2024 through September 25, 2024 the facility did not consistently provide adequate staffing on all units/shifts, to meet the needs of the resident/s. The findings are: During an interview on 09/25/24 at 11:20 AM, with the Administrator, the Facility Wide Assessment was reviewed and daily resident census information was requested. The Administrator stated they would provide clarification of minimum staffing requirements per shift, per title and per census. The following data was provided by Administrator: Certified Nurse Aides: 13-15 day shift, 10-13 evening shift, 6 night shift. Licensed Practical Nurses: 5-6 day shift, 4-5 evening shift, 3 night shift. Registered Nurses: 3-4 day shift, 1 evening shift, 1 night shift. A review of the facility staffing sheets from August 22, 2024 through September 25, 2024 and the minimum staffing provided by the Administrator based on Facility Wide Assessment and facility census, documented the facility was understaffed 35/35 days for Certified Nurse Aides and 24/35 days for Nurses. During Resident Council meeting on 9/25/24 at 2:06 PM, the [NAME] President stated there were not enough staff to provide resident cares. Sometimes residents could wait 3 hours to be changed, and there were only two Certified Nurse Aide on duty. During an interview on 09/27/24 at 03:53 PM Certified Nurse Aide #2 stated the facility is always understaffed and they routinely work double shifts and work extra shifts weekly. They stated they sometimes feel they have to accept overtime because there is not enough staff, and it is impossible to complete all tasks for all residents when staff is low. NY CRR 415.13(a)(1)(i-iii)

Based on record reviews and interviews conducted during the recertification and abbreviated surveys (NY00352594, NY00352648) from 9/24/24 to 9/28/24, the facility did not ensure that annual performance appraisals were performed for Certified Nurse Aides staff. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides (Staff #14, Staff #15, Staff #16, Staff #17 and Staff #18), received an annual performance appraisal. The Facility Policy titled Staff Development Program (dated 11/8/23) documented: Nurses aides (Certified Nurse Assistants) are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of nurse aides and address any specific areas of weakness identified in performance evaluations and through the facility assessment. The findings are: During an observation and interview on 09/25/24 at 03:10 PM with Director of Nursing and Human Resources Director, the Director of Nursing was provided a random sample of five staff members to provide documentation of annual performance appraisals (Staff #14, #15, #16, #17 and #18). The Director of Nursing and Human Resources Director were unable to provide documentation reflecting an annual performance appraisal for 5/5 staff members randomly sampled. The Director of Nursing stated they were not able to provide proof of annual performance appraisals. The Director of Nursing stated they were responsible for ensuring staff received annual performance appraisals. 10 NYCRR 415.26

Based on observation, interview and record review conducted during the Recertification Survey and Abbreviated Surveys (NY 00352594, NY 00352648) from 9/24/24-9/28/24, the facility did not ensure two residents (Resident #52 and #22) were fed by staff members who completed a State-approved training course to assist residents in eating or drinking as required by regulations. Specifically, the facility was not able to provide documentation that Resident Assistants successfully completed a State approved training course for two Resident Assistants (Staff #6 and Staff #10) observed feeding Resident # 52 with a diagnosis of dysphagia/receiving a pureed diet and Resident #22 assessed to hold food in the mouth/cheeks or residual food in the mouth after meals and receiving a mechanically altered diet. The findings are: 1. Resident #52 diagnoses included dementia, dysphagia, and significant weight change. The 5/14/24 Physician Order documented regular diet, pureed texture, thin liquids consistency. The 7/12/24 Quarterly Minimum Data Set documented Resident # 52 had severe cognitive impairment, received substantial/maximal assistance for eating and was on a mechanically altered diet (requiring change in texture of food/liquids). The 7/31/24 revised Activities Daily Living Care Plan documented extensive assist of 1 staff for eating. 2. Resident #22 diagnoses included dementia, Type I Diabetes Mellitus, and schizoaffective disorder. The 5/16/24 Physician Order documented low concentrated sweets diet, mechanical soft texture, thin liquids consistency. The Nutrition Care Plan (revised 5/17/24) documented: the resident had a nutritional problem or potential nutritional problem related to the need for a dysphagia diet, dementia. Monitor/document/report any signs or symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth. Several attempts at swallowing. Provide a soft diet as ordered. The Activities of Daily Living Care Plan with a revision date of 7/31/24 documented the resident required supervision for eating. The 9/13/24 Annual Minimum Data Set documented Resident #22 had severe cognitive impairment, received supervision or touching assistance for eating, held food in the mouth/cheeks or residual food in the mouth after meals and received a mechanically altered diet/therapeutic diet altered (requiring change in texture of food/liquids). During a brief interview on 9/24/24 at 12:23 PM the Director of Nursing stated the Speech Language Pathologist provided in-service for Resident Assistants upon hire. A thickened liquids competency was reviewed and after the in-service, resident assistants were able to feed residents. During observation/interview on 9/24/24 at 12:51 PM Resident Assistant #5 was observed handing out lunch trays on the second floor. They stated they frequently feed Residents and receive annual training from the facility Speech Pathologist. During an observation and brief interview on 9/24/24 at 12:54 PM, Resident Assistant #6 was observed feeding Resident #52. They stated they had worked for facility for about 4 weeks and they received an in-service on feeding the residents by Speech Pathologist on their first date of employment. During an interview on 9/26/24 at 10:30 AM the Speech Language Pathologist stated they were responsible for ensuring Resident Assistants received on their date of hire, an approximate one-hour training in-service/competency on feeding residents. They stated they had not completed and were not aware of a requirement for State approved training course. The Speech Language Pathologist stated the one hour competency documented the training provided: diet consistencies (regular, mechanical soft, ground, and pureed), fluid consistencies (regular thin, nectar, thick and honey) and positioning residents while feeding. They stated that upon completion of in-service/competency class, the facility considered Resident Assistants trained to feed residents. The Speech Language Pathologist stated Resident Assistants were informed to reach out to Unit Managers or them with any questions. The Speech Language Pathologist further explained that they believe feeding residents was allowed under the Certified Nurse Assistant or higher level of licensure scope of practice and not under the unlicensed Resident Assistant duties. They stated they had not discussed concerns about Resident Assistants feeding residents with Administration or Managers at the facility. During an observation on 9/26/24 at 12:33 PM, Resident Assistant #10 was observed feeding Resident #22 in the dining room on second floor of facility. During an interview on 9/26/24 at 2:18 Resident Assistant #10 stated they had been employed by the facility for about three weeks. They stated they had only received feeding assistance training at the facility on their date of hire and that the class was about 45 minutes and taught by the Speech and Language Pathologist. They stated the training covered resident swallowing problems, how to feed a resident, offering fluids, and food consistencies such as pureed and chopped. Resident Assistant #10 stated the Speech and Language Pathologist observed them feeding a resident on the 2nd floor about a week after their feeding assistance training date. They stated they were informed that feeding residents would be part of their duties when they interviewed with the Director of Human Resources. Resident Assistant #10 stated they had worked on different units in the building since their date of hire and feeding residents was frequently a part of shift duties. During an interview on 9/26/24 at 4:33 PM the Administrator stated Resident Assistants were provided with training from the Speech Language Pathologist and therefore they were allowed to feed the residents and that Nurses were responsible for supervising Resident Assistants. During a follow-up interview on 9/26/24 at 4:48 PM the Regional Director of Quality Assurance and Performance Improvement, the Administrator, and the Director of Nursing regarding Resident Assistants, the Regional Director of Quality Assurance and Performance Improvement stated that the Resident Assistants were allowed to feed residents after they took a one-hour competency in-service with the facility Speech Language Pathologist and demonstrated competency. The Regional Director of Quality Assurance and Performance Improvement stated they were not aware of any problem with Resident Assistants feeding residents with only a one-hour in-service/competency. The Regional Director of Quality Assurance and Performance Improvement stated that effective immediately, until they further investigate, they will allow only Certified Nurse Aidess and Licensed Nurses to feed residents. 10 NY CRR415.14

Based on record review and interview conducted during the recertification and abbreviated surveys (NY 00352594, NY 00352648) from 9/24/24 to 9/28/24, the facility did not ensure that Certified Nurse Aides were provided the required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aide #14, #15, #16, #17 and #18), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The findings are: The Facility Policy titled Staff Development Program (dated 11/8/23) documented: Nurses Aides are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of Nurse Aides and address any specific areas of weakness identified in performance evaluations and through the facility assessment. During an observation and interview on 09/25/24 at 03:10 PM the Director of Nursing and Human Resources Director provided documentation of 7.0 hours of in-service training for Certified Nurse Aide #14, #15, #16 and #17. The Director of Nursing stated they were not able to provide a full 12 hours of in-service training for Certified Nurse Aide # 14, #15, #16, and #17 and they did not have any in-service hours for Certified Nurse Aide #18. The Director of Nursing stated they did not perform staff competencies in 2024 and were not able to provide documentation of staff competencies after 4/2023 for Certified Nurse Aide #14, #15, #16, #17 and #18. The Director of Nursing stated they were responsible for ensuring staff received the required 12 hours of annual in-service. During an interview on 09/26/24 at 11:22 AM the Regional Director of Quality Assurance and Performance Improvement stated proof of in-services provided by the Director of Nursing and Human Resources Director on 9/25/24 had clerical errors documented for the length of time of each in-service. They stated they were not aware who documented the times on the in-service attendance sheets, but they were wrong. The Regional Director of Quality Assurance and Performance Improvement stated they did not know why four different staff members on two different dates would log incorrect times for the in-service training. They stated Certified Nurse Aide #18, who was missing documentation may have in-service documentation in the Human Resources office waiting to be scanned electronically. No further documentation was provided. 10NYCRR 415.26

Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY 00342701) from 9/24/24 to 9/28/24, the facility did not ensure that a resident's right to privacy was respected for 1 of 3 (Resident #80) residents reviewed for Dignity. Specifically, Resident #80's bathroom light was not working and they were told to leave the door open to create light while using the bathroom. The findings are: Resident #80 was admitted to the facility on [DATE] with diagnoses of hyperlipidemia, Alzheimer's Disease, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive deficits and needed partial to moderate assist for toileting and showering, and supervision for transfers. When interviewed on 9/24/24 at 1:51 PM, Resident #80's family member stated Resident #80 was told about 2 months ago to leave the door open for light while using the bathroom because the bathroom light was not working. The family member stated they had to call maintenance and, because they were not available over the weekend, it did not get fixed until Monday. There was no documented evidence in the 1/3/24 through 9/25/24 work order logbook of a request for the bathroom light to be fixed in Resident #80's room. When interviewed on 9/27/24 at 9:28 AM, Certified Nurse Aide #21 stated whenever anything was broken they would tell maintenance to fix it. They did not recall the light being broken in Resident #80's bathroom. When interviewed on 9/27/24 at 9:47 AM, the Director of Maintenance stated they were unsure why the facility did not call to make them aware the residents bathroom light was not working, since the family made the facilty aware in the middle of the day on Friday. The Director of Maintenance stated nobody called them over the weekend to inform them the light in Resident #80's bathroom was not working. The Director of Maintenance stated they could come in on weekends to fix things, as long as they were made aware. They further stated they should have been called or staff should have brought Resident #80 to another bathroom. NY CRR 415.3(d)(1)

Based on record review and interviews conducted during the recertification survey from 9/24/24 to 9/28/24, the facility did not ensure that each resident's screen for a mental disorder or intellectual disability was completed for 2 of 24 (Residents #31 and #48) residents reviewed for Pre Admission Screening and Resident Review. Specially, there was no documented evidence of pre-admission screening and resident review assessments for Residents #31 and #48. The findings are: The facility policy, Pre-Admission Screening and Resident Review dated 11/25/23 documented all residents have the required pre-admission screen prior to admission to the facility, and any time there is a significant change that has a bearing on the resident's specialized service needs. 1. Resident #31 had diagnoses which included mild cognitive impairment, depression, and seizure disorder. Resident #31's electronic medical record revealed there was no documented evidence that a pre-admission screen and resident review assessment was completed. On 9/26/24 at 3:05 PM during an interview with the Director of Social Work and the Administrator, they stated Resident #31 was admitted in 2016, and Resident #31's pre-admission screen and resident review assessment from that time must not have been scanned into Resident #31's electronic medical record, and the original document was not in the facility. They stated they were responsible to check if all residents in the building had pre-admission screen and resident review assessments on file. 2. Resident #48 with Diagnosis of unspecified sequelae of cerebral vascular accident, Hemiplegia, and hypertension Resident #48's electronic medical record revealed there was no documented evidence that a pre admission screen and resident review assessment was completed. On 9/27/24 at 3:05 PM during an interview with the Director of Social Work stated Resident #48's pre-admission screen and resident review assessment must not have been scanned into Resident #48's electronic medical record, and the original document was not in the facility. They stated they were responsible to check if all residents in the building had pre-admission screen and resident review assessments on file. 10NYCRR 415.11 (e) 47626

Based on observation, record review, and interview during the recertification survey from 9/24/2024 to 9/28/2024, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Residents #48) reviewed for Pressure Ulcers. Specifically, for Resident #48's bilateral heel floats while in bed for pressure reduction were not provided as per physician order and/or care plan. Findings include: The Policy and Procedure titled Pressure Injury Prevention and Management dated 3/2021 documented It is the policy of the facility to have appropriate interdisciplinary preventative care plan implemented when indicated. Purpose to prevent avoidable pressure injuries. Resident #48 had diagnoses of of cerebral vascular accident, hemiplegia, and hypertension. The Quarterly Minimum Data Set (an assessment tool) dated 7/26/2024, documented the resident's cognition was moderately impaired. The resident required set up assistance with eating and partial to moderate assistance for all other activities of daily living. The resident was assessed as being at risk for pressure ulcers, had an open lesion on the foot and had pressure relieving device/s to the bed and the wheelchair. The Care Plan titled Self-Care Deficit dated 3/29/24 and revised on 5/15/24 documented proper positioning, Heel Floats to both feet when in bed for pressure reduction and proper positioning. Physician orders dated 7/19/2024 documented Heel Floats to both feet when in bed, for pressure reduction and proper positioning . The 9/2024 Kardex directions documented Heel Floats to both feet when in bed, for pressure reduction and proper positioning; perform skin check when removed. There was no sign-off required for the CNAs. There was no documented evidence that heel floats were applied. There was no documented evidence in the September 2024 Medication Administration Record and/or Treatment Administration Record for the use of heel floats. There was no documented evidence that heel floats were applied. During observations on 09/24/24 at 6:51 AM, 10:10 AM, and 12:09 PM the resident was in bed, and their heels were positioned on the mattress. The black heel floats were not on the resident and were observed on the floor in the corner of the room. During observations on 9/25/24 at 8:58 AM, 12:19 PM and 3:38 PM, the resident was in bed with no heel floats on and their heels were positioned on the mattress. During an interview on 09/26/24 at 7:25 AM, Certified Nurse Aide #2 stated they knew how to take care of the resident as the nurse gave report. They stated they could look in the kiosk for directions. They stated they were unaware of any positioning devices for Resident #48. During an interview on 09/26/24 at 07:30 AM, Licensed Practical Nurse #3 stated the resident should have offloading booties and did not know why the resident did not have them on. If the resident refused the heel floats the Certified Nurse Aide should have notified the nurse and the nurse should write a progress note and notify the doctor. During an interview on 09/26/24 at 7:54 AM, Registered Nurse Manager #4 stated either the Certified Nurse Aide or the nurse should have applied the offloading device per the physician's order. If the resident refused the heel floats, the nurse should have notified the physician and written a note. During an interview 09/26/24 at 03:56 PM, Director of Nursing stated if a resident had an order and a care plan to off load their heels, they would expect the staff to apply the offloading device. If the resident refused it should have been documented and the medical provider should have been notified. 10NYCRR 415.12(c)(1)

Based on observation, interview and record review conducted during the recertification survey the facility did not ensure that residents were treated with dignity and respect. This was evident for 1 of 5 residents reviewed for dignity.(Resident #28). Findings include: Resident #28 was admitted with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set- a resident assessment tool) dated 12/21/2018 revealed the resident to be cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of a possible 15. During the initial screening process on 03/14/19 at 09:58 AM the resident stated that staff enter her room without knocking and requesting permission to enter. An observation performed on 03/14/19 at 10:25 AM revealed CNA #1 entering her room without knocking. On 03/15/19 at 09:25 AM Supply Manager #1 (SM#1) was observed on the 2nd floor entering resident rooms without knocking and waiting for permission to enter. On 03/19/19 at 09:45 AM, SM#1 was observed on the 1st floor entering resident rooms without knocking and waiting for permission to enter. In an interview with the resident on 3/19/19 at 12:15 PM she stated that her privacy is very important to her and that nothing ever changes at this facility. In an interview with SM#1 on 03/20/19 at 08:55 AM he stated he knocks when a resident's door is closed but not when the door is open. In an interview with the Director of Nursing on 3/20/19 at 9:55 AM she stated she will be in-servicing the staff today regarding the treatment of [REDACTED]. 415.3(c)(l)(i)

Based on record review and interview conducted during the recertification survey, the facility did not ensure that each resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including bed mobility, eating, personal hygiene, and dressing. Specifically, the facility did not evaluate and respond to a progressive decline in function as identified on the Resident Assessment. This was evident for 1 resident (#71) reviewed for activities of daily living. The findings are: Resident # 71 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS: an assessment tool) dated 7/31/18 documented the resident had severely impaired cognitive skills for decision making. It further documented the following; functional status and activities of daily living (ADLs) assistance was documented as: bed mobility: extensive assistance-one person physical assist, transfer: extensive assistance-two+ persons physical assist, dressing: extensive assistance-one person physical assist, eating: supervision-set up help only, toilet use: extensive assistance-one person physical assist, personal hygiene- extensive assist of one person. Further review revealed no nursing restorative programs in place and no physical therapy (PT) or occupational therapy (OT) being provided. The quarterly MDS dated [DATE] documented declines in bed mobility: extensive assist of 2+ persons, eating: extensive assistance-one person, no nursing restorative programs in place and no physical or occupational therapies were being provided. The quarterly MDS dated [DATE] documented further declines in dressing: total dependence-one person, personal hygiene-total dependence, decline in bed mobility as previously identified on the MDS of 10/25/18 remained the same. No nursing restorative programs and no physical or occupational therapies were being provided. The ADL function/Rehab potential care plan dated 8/10/18 and updated 1/21/19 documented: toilet use: extensive assist 1; personal hygiene: extensive assist 1; dressing: extensive assist (number of persons for assist not specified); eating: varied as limited assist/supervision; bed mobility: extensive assist 1; transfer: extensive assist 1. The goal for all care areas was to maintain current ADL functioning through the next review. The care plan progress note dated 1/21/19 documented: continue ADL. This care plan does not reflect the resident's current ADL status as identified on the MDS. The Activities of Daily Living, Range of Motion and Mobility policy and procedure dated 9/2017 revealed: A resident's ADL status is assessed on admission, quarterly, annually and as needed based on clinical observation. If a resident's ADL status is noted to have a decline, nursing will monitor the resident's status and send a referral to the appropriate department; the appropriate department is determined by how the resident is presenting clinically (i.e. if eating difficulty is noted a referral would be made to Speech Therapy). Review of the physician's orders [REDACTED]. Review of the Occupational therapist note dated 10/16/18 documented the patient was seen for assessment of divider dish but the divider dish was unavailable. Review of the Rehab. intervention note completed by the Director of Rehabilitation (DR) and dated 10/17/18 documented the resident received a divider plate on that date, the order was put in place and no further follow up needed; no further rehab services required. Review of the medical record revealed no documented evidence that declines in ADLs identified on the resident's MDS assessments, including bed mobility, personal hygiene and dressing were communicated to the physician and no orders were placed for screening, evaluation and treatment of [REDACTED]. The DR was interviewed on 03/20/19 at 9:21 AM and stated he reviewed the therapy record and reported the resident was last seen for OT on 6/8/18. When asked how declines in ADL status are communicated to rehab, the DR stated it would be based upon nursing documentation and a pattern of decline in function and increased assistance provided. The unit Nurse would obtain an order from the physician and it would be discussed in morning report. The rehab. staff would then evaluate. When asked if rehab. was made aware of the resident's decline noted between the MDS evaluations of 7/18 and 1/19, the DR revealed he was not notified and stated rehab. should have been notified to assess the resident. The MDS Registered Nurse (RN) was interviewed on 3/20/19 at 9:37 AM and revealed nursing is responsible for identifying declines in ADLs and referring residents to rehab. When asked if a change in ADLs for 2 or more areas would be identified as a significant change, the MDS RN stated if she thought the declines would resolve she would not do a significant change. When asked who completes the MDS section regarding ADLs, the MDS RN stated she completes this section. When asked if she would take any action regarding ADL declines identified on the MDS for ADLs, the MDS RN stated no, she does not make referrals as the unit Nurses are responsible for that. A follow up interview was conducted with the MDS RN on 3/20/19 at 12:09 PM. At that time the MDS RN reported that the MDS assessments dated 10/25/18 and 1/21/19, she had miscoded resident bed mobility as extensive assist of 2 whereas, the resident was extensive assist of 1 and she is submitting a correction as of today. When asked how she came to this conclusion, she replied through chart review. An interview with the Licensed Practical Nurse (LPN) responsible for resident care was conducted on 3/20/19 at 2:21 PM and revealed the certified nursing assistants (CNAs) would report declines in ADLs to the nurse. At that time the LPN reviewed the record and reported she did not see any decline in ADLs documented in the record. An interview with the RN responsible for corporate oversight of the facility was conducted on 3/20/19 at 2:50 PM. She revealed that she had spoken with the DR and she is aware the resident did not receive a therapy screen or services at the time of the order for the OT screen. She further stated she will be educating the DR on follow through for orders for rehab screens. 415.12(a)(1)(i-v) 415.12(a)(2)

Based on observation, record review and interview conducted during an abbreviated survey (NY# 0), the facility did not ensure that one of three residents reviewed was free from physical restraint imposed for purposes of convenience and not required to treat medical symptoms. Specifically, Resident #1 was seated close to the wall in the corner of the dining room and tables were moved close to her which prevented her from moving freely around the dining room in her wheelchair. The findings are: The facility policy for Abuse - Investigation and Reporting dated 9/2017 stated that residents shall not be physically restrained for any other reason than they are required to treat a resident's symptoms. The facility policy for Restraints dated 10/2017 stated that residents have the right to be treated with respect and dignity. This includes the right to be free from any physical restraints solely for purposes of discipline or convenience and that are not required to treat a medical symptom. Residents also have the right to be free from abuse resulting from the potential use of physical restraints that can limit freedom. This policy defined convenience as any action who's result has the effect of altering behavior so a resident requires a lesser amount of care and is not in the resident's best interest. Resident #1 had [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set, a resident assessment and screening tool) dated 8/15/17 revealed that the resident had severely impaired cognition, required extensive assistance of 2 with transfer, did not walk in her room or corridor, was totally dependent on the assistance of one person with locomotion on and off the unit and used a wheelchair as a mobility device. The Comprehensive care plan for Abuse Prevention was initiated on 8/14/17 and noted the resident had the potential to abuse others and had the potential to be abused by others. The care plan included goals that the resident would not be involved in peer abuse altercations and would not be a victim of peer abuse for 90 days. The interventions to achieve this goal included to assess causative factors resulting in behavior, to maintain an environment that provided safety and reduced agitation for the resident and to engage in activities that channel activity and reduce frustration by holding her baby doll. According to an Incident Report Form and summary of investigation, dated 5/10/18 and signed by the Director of Nursing (DON), on 5/10/18 a family member of another resident reported to the Director of Social Services that he observed CNA #1 push Resident #1 in a corner. CNA #1 was immediately removed from the schedule pending investigation. The DON interviewed CNA #1 who explained that Resident #1 was agitated and could not be controlled as she kept rolling her wheelchair around in the dining room. CNA #1 said that she placed the resident in her assigned area where she normally sat to have her meals daily. Other residents were interviewed and denied seeing any mistreatment towards Resident #1 from CNA #1. Surveillance camera was reviewed and confirmed that on 5/10/18 at 7:20 PM, CNA #1 did place Resident #1 close to the wall in the corner of the dining room and moved tables close to her which prevented her from moving around freely in the dining room. The facility concluded that there was evidence of mistreatment. CNA #1 did not believe that she did anything wrong despite attempts to educate her on her actions against the resident. She felt that her actions were protecting Resident #1 from falling in the dining room due to history of falls. CNA #1 wrote in a statement dated 5/10/18, that was part of the facility investigation, that she was not abusing the resident. She wanted to protect her. She had fallen and hit her head. CNA #1 did not want it happening again. The DON was interviewed on 1/9/19 at 8:40 AM. She stated that CNA #1 used the table to restrain Resident #1 who was cognitively impaired and continued to get up. Instead of engaging the resident with activities, she used the table to prevent her from getting up. CNA #1 was interviewed on 1/10/19 at 12:06 PM. She stated that Resident #1 got up from the table. She wheeled herself around and CNA #1 put her back by the table. Resident #1 was so confused. CNA #1 didn't want her to fall and she wanted to give her something to eat. She did not remember if she moved the table and put it in front of Resident #1. She claimed she put the resident where she normally sits. 415.4(a)(2-7)

Based on record review and staff interviews conducted during an abbreviated survey (NY 906), the facility failed to protect a resident's right to be free from abuse. Specifically, Resident #1 struck CNA #2. CNA #2 immediately responded by tossing liquid from a cup he was holding in his hand directly towards Resident #1's upper body and face area and then pushed Resident #1's wheelchair into the hallway towards LPN #1 and CNA #1, who were standing by the nurses' station. CNA #1 had to physically stop Resident #1 in his rolling wheelchair at it came towards her. The findings are: Resident #1 had [DIAGNOSES REDACTED].#1 was severely cognitively impaired, totally dependent on the assistance of one person for locomotion and used a wheelchair for mobility. A Comprehensive care plan for behavior and was initiated on 3/29/18 and was reviewed and revised on 4/12/18 and on 8/16/18, with a goal to minimize episodes of inappropriate behavior within 90 days. The interventions to achieve this goal included: Approach calmly, attempt to redirect resident, observe and document behaviors, psychiatric evaluation and follow-up. A Comprehensive care plan for psychosocial well-being was initiated on 4/12/18 and was reviewed and revised on 6/25/18 and on 7/9/18, with goals that included: Resident will exhibit a sense of well-being as evidenced by positive statements made by resident, observation of increased adjustment to facility for 90 days. The interventions to achieve this goal included: Approach resident in a calm manner; monitor for change in mood/behavior. A Summary of Investigation, dated 6/25/18 and signed by a corporate nurse for the facility, revealed that on, 6/23/18 at approximately 4:45 PM, LPN #1 overheard CNA #2 arguing with Resident #1 in the dayroom. LPN #1 called out to CNA #2 to release the brake on Resident #1's wheelchair so Resident #1 could wheel himself to her. LPN #1 started walking to the dayroom and saw CNA #2 throw liquid from a coffee cup of CNA #2. Then CNA #2 released Resident #1's wheelchair brake and pushed Resident #1 out of the dayroom and into the hall towards LPN #1. Per CNA #1, she was walking towards the dayroom when she witnessed Resident #1 hit CNA #2, CNA #2 threw coffee towards the resident and then pushed Resident #1's wheelchair out of the dining room towards LPN #1. CNA #1 had to stop the wheelchair from rolling and brought Resident #1 to LPN #1, who immediately called the supervisor. The Supervisor responded and assessed the resident for any injuries, did not note any reddened skin or discoloration to the face, neck and hands. At this time, Resident #1 did state to the supervisor that he (CNA #2) tossed coffee on me. CNA #2 returned to the facility after going outside briefly following the incident. The Supervisor obtained a statement from CNA #2 and asked him to leave the facility. Facility staff reviewed the camera and confirmed the statements provided by the witnesses, LPN #1 and CNA #1. It revealed in response to Resident #1 reaching out and hitting CNA #2 in his upper body, CNA #2 clearly and immediately responded by tossing liquid from a cup he was holding in his hand directly towards Resident #1's upper body and face area. CNA #2 then proceeded to take Resident #1's wheelchair by the handles and pushed the resident out of the dining room, releasing his hands from the wheelchair handles, sending Resident #1 in his wheelchair rolling towards the nurses' station. CNA #1 had to physically stop the resident's rolling wheelchair as it came towards her. As part of the investigation, CNA #2 wrote in his statement dated 6/23/18: On (MONTH) 23 at 4:45PM, I was sitting in the dayroom with a few residents. Resident #1 started getting upset. First, he started calling rude names, then he was hitting me. At first, I told him to stop but he continued for a few minutes. At that time of the incident, I had an ice coffee in my hands. As he was hitting me, I tossed the coffee on him and I moved him away from me in his wheelchair. The facility concluded based on all information collected and reviewed, that abuse and mistreatment did occur. CNA #1 was interviewed on 1/10/19 at 1:30PM. She stated that she worked on 6/23/18. As she was walking towards the nurses' station, she heard all the commotion, when she looked, Resident #1 was yelling and she saw CNA #2 throw a cup of liquid to the resident's face. She heard LPN #1 telling CNA #2 to bring resident over to her and CNA #2 pushed the wheelchair towards the nurse, who was by the nurses' station. CNA #1 was in between the nurses' station and the dining room and she stopped the wheelchair from going any further. Then CNA #2 picked up his things and left. LPN #1 was interviewed on 1/10/19 at 1:41PM. She stated that on 6/23/18, CNA #2 was monitoring the dining room and Resident #1 said, he hit me. LPN #1 was at the nurses' station, she stated she didn't see CNA #2 throw the liquid at resident. She further said that CNA #2 denied throwing the liquid at the resident's face but the resident was wet on the face. LPN #1 told CNA #2 to release the Resident #1's wheelchair but he pushed the wheelchair with the resident in it, it went too fast and CNA #1 caught him. CNA #2 was interviewed on 1/23/19 at 8:50AM. He stated that on 6/23/18, he was watching the dining room. Resident #1 was in the dining room and he aggressively was hitting CNA #2 who had a cup of coffee in his hand and it spilled on Resident #1. This occurred by the door of the dining room. He further said that after Resident #1 hit him, Resident #1 tried to spit on him and he pushed Resident #1 to his nursing aide. He thinks there was a nurse. He doesn't remember LPN #1 asking him to take Resident #1 towards her. 415.4(b)(1)(ii)

Based on record review and interview conducted during an abbreviated survey (NY 436), it was determined that the facility did not ensure that residents' personal funds deposited with the facility were conveyed to the individuals or probate jurisdiction administering the residents' estate within 30 days of death or discharge from the facility. This was evident for 5 out of 12 residents reviewed for personal funds who either expired or were discharged from the facility more than 30 days of the last quarterly resident funds statement of [DATE]. The findings are: A review of Resident Funds list ending [DATE] documented the names of residents, amount of savings deposited and date/discharge dispositions. Five out of 88 residents did not have their personal funds conveyed within 30 days of discharge or death including: - Resident #8, $571.10, discharged on [DATE]; - Resident #9, $ .00, expired on [DATE]; - Resident #10, $100.00, expired on [DATE]; - Resident #11, $2831.99, discharged on [DATE]; and - Resident #12, $7021.15, discharged on [DATE]. The person in charge of the business office (BO #1) was interviewed on [DATE] at 10:20 AM regarding the residents' personal account funds. BO #1 stated the facility policy was that the personal funds of residents are sent or forwarded to the resident or responsible party within 30 days after discharge or death. She stated further that if the resident is transferred to another facility, the funds are sent to the admitting facility. When asked as to why the residents' account have not been conveyed or transferred, she stated that the business office has had changes in personnel and had challenges to overcome. 415.26(h)(5)(iv)

Based on observation, record review, and interview conducted during a recent recertification survey, the facility did not ensure an environment as free of accident hazards as is possible. It was determined that 17 of 25 bed siderails observed on all three resident units (First, Second and Third Floors) were not properly fitted in the bed to prevent accidents and injuries. The bed siderails were either loose, wobbly or unsteady. The findings are: A room observation was conducted on 5/3/16 at about 10:25 AM for the resident in Room 326-A. It was noted that the siderail on the left side of the resident's bed was loose and this observation was brought to the attention of the unit charge nurse where the resident resides. A follow up environmental observation was conducted on 5/4/16 between 1:00 PM- 2:00 PM on all three resident units to determine the presence of the above observation in the other units. It was revealed that 16 more bed siderails were found to be either loose or unsteady: - First Floor: 102, 104-A, 108- A and B, 115-B and 119-A; and 115-B; - Second Floor: 208-A -Third Floor: 306-A, 318, 317-A and B, 322, 319-B, and 324-A and B. The maintenance log on all three resident units were reviewed. It was revealed that there were no entries documented regarding request for needed repairs for loose, wobbly or broken bed siderails, with the exception of a 5/3/16 entry in room 326-A that the surveyor brought to the attention of the First Floor unit charge nurse on that date. The First Floor unit charge nurse was interviewed on 5/4/16 at approximately 2:00 PM and stated that a maintenance log is kept by nursing for staff members to document any maintenance issues that needed to be addressed by the engineering/ maintenance department including broken bed side rails. The Director of Maintenance was interviewed on 5/4/16 at approximately 2:00 PM and stated that he has awareness of any problems related to repairs by checking the maintenance log book. The Director of Maintenance further stated that he would conduct periodic maintenance schedule to ensure proper functioning and safety of the side rails. The Assistant Administrator was interviewed following the above interview and stated that she would utilize a five-week cycle program to ensure all side rails are safe and in good working condition. 415.12(h)(1)

Based on observation and interview conducted during a recent recertification survey, the facility did not ensure that food safety practices were employed to prevent bacterial contamination of food. Specifically, foods that were cooked and cooled for later use were not being cooled according to industry standards. Additionally, potentially hazardous foods were not being held for service at the level of, or above the required temperature. The findings are: A tour of the kitchen was conducted on 5/4/16 at 8:45 AM. Ground beef was observed cooling in the refrigerator in a six-inch deep pan that was tightly covered with plastic wrap. The pan was still warm to the touch. Heat was being trapped in the pan preventing the ground beef from cooling properly. The Food Service Director (FSD) was interviewed at that time and stated that the usual cooling procedure is to put the food in the freezer until it cools down to 70 degrees. The FSD further stated that once it reaches 70 degrees, it is put back in the refrigerator. The FSD could not state what the time frames were for the food to reach 70 degrees and then 41 degrees (2 hours and 4 additional hours respectively). The FSD had no cooling logs to document and ensure that foods were being cooled according to industry standards. Other foods observed in the refrigerator that had been cooked and cooled were chicken quarters and manicotti. The FSD stated that he uses the leftovers as menu alternatives. A second visit to the kitchen was made on 5/4/16 at 12:15 PM. Temperatures were taken on the serving line to ensure proper holding temperatures of 135 degrees or above. All items tested on the serving line were in compliance. Hamburgers, the main menu item for lunch, were being held in a warm oven on several large sheet pans. The temperature of the hamburgers was checked several times and on different sheet pans. The temperature of the hamburgers ranged between 110 degrees and 120 degrees. These holding temperatures were significantly below the minimum required holding temperature of 135 degrees. In an interview with the FSD at that time, he stated that he knew that the hamburgers were not being held at the required temperature. He further stated that he would reheat them to 165 degrees before serving them. 415.14(h)

Based on observation and interviews conducted during a recertification survey, individualized care and services were not provided in a manner that maintained dignity for one randomly observed resident (Resident #23). Specifically, assistance to eat concurrently with tablemates, and in a timely manner, was not provided to Resident #23 during a lunch meal observation on one of three facility units (First Floor). This resulted in the potential for more than minimal harm that is not immediate jeopardy. The findings are: During a lunch meal observation on 3/3/15 at 12:33 PM, seven residents were noted to be sitting at the same table including Resident #23. At 12:35 PM, the six other residents (#16, #22, #24, #28, #62, #121) were served their lunch trays and started eating. A tray was not served to Resident #23. At approximately 12:55 PM, most of the residents at this table had finished eating their lunch. At that time, a CNA (Certified Nurse Aide) placed a lunch tray in front of Resident #23. The CNA did not start assisting the resident to eat. The CNA went back to the food truck and continued distributing the food trays to other residents in the dining room. The Licensed Practical Nurse (LPN #1) was interviewed immediately following the above observation. LPN #1 stated that Resident #23 needed assistance and had to be hand fed. LPN #1 stated that she was instructed that the resident may wait until all the residents in the dining room have received their trays. LPN #1 did not state the source of the instruction. The Registered Nurse Supervisor(RNS #1) was interviewed at 1:15 PM on 3/3/15 and stated that Resident #23 should have been assisted with the meal at the same time as the other residents. 415.5(a)

Based on observation, record review and interview conducted during a recertification survey, pressure relieving devices were not provided in accordance with the written plan of care to prevent development/redevelopment of pressure ulcers for one of one residents reviewed for pressure ulcers (Resident #107). Specifically, heel floats to keep the resident's heels off the surface of the bed were not applied. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #107 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment record of 12/30/14 identified that the resident had multiple small and discolored areas in the abdominal region, a new Stage 3 pressure ulcer acquired in the hospital, redness to the right heel and DTI on the left heel. The Minimum Data Set (MDS; a resident assessment tool) completed on 1/7/15 for a significant change in status indicated that the resident had a BIMS score of 5 out of 15 (Brief Interview for Mental Status; a test used to measure orientation and memory recall), was non-ambulatory, required extensive assistance to perform activities of daily living(ADLS) including bed mobility and total assistance for transferring. This MDS also indicated that the resident was at risk for developing pressure ulcers. An entry in the MD progress notes of 2/17/15 noted that the DTI pressure ulcer of the left heel ulcer was resolved. The use of heel floats to both feet while in bed was included in the resident's Comprehensive Care Plan(CCP) for "Actual Alteration in Skin Integrity" that was updated on 2/25/15 and in the current CNA (Certified Nurse Aide) Resident Care Profile record that provided information to the assigned CNA regarding the care of resident. The resident was observed in bed on 3/9/15 at approximately 8:00 AM. The resident's toes were slightly uncovered. No heel float or other device was applied to keep the resident's feet off the surface of the bed. The assigned 7-3 CNA (CNA #1) was interviewed on 3/9/15 at 8:50 AM and stated that the resident did not require the use of any pressure relieving devices. The resident was further observed at 10:00 AM and 11:00 AM on 3/10/15 and no heel floats or other type of pressure-relieving devices were observed to be applied on the resident's feet. CNA#1 was further interviewed at 11:05 AM on 3/10/15 and stated that she did not know that the resident required heel protectors. CNA #1 stated that she had not read the Resident Care Profile which documented the use of heel floats. The unit Registered Nurse Supervisor (RNS #2) was interviewed on 3/10/15 at 11:15 AM and stated that the resident needed heel floats. RNS #2 stated that a heel float is a kind of device where the heel portion was removed to prevent the heel from direct contact with any surface and, at the same time, elevates the heel off the bed. RNS #2 stated that the CNA Resident Care Profile provides information for the assigned CNA as to the use of pressure-relieving devices needed by the resident. (The assigned 11-7 CNA, who was responsible for applying the heel floats, was called via phone but did not return calls). The assigned 11-7 unit nurse Licensed Practical Nurse (LPN #1) and the 11-7 RNS (RNS #3) were interviewed on 3/10/15 at 7:30 AM. LPN #1 and RNS #3 stated that the heel floats were probably sent to the laundry and that there were no replacement heel floats available for the resident. 415.12(c)(1)(2)

Based on observation, record review and interview conducted during a recertification survey, the facility did not provide the necessary care to prevent potential development/redevelopment of pressure ulcers for one of one residents reviewed for pressure ulcers (Resident #107). Specifically, pressure-relieving devices (heel floats) to keep the resident's heels off the surface of the bed were not applied in accordance with the resident's written plan of care to prevent pressure ulcers. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #107 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment record of 12/30/14 identified that the resident had multiple small and discolored areas in the abdominal region, a new Stage 3 pressure ulcer acquired in the hospital, redness to the right heel and DTI on the left heel. The Minimum Data Set (MDS; a resident assessment tool) completed on 1/7/15 for a significant change in status indicated that the resident had a BIMS score of 5 out of 15 (Brief Interview for Mental Status; a test used to measure orientation and memory recall), was non-ambulatory, required extensive assistance to perform activities of daily living(ADLS) including bed mobility and total assistance for transferring. This MDS also indicated that the resident was at risk for developing pressure ulcers. An entry in the MD progress notes of 2/17/15 noted that the DTI pressure ulcer of the left heel ulcer was resolved. The use of heel floats to both feet while in bed was included in the resident's Comprehensive Care Plan(CCP) for "Actual Alteration in Skin Integrity" that was updated on 2/25/15 and in the current CNA (Certified Nurse Aide) Resident Care Profile record that provided information to the assigned CNA regarding the care of resident. The resident was observed in bed on 3/9/15 at approximately 8:00 AM. The resident's toes were slightly uncovered. No heel float or other device was applied to keep the resident's feet off the surface of the bed. The assigned 7-3 CNA (CNA #1) was interviewed on 3/9/15 at 8:50 AM and stated that the resident did not require the use of any pressure relieving devices. The resident was further observed at 10:00 AM and 11:00 AM on 3/10/15 and no heel floats or other type of pressure-relieving devices were observed to be applied on the resident's feet. CNA#1 was further interviewed at 11:05 AM on 3/10/15 and stated that she did not know that the resident required heel protectors. CNA #1 stated that she had not read the Resident Care Profile which documented the use of heel floats. The unit Registered Nurse Supervisor (RNS #2) was interviewed on 3/10/15 at 11:15 AM and stated that the resident needed heel floats. RNS #2 stated that a heel float is a kind of device where the heel portion was removed to prevent the heel from direct contact with any surface and, at the same time, elevates the heel off the bed. RNS #2 stated that the CNA Resident Care Profile provides information for the assigned CNA as to the use of pressure-relieving devices needed by the resident. (The assigned 11-7 CNA, who was responsible for applying the heel floats, was called via phone but did not return calls). The assigned 11-7 unit nurse Licensed Practical Nurse (LPN #1) and the 11-7 RNS (RNS #3) were interviewed on 3/10/15 at 7:30 AM. LPN #1 and RNS #3 stated that the heel floats were probably sent to the laundry and that there were no replacement heel floats available for the resident. 415.12(c)(1)(2)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that (1.) items other than narcotics were not stored in the narcotic box to prevent possible diversion and that (2.) Lantus insulin in a multi-dose vial was discarded in 28 days after opening per manufacturer's recommendation. This was evident during review of medication storage on one of three facility units (First Floor) and resulted in the potential for more than minimal harm. The findings are: Observation of the First Floor medication cart was conducted on 3/10/15 at 8:20 AM. It was noted that two vials of insulin (regular Novolog and Novolog 70/30) were stored in the narcotic box of the medication cart. These two vials were placed in a cup that also contained a bottle of Morphine Sulfate solution. The unit medication Licensed Practical Nurse (LPN #4) stated that she was aware that the narcotic box should not contain items other than narcotics but had to place these insulin vials in the narcotic compartment until she was ready to use them. Observation of the First Floor medication room was conducted at 8:30 AM on the same date. It was noted that a multi-dose vial of Lantus insulin, which was in active use for Resident #32, had an expiration date of 1/30/15 inscribed on its label to indicate 28 days after opening the vial. The label on the vial indicated that Lantus insulin "expires in 28 days once opened." The Registered Nurse Supervisor (RNS #1), who was present during this observation, stated that the Lantus insulin should have been discarded on the date inscribed on the vial which was 1/30/15. The manufacturer recommends that Lantus insulin must be discarded after 28 days once opened. 415.18(d)

Based on observation and interview, the facility did not ensure that food was prepared under sanitary conditions. Specifically, food preparation areas were not being sanitized after cleaning. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: During a tour of the kitchen on 3/5/14 at 2:15 PM, there was no evidence that sanitizer buckets were available at work stations for food service workers to sanitize work surfaces. The Food Service Manager stated at that time that the staff used a two sided bucket with soapy water on one side and sanitizer or bleach on the other side. The Food Service Manager then produced the bucket and it was an empty mop bucket. The Food Service Manager then stated that the staff have spray bottles that they can put the sanitizer in. He next produced an empty spray bottle and a full bottle of sanitizing solution. Following surveyor intervention, a station was set up in the kitchen with a bucket of soapy water and a spray bottle of sanitizer for the food service workers to clean and sanitize their work stations and equipment. 415.14(h)

Based on observation interview and record review, care was not provided in accordance with residents' written care plans. Specifically, fall prevention alarm devices were not in place for a resident with a history of falls and a toileting program was not implemented for a resident with a documented decline in urinary continence. This was evident for one of one residents reviewed for accidents (Resident #11) and for one of three residents reviewed for incontinence (Resident #34) and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #11 is [AGE] years old with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment of 1/29/14, the resident had a score of 11 out of 15 on a BIMS (Brief Interview for Mental Status) test used to measure orientation and ability to recall information. The MDS also indicated that the resident required the limited assistance of one person with bed mobility and transfer and required supervision with set-up help for walking and locomotion. An incident investigation indicated that the resident had a fall on 2/7/14 that resulted in pain to the hips, head and rib cage. The recommendation to prevent further falls was to initiate the use of the bed and wheelchair alarms. The resident ' s care plan that addressed falls was updated on 2/11/14 and identified numerous risk factors for further potential falls including mild dementia, history of falls and fracture, [MEDICAL CONDITION], cardiac history, vision and hearing problems, unsteady gait and balance, use of medications that may cause dizziness, incontinence, and non-compliance. Interventions to prevent further falls included the use of bed and chair alarms, which were initiated on 2/8/14. The current March 2014 Resident Care Profile, a care guide used by Certified Nurse Aides, included a note stating that the resident "ambulates unassisted in the room - monitor closely - respond to bed and wheelchair alarms immediately." The resident was observed in the unit dining room sitting in a wheelchair without an alarm device in place during lunch on 3/4/14 at about 12:35 PM. The resident was further observed in the dining room on the same date at about 2:30 PM. The resident stood up from the wheelchair at that time and no alarm sounded. A CNA (Certified Nurse Aide) observed the resident, responded and assisted the resident. The resident was again sitting in a wheelchair in the dining room without any chair alarm in place on 3/5/14 at 2:20 PM. The resident was observed in her room having breakfast in bed on 3/6/14 at 9:21 AM. At that time, no bed alarm device was in place and properly assembled to produce an audible alarm. An alarm box was noted on top of the mattress on the left side of the bed. The alarm box was not connected to the alarm pad on the bed in order to be functional. Another alarm box that was also not connected to the pad alarm device was observed on the floor on the right side of the resident ' s bed. A Licensed Practical Nurse (LPN) medication nurse was interviewed at the time of the above observations and inspected the bed alarm devices. The LPN stated that both alarm boxes were not working. The LPN medication nurse and the LPN charge nurse stated on 3/6/14 at 9:45 AM that use of the alarm devices was implemented in order to alert the staff of the resident ' s unsafe movements, transfers and ambulation in order to prevent further falls and injuries. The LPN charge nurse further stated at 10:45 AM on the same date that the alarms should be functioning because the resident was non-compliant and does not call for assistance. The CNA assigned to care for the resident was interviewed on 3/6/14 at 10:55 AM. The CNA stated that she did not observe whether a bed alarm was in place or functioning that morning. 2. Resident #34 is [AGE] years old with [DIAGNOSES REDACTED]. According to the MDS of 11/1/13, the resident had a BIMS score of 8 out of 15, required the extensive assistance of one person for toileting, and was frequently incontinent of urine, which was defined as seven or more episodes of urinary incontinence, but at least one episode of continent voiding, during the assessment period. The succeeding MDS assessment, dated 1/27/14, identified that the resident had a BIMS score of 7 out of 15, was totally dependent on two persons for toileting, and was then always incontinent of urine, which indicated that the resident had no episodes of continent voiding. The Bowel and Bladder Elimination care plan of 1/27/14 indicated that the resident was incontinent of bladder. Interventions to address incontinence included a toileting program, to monitor for changes in urine output and to educate the resident. There was no documented evidence in the clinical record that a toileting program was in place for the resident. Two CNAs assigned to the resident ' s care (CNA #1 and CNA #2) were interviewed on 3/6/14 between 12:00 PM and 1:45 PM. CNA #2 stated that the resident was incontinent of urine and that she, CNA #2, did not keep track of or document the time of day or the number of times the resident was observed to be wet from urine. CNA #1 stated that the resident was incontinent of urine. CNA #1 stated that oftentimes, the resident was already wet by the time the resident was taken to the bathroom. The LPN nurse in charge was interviewed on 3/6/14 at 1:50 PM and stated that the resident was on a toileting program and that the resident was supposed to be taken to the bathroom every two to four hours. The LPN nurse in charge stated that a toileting schedule was necessary in order to determine or establish a urinary pattern to assist the resident to regain his usual bladder function, as much as possible. The LPN in charge stated that the assigned CNAs were supposed to document the times the resident was taken to the bathroom. The LPN further stated that there was no monitoring that included a description of whether the resident was observed to be dry or was wet at the time of toileting. 415.11 (c) (3) (ii)