Every finding on record at Ten Broeck Commons

Based on observation and interview the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated foods were stored in the kitchen refrigerator and unit pantry, and eight (8) cups of pre poured undated almond milk at the bedside of Resident #160; 2) expired foods were stored in the dry pantry, walk in cooler, and reach-in refrigerator; 3) staff were observed not wearing hair and beard restraints while in the kitchen; 4) ice packs were observed in the Catskill unit pantry freezer; and 5) staff were observed not changing gloves between tasks.The findings include: The policy last revised 10/2025 titled Storage of Non-Perishable Foods documented, Dry goods (grains) shall be stored for a period not to exceed three months. All foods must be labeled and dated to ensure foods are being used in a proper timeframe, and any unopened food item will be discarded by the manufacturer labeled expiration date.The policy dated 2025 titled Storage of Perishable Goods documented, Left-over food items will be discarded after 72 hours. Food items shall be dated after opening and discarded after 72 hours or before the use by/ expiration date, whichever comes first. Any non- food items shall not be stored in refrigerator/freezer.The policy dated 2025 titled Personal Hygiene documented employees must have clean hair and worn in a manner that can be completely covered by the hair restraint.During the initial tour of the kitchen on 01/05/2026 at 9:39 AM with the Food Service Director, the following was observed:A dietary staff member not wearing a hair restraint. The main walk-in refrigerator and tray line refrigerator contained multiple racks of unlabeled and undated single serving puddings, desserts, prunes, salads, and drinks.The refrigerator contained a large carton of potato salad with a use by date of 12/02/2025 and a pan of ground macaroni salad covered in plastic wrap dated 12/20/2025. The cook's refrigerator contained thawed deli cut ham dated 12/30/2025.The dry storage room contained a pan with five (5) bags of portioned powdered rice dated 01/14/2025, clam base and ham base with no expiration dates, and an opened jug of soy sauce that required refrigeration. During an interview with the Food Service Director on 01/05/2026 during the initial tour at 9:39 AM they stated the dietary staff had just returned from break and despite being in the kitchen, did not have their hair restraint on yet. They stated the food items in refrigeration at the tray line were for production that day. They never label or date those items because they would be used that same day. They stated anything uneaten from the meal trays would be thrown out and any items left after tray line was complete at the end of the day would be dated at that time. Stock is rotated by the stocking staff person, but the disposal of expired food was everyone's responsibility.During an observation of the Catskill unit pantry on 01/05/2026 at 11:04 AM there was opened and undated prune juice in the refrigerator and four (4) medical ice packs in the freezer. Registered Nurse Unit Manager #1 was interviewed during the observation and stated the ice packs should not have been in the freezer and it was the nursing staff's responsibility to date the prune juice when it was opened. They removed the freezer packs and discarded the prune juice. During an observation and interview on 01/05/2026 at 11:23 AM there were eight (8) Styrofoam cups with lids on the bedside table of Resident #160. The cups were marked with a black letter A only, no date. Resident #160 stated they were cups of almond milk that were delivered with each meal. They had been saving the cups of almond milk to drink at their leisure. Resident #160 stated they would smell and/or taste the almond milk to determine if it was safe to drink.During an interview on 01/05/2026 at 11:34 AM, Certified Nurse Aide #2 stated they knew to discard food that had expired by looking at the date. They were aware the resident was keeping the almond milk and did not realize it was not dated. They stated the resident did not want it thrown away. They would speak with Resident #160 about discarding the undated almond milk. During an observation on 01/06/2026 at 2:00 PM two (2) kitchen staff members with beards and moustaches were observed without beard restraints while cutting raw meat and preparing sandwiches. During an interview with the Food Service Director on 01/07/2026 at 11:30 AM regarding the undated almond milk observed in Resident #160's room, they stated residents should not be storing food from their meal tray in their room and that the kitchen had no control over what was left in resident rooms. Surveyor asked about male dietary staff not wearing beard restraints. The Food Service Director stated staff with facial hair have been educated on wearing beard restraints. The Food Service Director then provided an in-service on hygiene that was completed in August 2025.During observations and interviews on 1/8/26 at 4:39 PM there were five (5) dietary staff members in the kitchen not wearing hair restraints. The Food Service Director stated the staff had just started their shift. Dietary Supervisor #11 was observed not wearing a hair restraint as they helped set hot food on the tray line. Dietary Supervisor #11 yelled for staff to put on hair restraints and put their's on too. Then Dietary Supervisor #11 was observed wearing gloves while touching a cart handle and then touched the spoon/ ladle part of serving utensils for service at tray line. They stated they realized they should have changed gloves after touching the cart handle. 10 NY CRR 415.14(h)

F880 AMBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the annual water sampling report for the year 2025 was missing, the annual facility assessment for legionella and required components were missing and not provided at time of survey. The findings are: During a review of facility records on 01/05/2026 at 10:00 AM, a water temperature log documented chlorine was added. A vendor service report dated 11/2025 had a sticker attached that documented the water report was due 12/2024. A lab report for legionella testing was dated 11/27/2024. When requested, the Maintenance Director was unable to provide a legionella lab report for 2025, a Water Management Plan and the annual facility assessment/ Department of Health form for Environmental Assessment of Water Systems in Healthcare Settings.The facility provided a policy and procedure for Water Management that did not document control locations or control limits or prevention measures.In an interview with the Maintenance Director on 1/6/25 at approximately 1:30 PM, the Maintenance Director stated that chlorine was added to the water to prevent legionella and water sampling was scheduled for next week.10 NYCRR 415.19

Based on observations, interviews, and record review conducted during the recertification survey from 1/5/2026-1/22/2026 the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life for 1 of 1 resident (Resident #43) reviewed for Dignity. Specifically, Resident # 43 was observed out of bed wearing socks that were labeled with the resident's name in front of the sock clearly visible to other residents, visitors and staff. The findings include:Resident #43 had diagnoses including Diabetes Mellitus, Cardiomyopathy (enlarged heart, makes it harder to pump blood) and an Immunodeficiency condition.The Facility Policy titled Quality of Life dated 2025 documented residents shall always be treated with dignity and respect. The residents will be assisted in maintaining and enhancing his self-esteem and self-worth.The admission Minimum Data Set (assessment) dated 11/26/2025, documented Resident #43 had moderately impaired cognition, could usually understand others and could make himself understood. The resident was dependent on staff for lower body dressing and donning footwear.The Care Plan Titled Activity of Daily Living dated 7/11/2025 documented Resident #43 was dependent on staff daily to meet activities of daily living. The care plan documented the resident required substantial to maximal assistance with putting on and taking off footwear; and required partial to moderate assistance with lower-body dressing. During observations on 01/08/2026 at 5:02 PM and 1/9/2026 at 4:09 PM, Resident #43 was in the hallway, seated in their wheelchair, and wearing socks labeled with their name clearly visible to other residents, staff, and visitors on the top of their foot.During an interview 1/8/2026 at 3:42 PM, Certified Nurse Aide # 8 stated the socks belonging to the residents were labeled on the outside near the toe area. They stated the socks should have been labeled on the inside and not visible to visitors and staff.During an interview on 1/8/2026 at 4:17 PM, Licensed Practical # 9 stated when the family brought clothes they were sent to the laundry for labeling. They stated the socks should have been labeled on the inside, so the names were not visible to others.During an interview 1/9/2026 at 3:00 PM, the Director of Environmental Services and Maintenance stated that resident clothing was first taken to the reception desk and then sent to the laundry, where labels were created and applied. The Director of Environmental Services and Maintenance stated that shirts should be labeled on the inside near the manufacturer's tag, pants should be labeled on the rear waistband, and socks should be labeled on the back rather than on the toe area where labels may be visible. 10 NYCRR 415.5(a)

Based on observations, interviews, and record review during the recertification survey from 01/05/2026-01/12/2026, the facility did not ensure that the Comprehensive Care Plan was revised to reflect changes and/or new interventions for one (1) of six (6) residents (Resident #71) reviewed for Accidents, and one (1) of three (3) residents (Resident #139) reviewed for Activities. Specifically, 1) Resident #71 had a behavior of wandering, entering other residents' rooms and laying in other residents' beds, and the behavior care plan did not reflect this behavior or interventions for the behavior; 2) Resident #139's care plan had not been revised to reflect their current activities they participated in.The findings included:The facility policy Care Planning last reviewed 02/2025 documented that the comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change1)Resident #71 was admitted to the facility with diagnoses that included dementia, depression, and falls. The admission Minimum Data Set, dated [DATE] documented Resident #71 had severely impaired cognition, no behaviors including wandering, was dependent on staff for transfers, and ambulation not attempted due to medical condition and fall history. The Behavior Care Plan created on 01/06/2026 with an initiation date of 10/29/2025, documented the resident has the potential to be physically aggressive related to anger, dementia, depression, poor impulse control. The goal was the resident will demonstrate effective coping skills, will not harm self or others. Interventions included to administer medications as ordered, monitor for side effects and effectiveness, analyze times of day, places circumstances, psychiatric consult as indicated. When resident becomes agitated intervene before agitation escalates, guide away from source of distress engage calmly in conversation, if response is aggressive staff to walk calmly away and approach later. There was no documented evidence in the care plan describing Resident #71's wandering behavior, entrance into other resident rooms, or occupying other residents' beds and interventions to protect them and other residents from potential resident-resident altercations. During an observation on 01/05/2026 at 11:38 AM, Resident #71 was observed alone laying in Resident #11's bed. Licensed Practical Nurse Unit Manager #9 came to the area and stated Resident #71 often goes in other residents' rooms. During an observation on 01/07/2026 at 12:13 PM, Resident #71 was in Resident #162's room laying in their bed. Resident #162 was outside the room, appeared upset that Resident #71 was in their room and bed, and went to get staff assistance. Resident #162's verbalization was mostly unclear when speaking with staff but gestured frustration with the situation and stated clearly, all the time. Resident #162 was reassured by Licensed Practical Nurse #15 who stated they would get Certified Nurse Aide #16 who would convince Resident #71 to get out of their bed. During an interview on 01/12/2026 at 10:32 AM, Licensed Practical Nurse Unit Manager #9 stated that Resident #71 does wander on the unit and does go into other residents' rooms. This specific behavior is not in the care plan but agreed it should be. They are responsible for reviewing the care plans for accuracy. They then collaborate with a Registered Nurse, and the Registered Nurse updates the care plan. 2) Resident #139 was admitted with diagnoses that included Alzheimer's Disease, major depressive disorder, and anemia.The Annual Minimum Data Set, dated [DATE] documented severely impaired cognition, no behaviors, moderate assistance required with eating, dependent on assistance for all other activities of daily living.During an observation on 01/05/2026 at 12:25 PM, Resident #139 was sitting in a wheelchair/recliner in common area, spouse visiting.During an observation on 01/06/2026 at 11:48 AM, Resident #139 was sitting up in recliner in the unit common area, spouse visiting. An activity recently ended but resident had not actively participated.During an observation on 01/07/2026 at 10:35 AM, Resident #139 was sitting up in a recliner in the unit common area, resting with eyes closed, music playing.The Activities Care Plan dated 2/15/22 documented that resident had a sense of humor and was dependent on staff for assistance. A biography followed with preferences they had in the past prior to admission. The goal dated 08/16/2023 documented that resident will maintain physical, cognitive and social skills by participating in activities of her capabilities and interests such as movie day. The interventions, last revised 5/2/22, documented that staff will ensure activities are those of her capability and interest. Monthly calendar will be provided.During an interview on 01/08/2026 at 9:30 AM, the Activities Director stated that they reviewed all the activities care plans and was responsible for updating them quarterly and as needed. The activities staff directly involved with the resident on the unit may update as well. They stated that Resident #139's spouse came every day and that was their main activity. Otherwise, they provide one to one visits. Resident #139 also sits in the unit common area and watches the lucynt table (a table that projects images on it), will participate with fidgets, and attend socials and worship service. They had not revised the care plan to reflect the spouse visits and other activities described but could add them.During an interview on 01/09/2026 at 9:40 AM Activities Leader #17 stated Resident #139 enjoys music, they read chronicles to them, perform manipulatives at the table, and enjoys hand massages. They stated they did not attend the care plan meetings. They could review and edit the care plans, but really the Activities Director handles the care plans. They were focused on performing the activities on the unit with the residents. During an interview on 01/12/2026 at 2:31PM, the Director of Nursing stated that care plan updates were quarterly, annually, and as needed. If there was a change between care plan meetings, they would expect that to be completed. Registered Nurse Unit Managers complete the care plans, Licensed Practical Nurse Unit Managers work with a Registered Nurse to complete the care plans. The activities care plan should be completed by the Activities Director. The nutrition care plan was completed by Dietary, and the Social Worker was responsible for the advanced directives care plan. NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that care was provided to prevent pressure ulcers for 1 of 5 residents (#9) reviewed for pressure ulcers. Specifically, Resident #9 had a physician order for offloading gel boots, to be worn at all times, and was observed without the gel boots. The findings include: Resident #9 had diagnoses including Cerebral Infarction, Type 2 diabetes mellitus, hemiplegia. The Quarterly Minimum Data Set, dated [DATE] documented the resident's cognition was intact, the resident required substantial to max assist with all activities of daily living. The resident was at risk for pressure ulcers and pressure relieving devices for both the chair and bed were used. A Braden Scale assessment completed on 12/15/2025 documented a score of 16 indicating the resident was at risk for pressure injuries. The Care Plan titled At Risk for Skin Breakdown dated 8/27/2025, revised 12/9/2025, documented interventions included the physician would be notified for skin breakdown, and to do weekly skin observations. The Care Plan Activities of Daily Living dated 8/27/2025, documented the resident wore gel boots at all times. The Physician Order dated 12/23/2025 documented gel boots to bilateral feet at all times. Licensed Practical Nurse #4' progress note dated 12/23/2025, documented the resident complained of tenderness to right heel and the right heel had blanchable redness. The left lateral foot near metatarsal had blanchable redness. Gel boots were applied to both feet. During an observation on 01/05/2026 at 12:23 PM the resident was positioned in a Geri chair, socks on both feet and the gel boots were not in use. The resident's heels were pressing against the footrest. During an observation on 01/07/2026 at 9:42 AM the resident was out of bed in a Geri chair positioned with a black wedge to the left and a pillow under their left arm. The resident's feet were in socks, and they did not have gel boots on. During an interview on 01/07/2026 at 11:42 AM, Resident #9 stated they wanted to wear the off-loading boots, and the staff had not been putting them on them. During an observation on 01/07/2026 at 11:55 AM, Resident #9 was in the dining room, in the Geri Chair, and was not wearing gel boots. The resident's heels were pressed against the footrest of the Geri Chair. During an interview on 1/7/2026 at 12:00 PM, Licensed Practical Nurse #4 stated Resident #9 had a reddened area to their left heel. The resident should have been wearing the pink boots to offload their heels. They stated the resident had a stroke, and the left side was paralyzed which put them at risk for skin break down. During an interview on 01/07/2026 at 11:44 AM Certified Nurse Aide #3 stated they thought the resident only needed the boots while in bed. During an interview on 01/09/2026 at 10:12 AM the wound nurse stated the staff reported the resident heels were red, and gel boots were ordered for the resident. When the wound team looked at the heels, they were not red, and the order for the gel boots was continued for prevention. The resident should have been wearing the gel boots at all times. The resident was at risk for developing skin breakdown of the heels related to the history of a stroke and a left hemiplegia (weakness). During an interview on 01/09/2026 at 2:59 PM the Director of Nursing stated the resident had a physician order for gel boots and it was care planned in the Activities of Daily Living Care Plan. The resident should have been wearing the gel boots and if they were unavailable, at a minimum, the heels should have been offloaded. 415.12(c)(1)

Based on observation, record review and interview during the recertification survey conducted 01/05/2026 through 01/12/2026, the facility did not ensure proper disposal of garbage and refuse. Specifically, the garbage/recycle dumpster was left open and there were cardboard boxes spilling over the top and debris on the ground around the dumpster.The findings are:The facility policy titled Disposal of Refuse reviewed 12/2025 documented outside dumpsters or compactors provided by waste management services will be kept closed and free of surrounding debris.During an observation of the garbage area on 01/05/2026 at 11:39 AM with the Food Service Director, the recycle dumpster lid was open with cardboard boxes spilling over the top; pieces of cardboard box; used gloves; plastic packing material; and plastic drink lids laying on the ground surrounding the dumpster.During an interview with the Food Service Director on 01/05/2026 at 11:39 AM, they stated the garbage and recycle is picked up once weekly. They do not think the lid to the recycle dumpster is ever closed, and stated, it is too high for anyone to reach it to close.During a follow up observation of the garbage area on 01/08/2026 at 4:36 PM the recycle dumpster lid remained open, no debris surrounding the area. During an interview on 01/12/2026 at 9:51 AM, the Director of Maintenance stated the door to the recycle dumpster should be closed per the facility policy. They stated maybe kitchen staff did not close the lid because it has been cold, and staff didn't want to stay out in the cold. They will provide education to the kitchen staff since they are the last to use the dumpsters each day. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during the abbreviated survey (NY00371242) the facility did not ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents. Specifically, on 02/04/2025 Resident #1 who was severely cognitively impaired and required a two person assist for transfers via mechanical lift as per their care plan, was transferred by Certified Nurse Aide #1 from chair to bed alone and unassisted. Resident #1 was found with flaccidity and deformity to right hip/leg and was ordered by the Nurse Practitioner to be transferred to the hospital. According to report received by the facility from the hospital, Resident #1 sustained a right spiral hip fracture requiring surgical intervention. Certified Nurse Aide #1 admitted transferring Resident #1 via mechanical lift without assistance.The Findings are: The policy titled Mechanical Lift revised 2025, documented two or more people are necessary to safely transfer a resident with a mechanical lift to provide a safe mechanism to transfer residents from bed to chair or chair to bed. The policy titled Certified Nurse Aide Kardex/Task List revised 2025, documented an essential communication tool outlining each resident's current plan of care and certified nurse aides are required to review the Kardex at the beginning of each shift noting transfer and mobility needs. The policy titled Activities of Daily Living revised 01/2025, documented the facility is to provide activities of daily living care to all residents based on assessment of needs, the responsibility of the Certified Nurse Aide is to provide the necessary assistance the resident requires in accordance with the plan of care. Resident #1 was admitted with diagnoses including but not limited to dementia, atrial fibrillation, hypertension, and anxiety disorder. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident #1 had severe cognitive impairment, unable to speak and dependent for all transfers and bed mobility. Review of the Care Plan dated 09/28/2023 documented Resident #1 was dependent on staff for activities of daily living and transfer from chair /bed to chair, dependent of 2 (two) with use of Hoyer lift. Review of the progress note dated 02/05/2025 at 7:40 AM by Licensed Practical Nurse Unit Manager #6 documented they arrived on the unit to evaluate Resident #1 lying in bed. Resident #1 was noted with evident flaccidity and deformity to right hip/leg. There was no bruising/discoloration/swelling to the site. Resident was given Tylenol as needed for comfort. The Assistant Director of Nursing was notified and called to assess; Nurse Practitioner notified and placed order for resident to be sent to hospital for evaluation. Resident's daughter notified and agreed with emergency room evaluation. The ambulance company was called for transport. Report given to hospital emergency room. Resident left facility at approximately 8:30 AM. Review of the progress note dated 02/05/2025 at 8:16 AM written by Assistant Director of Nursing documented the Resident was noted in bed in left side laying position, pillow between legs being attended to by assigned Certified Nurse Aide #2 providing morning cares. Noted Residents right lower extremity was flaccid with deformity at hip/femur head. No bruising was noted to affected extremity. Resident noted with contractures at left hip and bilateral knees. Resident had facial grimacing. Nurse Practitioner called and notified, with new orders given to transfer to emergency room for evaluation. Resident's hip was stabilized with a hip abductor wedge for transportation to emergency room. Later the Facility received report that the hospital assessed Resident with a periprosthetic right spiral hip fracture with an unstable prosthesis status post unknown injury with recommendation of revision surgery of the right hip prosthesis. Surgery scheduled for 02/06/2025. Review of the 02/2025 Investigative summary revealed that on 02/05/2025 Certified Nurse Aide # 2 went to provide morning cares to Resident #1 when they noticed the Resident's right leg was not aligned at baseline. Resident #1 reached for their right hip and grimaced. Certified Nurse Aide #2 notified Licensed Practical Nurse Unit Manager #6 who also notified Assistant Director of Nursing to assess Resident #1 at bedside. The Nurse Practitioner was made aware and gave an order to transfer Resident #1 to emergency room for evaluation. Resident #1 was unable to give statement due to diagnosis of dementia. Staff members that cared for Resident #1 in the previous 24 hours were interviewed. The investigative summary documented it was noted that Certified Nurse Aide #1 transferred Resident #1 back to bed at approximately 9pm, unassisted. Certified Nurse Aide #1 stated during an interview by facility staff that they were aware of Resident #1's plan of care to transfer with two-person assist, I looked at her and thought I could do it by myself'. Certified Nurse Aide #1 stated they used the Hoyer lift and that they did not note any abnormalities with Resident #1 following the transfer. Certified Nurse Aide #1 had received all education related to mechanical lift transfers (completed with two (2) assist) and had signed the material confirming understanding and agreement to follow policy. During an interview on 08/21/2025 at 1:28 PM, Certified Nurse Aide #2 stated they went to provide morning cares to Resident #1 and noticed their leg looked different. This was reported to the nurse. Certified Nurse Aide #2 stated they know to check the Kardex for resident transfer status and can also check the care plan. The facility provide education during new hire orientation and annually to reinforce the use of 2 (two) staff for all mechanical lifts and to report any resident behavior or physical changes to a nurse right away. The Certified Nurse Aides give report to each other about their assignment during change of shift. During a phone interview on 08/22/25 at 4:19 PM Licensed Practical Nurse #4 stated they worked the overnight shift on 02/04/2025 and Resident #1 was noted to be calm and quiet. They did not observe any abnormal behaviors when they irrigated Resident#1's foley. They did not have to manipulate the Resident's leg for this task. They did not recall Certified Nurse Aide #1 reporting any concerns during change of shift. During a phone interview on 08/26/2025 at 12:10 PM Certified Nurse Aide #12 (Lead) stated they provided Kardex plan of care orientation and training including activities of daily living care and documentation to Certified Nurse Aide #1. Certified Nurse Aide #1 signed the orientation form acknowledging the training. During an interview on 08/26/2025 at 9:25 AM Unit Manager Licensed Practical Nurse #6 stated Certified Nurse Aide #1 was deliberate by transferring Resident #1 alone, they were aware they needed to get someone to help with the transfer because of the Hoyer pad underneath Resident #1 and all Hoyer transfers are a 2 (two) person assist. Certified Nurse Aide #1 had stated that they had transferred residents by themselves before. During an interview on 08/22/2025 at 2:35 PM with Assistant Director of Nursing stated Certified Nurse Aide #1 was a new aide to the facility and had received extensive onboarding education, they should have never attempted a transfer alone. There were no staffing issues the evening of the incident, there were other certified nurse aides that could have helped with the transfer. During an interview on 08/21/2025 at 3:23 PM the facility Administrator stated Certified Nurse Aide #1 was terminated 02/08/2025 for failure to follow plan of care and refused to sign the letter of termination. During a phone interview on 08/27/2025 at 1:18 PM facility Medical Director stated they were informed Resident #1 was injured as a result of a transfer. They read the x ray /cat scan report, and the injury was likely from the transfer. The Medical Director stated Resident #1 had a right hip fracture in 2018 with surgical repair, and prosthetics could weaken from stress. The Medical Director stated this would be less likely the cause of the recent injury and is probably a result of harm to Resident #1 from the improper transfer. 10NYCR 483.25 (d)(1)(2)

Based on observations, record review, and interviews during a recertification survey, it was determined the facility did not ensure all residents had the right to a dignified existence for 1 of 2 residents (Residents #116) reviewed for personal property. Specifically, the facility did not ensure Resident #116 received a dignified existence as they were transferred to the facility from an assisted living home without their belongings, and actions were not taken to ensure the resident was able to receive their personal property. Findings include: Resident #116 was admitted to facility with diagnoses including peripheral vascular disease, diabetes, cerebral vascular attack, and acquired absence of left leg above knee. The quarterly Minimum Data Set (MDS, an assessment tool) dated 7/21/23, documented Resident #116 was cognitively intact. A psychosocial note dated 6/23/22 documented the social worker and the resident contacted the assisted living facility and spoke with the Administrator. The Administrator believed the resident's belongings were still in storage and would follow up with the social worker by the end of the day. A comprehensive care plan note dated 6/22/22 documented the team met with Resident #116 and the Ombudsman and discussed concerns about obtaining the resident's belongings from assisted living facility. A psychosocial note dated 7/8/22 documented the resident and social worker called the assisted living facility together yesterday and expected a returned call and none occurred. The social worker spoke to the Administrator and they said they gave the message to the owner yesterday. They stated the owner was not in the building and would relay the message. They added the owner was the only one who had access to the outside storage facility where resident's belongings were be stored. A psychosocial note dated 7/19/22 documented the social worker spoke to resident again about the owner of assisted living facility not returning their calls. Resident #116 stated they wanted to try to call again and if the owner did not respond they would call legal aide to open a case and suspected the personal items might be gone. When interviewed on 9/14/23 at 1:32 PM, Resident #116 stated he previously was a resident at an assisted living facility and his personal wheelchair and belongings were still there. Resident #116 stated they would be able to do more with their electric wheelchair. When interviewed on 9/14/23 at 3:49 PM, the Director of Social Work (DSW) stated Resident #116 informed them that they requested their personal items from the assisted living facility, and they were never brought over. DSW stated this was about 1 year ago and the resident never mentioned it again. DSW stated at that time they had a care plan meeting with the ombudsman, the resident and the family via phone. They discussed the personal items Resident #116 had at the assisted living facility and were informed that their belongings were put in storage. DSW stated they spoke to the facility 6/23/22 and was told the items were still in storage. DSW stated they called again 7/7/23 and 7/8/22 and spoke to facility staff and DSW was informed the personal items were in an outside facility and the owner was the only one who had access. On 7/19/22 a social worker met with Resident #116 who informed the social worker if the facility did not find his belongings, they would take legal action. The DSW stated they thought the resident was handling it by taking legal action. The DSW was unaware if the resident took any further action and they did not follow up. When re-interviewed on 09/18/23 10:17 AM, the DSW stated they spoke to Resident #116 who wanted to take further action and they would be following up. 10 NYCRR 415.5(a)

Based on observations, interviews and record review during the recertification survey completed on 9/20/23, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #226) of six residents reviewed for skin care. Specifically, Resident #226 received active ice temporary pain relief cream to the perineal area by a certified nurse aide (CNA). There was no order for this cream; the treatment cart was not locked, and were no documented evidence that the resident was assessed by a registered nurse (RN) or Resident #226's physician was notified. Findings include: The facility policy Certified Nursing Assistant undated documented CNAs are not allowed to perform certain tasks that are considered invasive, dangerous, or neglectful. Supplies within the CNAs scope of practice must be retrieved from the locked treatment cart by a licensed nurse. Only licensed nurses can assess and remove any treatment supplies from the treatment cart. Resident #226 was admitted to the facility on [DATE] and had diagnoses including but not limited to anemia, essential hypertension, muscle weakness, and ulcerative colitis. The 7/3/23 Admission Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assist of two with most activities of daily living (ADL). The care plan dated 6/26/23 documented the resident was at risk for development of a pressure ulcer as evidenced by: decreased mobility and refusal to remove brief at bedtime to allow the skin to breath. Interventions included barrier cream after peri care; checking the resident for incontinence every 2 hours and changing as needed with toileting; and the physician would be notified if skin breakdown was noted. The physician's order dated 8/11/23, revealed an order for Triad cream combined with zinc applied to the sacrum every day and evening shift for moisture associated skin damage (MASD). During an interview with Resident # 226 on 9/14/23 at 9:49 AM, the resident stated CNA #7 applied Active ice temporary pain relief (compared to biofreeze) to the resident's perineal area, which caused burning. Review of the resident's electronic medical record (EMR) on 9/14/23 revealed no documented evidence that the incident occurred and no evidence Resident #226 was assessed by a registered nurse or that a physician was notified. During an interview with CNA # 7 on 9/18/23 at 10:43 AM, CNA stated that she applied Active ice temporary pain relief instead of A&D skin protectant ointment to the resident's perineal area and the resident screamed. CNA #7 stated that both the Active Ice cream and the A&D ointment were in the unlocked treatment cart. CNA#7 stated she was aware that only licensed staff were supposed go into the treatment carts but there was no A&D ointment in the clean utility room, where it was usually kept. Upon observation on 9/18/23 at 10:59 AM, Active Ice temporary pain relief cream was observed in treatment cart not labeled. Both the soothe and cool protect Vitamin A&D skin protectant ointment and Active Ice temporary pain relief tubes were observed to be similar in color and shape. During an interview on 9/18/23 at 11:11 AM, the RN Unit Manager (RNUM) #1 stated treatment carts should be locked and CNAs were not allowed to apply treatments except A&D ointment or peri guard (type of barrier ointment). During an interview on 09/18/23 at 11:13 AM, the Director of Nursing (DON) stated that prescribed creams and ointments were to be labeled with the specific resident's name and should not be in the treatment carts unlabeled. During an interview on 9/18/23 at 12:27 PM, NP #2 stated she was not notified that Resident #226 received active ice temporary pain relief and that she expected to be notified of any medication errors. During an interview on 9/20/23 at 05:06 PM, CNA #8 stated that she was assisting CNA # 7 with Resident # 226's cares when CNA # 7 applied active ice temporary to Resident # 226 perineal area. CNA #8 stated did not remember the day of the incident but did remember the nurse on duty was notified and did not attend to Resident #226. [10 NYCRR 415.11(c)(2)(ii)]

Based on observations, record reviews, and interviews conducted during the recertification and abbreviated surveys (NY00313960), the facility did not ensure 1 of 5 residents (Residents #450) reviewed for pressure ulcers received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #450 had a pressure ulcer worsen, there was no documented turning and positioning and the medical provider was not notified timely of a change in condition. Findings include: Resident #450 was admitted to the facility on [DATE] for short term rehabilitation with diagnoses including cerebrovascular accident (CVA, stroke), urinary tract infection (UTI), and diabetes (unstable blood sugar). The admission Minimum Data Set (MDS, assessment tool) dated 8/22/22, documented Resident #450's cognition was intact and the resident required extensive assistance of 2 staff for transfers, bed mobility and toilet use, and extensive assistance of 1 staff for personal hygiene and dressing. The resident was always incontinent of urine and frequently incontinent of bowel. The resident had a Stage 3 pressure ulcer present on admission and treatments included pressure reducing devices for the chair and bed, pressure ulcer care and applications of ointments/medications. The admission assessment dated [DATE] documented Resident #450's skin assessment revealed a healing scab on the left gluteus near the sacrum measuring approximately 1 x 1.5 (unit of measurement not specified), bilateral boggy heals, and 2 scabs on the left lower leg. The comprehensive care plan initiated 8/15/23 documented the resident was at risk for development of pressure ulcers due to impaired mobility. Interventions included turning and positioning every 2 hours and a pressure relieving mattress when in bed. The comprehensive care plan initiated 8/16/23 documented the resident had a Stage 3 pressure ulcer on the right buttock and interventions included administering treatments as ordered and monitoring for effectiveness; assessing and documenting the status of the wound perimeter, wound bed and healing progress; and reporting improvements and declines to the physician. The wound care consult (nurse practioner (NP #1) from a contracted agency) progress notes documented Resident #450 had a Stage 3 pressure ulcer on the right buttock and on: - 8/16/22, measured 1 centimeter (cm) x 0.3 cm x 0.1 cm (length x width x depth), the wound bed was 50% slough (dead tissue) and 50% epithelialization (healing tissue), the treatment was Zinc oxide and A&D ointment. - 8/23/22, measured 1 cm x 0.3 cm x 0.1 cm, there was no drainage, 100% pink epithelial tissue, the treatment remained the same. - 8/30/22, measured 1 cm x 1 cm x 0.1 cm, there was no change in wound progression, the wound bed was 100% slough, and the treatment was changed to honey alginate and triad to periwound. A physician order dated 8/30/23 documented the treatment to the right buttock was to cleanse with soap and water, pat dry, apply honey alginate (wound product to remove dead tissue and aid in healing) daily, cover with a clean dry dressing, and report any decline in site. The treatment administration records (TAR) dated August 2022 and September 2022 revealed Resident #450: - had the honey alginate dressing change signed for daily from 8/31/22 to 9/8/22. -a weekly skin check was done on 8/30/22 and 9/6/22. The Weekly Skin Assessment documented on 8/30/22, the wound was still there; and on 9/6/22, area remains, no new skin issues. The wound care consult progress note dated 9/8/22 documented Resident #450's Stage 3 pressure ulcer on the right buttock measured 7 cm x 7 cm x 0.2 cm, the wound bed was 60% slough, 25% granulation tissue, and 25% epithelial tissue, the treatment was changed to a Dakins wet to dry dressing. The NP #1 documented the wound was deteriorating and an air mattress was ordered. There was no documentation in the EMR from 8/30/22 to 9/8/22 (9 days) of a wound assessment or notification to a medical provider regarding the wound worsening. The attending physician (MD #2) progress notes documented on 9/5/22 Resident #450 was seen for anemia/weakness; on 9/8/22 for weight loss; on 9/12/22 for acute follow-up visit; on 9/15/22 for monthly medication renewal. The physician's discharge summary, dated 9/19/22, documented Resident #450 was admitted to the facility for rehabilitation after stroke. The resident participated in PT/OT (physical therapy/occupational therapy) with improvement and was medically cleared for discharge. There was no evidence in the physician progress notes that MD #2 was aware Resident #450 had a pressure ulcer. The wound care consult progress note dated 9/19/22 documented Resident #450's Stage 3 pressure ulcer on the right buttock measured 5.5 cm x 9.5 cm. x 0.8 cm, the wound was improving, consent for debridement was obtained and the treatment was changed to Santyl. The nursing progress noted dated 9/19/22 documented NP #1 debrided the pressure ulcer. The progress note by NP#3, dated 9/21/22, documented the resident was discharged home. There was no documentation regarding the resident's pressure ulcer. Review of CNA documentation, dated 8/15/22 to 9/21/22, revealed no documented turning and positioning. When interviewed on 9/18/23 at 3:10 PM, the Registered Nurse Unit Manager (RNUM) #5 stated residents with pressure ulcers were followed by the wound team. The team consisted of NP#1 (wound care provider from an outside agency), the facility's wound nurse (RN#2), Unit Manager, and another nurse or the Assistant Director of Nursing (ADON). If something came up in between NP #1's rounds, RN#2 would see the resident. The Weekly Wound sheet was done by RN #2 and the Weekly Skin Assessment was done by the licensed practical nurse (LPN) on the shower day. RNUM #5 reviewed the wound care consult progress notes dated 8/30/22 and 9/8/22 and stated the wound deteriorated significantly and they could not recall what was going on at the time. RNUM #5 stated they were usually pretty good at reporting changes and would have reached out to RN #2 between NP #1's visits. RNUM #5 stated turning and positioning was signed for by CNAs but she was unable to locate it in the EMR. When interviewed on 9/19/23 at 8:30 AM, RN #2 stated she was the facility wound care nurse and was contacted by staff when residents were identified with skin impairments. She stated NP #1 did weekly rounds and the Unit Manager would call or email if there was a change in the wound between weekly rounds. Care Plan interventions were determined by the team including the Unit Manager, wound nurse, physician, and dietary. Weekly skin check were done by the LPN on the unit and document on the weekly skin assessment form. The Weekly Wound assessment sheet was completed by them (RN #2). RN #2 stated she did not recall if Resident #450 needed assistance with turning and positioning and if they did, it would be on the care plan and CNA task list. When asked for documentation regarding turning and positioning, RN #2 stated she was unable to find it. When reviewing wound consultation notes, RN #2 stated on 8/30/22 the wound got a little bigger and was all slough and the dressing was changed to a different agent. On 9/8/22 it got much bigger and the treatment was changed. When asked, RN #2 reviewed the EMR and said a skin assessment on 8/30/22 documented wound is still there, and on 9/6/22 area remains, no new skin issues. RN #2 stated there were no wound assessments between 8/30/22 and 9/8/22 and that they were off during that time. RN #2 stated someone should have been notified during that time. Usually when there was a significant change in the wound size, we would look at nutrition and changes in overall condition. When interviewed on 9/19/23 at 3:08 PM via telephone, NP #1 stated they came to the facility weekly and did rounds with the facility wound nurse, RN #2. If there was a change or concern, between visits RN #2 would get in touch. NP #1 stated there were also other NPs and physicians in house and who looked at wounds when needed. When reviewing wound care consult progress notes, NP #1 stated on 8/30/22 the wound was slightly bigger and had gone back to slough in the wound bed so she ordered a treatment to remove the slough. On 9/8/22, it was deteriorating and was a lot bigger. NP #1 stated it was unknown when the change occurred and notification was up to the facility. When interviewed on 9/21/23 at 9:39 AM, the attending physician (MD #2) stated there was a wound consultant that came weekly and rounded with the wound care team. If a resident's wound was not improving, they would call him to evaluate. MD #2 stated if he was contacted he would assess the wound, check mobility status, nutrition, labs, and write a progress note. MD #2 sated the wounds usually improved and he did not ever hear about them. When asked to review NP #1's wound consultation progress notes, MD #2 stated he would have expected to be informed when seeing the change from 8/30/22 to 9/8/22. 10NYCRR 415.12(c)(1)

Based on observation, record review, and interview during the recertification survey and an abbreviated survey (# NY00311693, NY00321960) completed on 9/21/2023, the facility did not ensure that 2 of 3 residents (Resident #84 and #354) reviewed for accidents, received adequate supervision and assistance to prevent accidents. Specifically Resident #84 was not transferred as care planned and sustained a fracture of the right leg. Resident # 354 who has a history of behavior hit resident #135 with a wet floor sign on the head that resulted in a laceration to his head. The Findings are: 1. Resident # 84 had diagnoses including a fracture of the right femur, dementia, and Major Depressive Disorder. The Quarterly MDS (Minimum Data Set, a resident assessment and screening tool) dated 1/18/23 revealed the resident's cognition was severely impaired and no behavior problems. The resident required total assistance of 2 staff for bed mobility and transfers. The Policy and Procedure titled Accidents revised 2023 documented the facility to provide accurate timely examination and documentation. Implement interventions and to maintain records of unusual occurrences for identification and resolution of safety risks. A Comprehensive Care Plan Titled Activity of Daily Living initiated on 2/26/19, documented the resident was non ambulatory and transferred with a Hoyer (mechanical lift), full pad and two staff assist. The certified nurse aide (CNA) Care Card dated 2/23 documented the resident required a two person assist and used of a mechanical lift. The Assignment sheet for 2/2323 -2/25/23 documented CNA #1 was assigned to Resident #84 on 2/24/23. The progress note dated 2/25/23 documented the resident presented with dark purple colored bruising to right ankle and an x-ray was completed. The x-ray report dated 2/25/23 documented a fracture of the right distal tibia and fibula. (Fracture of the Right ankle) The Progress note dated 2/25/23 documented the resident was transferred to the hospital for evaluation. The progress note dated 2/25/23 documented the resident returned from the hospital and family declined treatment. A brace splint was in place to right extremity. Review of the incident report dated 2/25/23 documented the fracture occurred during the evening of 2/24/23 and CNA #1 transferred the resident not according to the plan of care. A review of the footage of the video surveillance on 2/24/23 at 7:00 AM, revealed at 7 PM CNA #1 entered the Resident #84's room without any other staff member and was in the room for approximately 10-15 minutes. The Medical Progress note dated 2/27/23 documented to maintain the gel boot on right foot and neurovascular checks every four hours. Review of the statement dated 2/27/23 written by CNA #4 documents morning cares was provided to resident on 2/24/23 no injury or pain was noted. During an interview on 9/19/2023 at 11:34 AM with LPN #1 she stated I worked a double on 2/24/23 days into evening and wheeled the resident to their room. no one reported any bruising or discoloration to me. The resident also was not reported as having pain the following morning. I was told she had the swelling and the discoloration and was sent to the hospital for evaluation. During an interview on 9/19/2023 at 11:04 AM CNA # 1 stated they were assigned to the resident on 2/24/23 on the evening shift. When they went in the resident's room, the resident was already in bed. During an interview on 9/19/2023 at 11:46 AM, CNA #2 stated, on 2/25/23 they provided cares to the resident and took off her boot and saw bruising and swelling to the right leg. The resident cried out in pain upon touching their leg, it was immediately reported it to the nurse. During an interview on 9/19/2023 at 1230 pm LPN #2. stated on the morning of 2/25/23 the residents's right leg was swollen with discoloration, the supervisor assessed the leg and call for an x-ray which showed a fracture of the tibia and fibula resident family was updated, and resident was transferred to the hospital. During an interview on 9/19/2023 at 11:18 AM, the Administrator stated video was reviewed during the investigation and CNA #1 was seen going into the room and no other staff with him although he denied transferring the resident by himself. 2. Resident # 354 with a diagnosis of Alzheimer Disease, Heart Failure and Anxiety. The Quarterly MDS (Minimum Data Set, a resident assessment and screening tool) dated 7/15/23 revealed resident's cognition was moderately impaired and the resident had physical, verbal and wandering behavior problems. The psychiatrist progress note dated 8/9/23 documented to discontinue Buspar and decreasing Seroquel and Zoloft and continue Ativan; the benefits of medication outweigh the risk. The Behavior note dated 8/11/2023 documented Resident #354 was wheeling wheelchair around the unit, into peers and kicking staff. Staff attempted to redirect and were unsuccessful. Ativan was offered as scheduled and accepted. The Behavior note dated 8/11/2023 documented resident was assigned a staff member to sit with her because of combative behavior. The Behavior note dated 8/12/2023 documented Resident #354 became agitated after awakening from sleeping and Ativan was offered and accepted. The Progress note dated 8/13/2023 documented Resident #354 was observed up on her wheelchair by the nursing station. Resident hit resident #135 on the forehead with blunt object. During an interview on 9/20/202 at 12:58 PM, CNA #3 stated the resident had a lot of behaviors and responded well to familiar faces and familiar routine. The wet floor sign was within her reach, and she hit Resident #135 on his head. During an interview on 9/20/2023 at 10 AM, LPN #4 stated the resident had a history of having behaviors and both residents were sitting at the nursing station when Resident #354 hit Resident #135 on the head with a wet floor sign, he sustained a small laceration to the head and sent to the hospital for evaluation. During an interview on 9/20/2023 at 12:21 PM, the Director of Nursing (DON) stated the facility did many things to manage the resident behavior and one staff was assigned for monitoring. During an interview on 9/20/2023 at 10:15 am the administrator stated the facility did many things to manage the resident behavior she had Lewy body dementia which was very hard to manage. In summary, the facility was aware of Resident #354's behaviors and did not provide adequate supervision to protect other residents. 483.25(d)(1)(2)

Based on record review and interview conducted during an abbreviated survey (NY00317720), the facility did not ensure that all alleged violations involving physical abuse, including injuries of unknown source was reported immediately to the New York State Department of Health (NYS DOH). This was evident for 1 of 4(Resident # 1) reviewed for Abuse. Specifically, Resident # 1 reported on 6/03/2023 that a staff member slammed their right hand and they had a bruise to the dorsal (back) of their hand and complained of pain to the site. The facility did not report the incident to the NYSDOH. The findings are: The Facility Policy titled Freedom from Abuse Neglect and Exploitation dated 8/2022 documented that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone including staff. The facility will investigate and promptly notify the Department of Health (DOH) when there is reasonable cause to believe abuse has occurred. The Director of Nursing (DON)/Designee) will ensure the DOH is notified promptly, but not to exceed 5 working days from the incident. Facility Policy was not in accordance with State/Federal regulations. Resident # 1 had diagnoses that included but were not limited to Hypertension, Renal Insufficiency, and Dementia. The Quarterly MDS (Minimum Data Set, an assessment tool) Quarterly Minimum Data Set (MDS, an assessment tool) dated 5/01/2023 documented a Brief Interview for Mental Status (BIMS) score of 13, indicating moderate cognitive impairment. Resident # 1 required extensive assistance of two staff for dressing, and toileting; extensive assistance of one staff for bed mobility, transfer, and personal hygiene; and supervision for eating. The resident had behavior problems and wore a wander guard. Review of the Facility Accident/Investigation (A/I) report dated 6/03/2023 documented that the incident occurred on 6/03/23 at approximately 8:00am when a Certified Nursing Assistant (CNA) called for the other CNA on the unit to assist them with Resident # 1 who was physically combative and had punched and kicked the CNA. Immediately the CNA was removed from the resident's care. Resident # 1 reported to staff that the CNA had slammed their hand. The allegation was reported to the nurse who notified the Registered Nurse Supervisor (RNS) who conducted the assessment and investigation, reported the incident to the resident representative (RR) and to the Physician, Director of Nursing (DON), and the Administrator. The resident had bruising to the dorsal side of the hand, had no complaints of pain, and was at baseline with range of motion (ROM), skin intact and without swelling. With the findings from the investigation and the resident's behavior history, the Administrator determined that they believed no abuse neglect or mistreatment occurred. Incident was not reported to NYSDOH. During an interview conducted with the Administrator on 6/6/23 at 4:26 pm, the Administrator stated that they were made aware that Resident #1 had a bruise to their finger in the shift report generated every day. RNS started the investigation based on the injury of unknown origin(bruise). CNA#1 was removed from the resident's care and the physician was notified. It is protocol to notify the family member. The Administrator stated that the RNS ruled out abuse, neglect, on Saturday 6/3/2023. No report was made to the NYSDOH because the investigation concluded that there was no abuse. During an interview conducted with DON on 6/12/23 at 12:45 PM, the DON stated that the supervisor called to report what Resident# 1 alleged and what their findings were. The report to the DON was that Resident # 1 was combative with a CNA#1, and another CNA assisted the resident with morning cares. Resident # 1 stated someone punched them. The RNS interviewed CNA#1 and the resident. Resident # 1's story was inconsistent. The DON stated whenever there was an allegation of abuse, the facility completes an investigation, and the nursing supervisor completes the assessment. CNA#1 was removed from the assignment during the investigation and it was reported to the Administrator. If it is determined that abuse occurred, then the incident is reported to the NYSDOH. 415.4(b)(1)(i)

Based on observation, interview and record review conducted during an abbreviated survey (NY 794), the facility did not ensure that a resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #2) reviewed for dementia care. Specifically, a Certified Nurse Aide (CNA#2) was noticed to pull on Resident #2's shirt while the resident was trying to get up from a chair and was also observed to forcibly sit Resident #2 in a chair. The incident was observed on video footage and witnessed by the Licensed Practical Nurse who reported it to the Administrator. CNA #2 was suspended subsequently terminated at the end of the investigation. The findings are: The facility Policy and Procedure entitled Dementia Care Policy and Procedure dated 7/25/22 documented that it is the policy of the facility to optimize the quality-of-life function of the residents by improving approached to meet the health, psychosocial and behavioral health needs of all residents, especially those with dementia. The policy further documented residents should be provided with a supportive environment that promotes comfort and recognizes individual needs and preferences. In addition, staff should meet the needs of the residents as determined by resident assessments and individual plans of care. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/14/21 documented that the resident had a Brief Intermittent Score of 0, indicating a severe cognitive impairment. Resident #2 required one-person extensive physical assist for bed mobility, transfers, walking, locomotion, dressing, toileting, and personal hygiene, and supervision/set up for eating. Review of the Dementia Comprehensive Care Plan (CCP) revised 4/3/19 documented that the resident had impaired cognitive function/dementia/impacted thought processes related to dementia. Resident had difficulty making decisions. Interventions included keep resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Present just one thought, idea, question, or command at a time. Review of the Communication CCP dated 4/3/19 documented that the resident had a communication problem related to unspecified sensorineural hearing loss. Interventions included to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, and use simple, brief consistent words/cues. Review of the dementia and communication CCP indicated that CNA #2 did not utilize interventions resulting in Resident #2's inability to achieve their highest level of practical functioning and reduce confusion. Review of the Conclusion / Summary of the Accident & Incident Report dated 4/20/21 written by the administrator (after review of video footage) revealed CNA #2 was serving a dinner tray to another resident and Resident #2 was attempting to stand up from the table. CNA #2 went over to the table and appeared to be aggressive when sitting Resident #2 back down by pulling on the bottom of their shirt and then stood by the Resident in what appeared to be CNA#2 talking down to the resident. A couple of minutes after the incident, CNA #2 went over and helped Resident #2 stand up with their rollator and walked resident to the head of the table. Another CNA in the room gave Resident #2 a chair and CNA #2 appeared to pull on the bottom of the resident's shirt until they were sitting. It appeared CNA #2 was talking to Resident #2 for a moment and then walked away. After the meal, CNA #2 was walking Resident #2 out of the dining room towards the nurse's station where there was a chair and what appears CNA #2 was directing Resident#2 towards the chair and then what seemed aggressively plopping resident down in the chair. LPN #2 saw and intervened. During an interview on 11/3/22 at 1:28 PM, the administrator stated they no longer have access to the video footage of the incident. The administrator stated that video footage deletes after 30 days. During an interview on 11/17/22 at 10:34 AM, Unit Manager (UM #2) stated CNA #2 had not exhibit inappropriate aggressive behaviors towards Resident #2 or other residents. Resident #2 was constantly attempting to stand for unknown reasons. Staff were always trying to meet the resident needs and found it difficult sometimes because Resident #2 was unable to communicate her needs verbally. Staff assigned to dementia unit have many years of experience working with dementia residents and are trained on dementia centered care. CNA #2 had experience working with dementia residents and was very familiar with Resident #2's care. UM #2 stated CNA #2 should have asked for assistance from another staff member if they needed help. CNA #2 made a bad decision because of frustration. During an interview on 11/17/22 at 10:45 AM, the Director of Nursing (DON) stated that CNAs are assigned a task list (Kardex) which is generated from the resident care plan. CNAs have access to care plans when they are charting. The DON stated CNA #2 was aware of the care plan interventions for Resident #2. If there is a staff noted struggling in one area, they would be pulled for re-education. There was never a reason for re-education for CNA #2 as there were no concerns. The DON did not believe there was intent for CNA #2 to cause harm to Resident #2. There was concern for Resident #2 overall well-being which is why CNA #2 was terminated. During an interview on 11/17/22 at 10:57 AM, the Staff Development Coordinator (SDC) stated dementia trainings are conducted during initial hire and annually. Staff are advised to put personal feelings and emotions aside wen providing cares to dementia residents especially for those who exhibit behavior symptoms. SDC advises staff to use redirection and remain calm as long as the situation is not emergent and dangerous. If the resident is deemed safe, staff should step away and reapproach when appropriate. Staff are always reminded that residents have rights and staff must respect their right to dignity. During an interview on 11/17/22 at 11:18 AM, the Administrator stated LPN #2 witnessed the incident and reported the occurrence immediately. CNA #2 was suspended the same day of the incident until the investigation was completed. Ultimately, after reviewing the video footage, CNA #2 was terminated at the conclusion of the investigation. CNA #2 completed the annual mandatory in-services related to dementia care and abuse. The administrator stated CNA#2 had sufficient trainings on dementia care and abuse prevention. During an interview on 11/17/22 at 2:10 PM, CNA #2 stated they recall the incident occurred around dinner time. Resident #2 was at one end of the table. Resident #2 was continuously pushing the table towards other residents. CNA #2 tried to prevent Resident #2 from injuring other residents who were sitting at the same table. CNA #2 asked Resident #2 to stop multiple times. CNA #2 stated they were having a bad day and acknowledged handling Resident #2 roughly. CNA #2 stated they viewed video footage of the incident with the administrator and the Assistant DON (ADON) and saw themself holding Resident #2 hands up while helping with sitting. CNA #2 stated as they sat Resident #2, her behavior did appear aggressive in the video but was not their intent. Normally the best course of action was to attempt to calm the resident, give the resident a few minutes and reapproach. If this approach is not effective, ask for help from another staff. CNA #2 could not recall the dementia the care plan interventions for Resident #2 at the time of the incident. CNA #2 also did not recall LPN #2 intervening during the incident. During an interview on 11/18/22 at 10:45 AM, LPN #2 stated s/he witnessed CNA# 2 roughly push Resident #2 into a chair. Resident #2 was a very slow walker and needed time to go from point A to point B. Resident #2 was his/her typical self that day; nothing out of the ordinary. Resident #2 did not exhibit serious behavior concerns. All staff are trained on the dementia unit on how to provide cares to dementia residents. 415.12

Based on observation and interview conducted during the recertification survey, the facility did not ensure that each resident's right to privacy and confidentiality of personal health information was maintained. Specifically, positioning profiles (photographs of residents wearing assistive / positioning devices) were observed on closet doors in resident rooms. This was evident for 3 of 3 residents (Resident #5, #31 and #109) reviewed for privacy. The findings are: According to the facility's policy on resident rights dated October 2017, residents have rights to privacy and confidentiality of personal and clinical records. Observations conducted during the initial screening process on 01/03/20 revealed positioning profiles displayed on the outside of closet doors for Resident #5, Resident #109 and Resident #31, all residing on the Foxhall Unit. These photographs were visible to anyone entering these rooms. In an interview with a certified nursing assistant (CNA) #1 on 0[DATE]20 at 11:12 AM it was revealed that photographs similar to the ones posted on resident #109's and resident #31's closet doors were commonly displayed to guide them on the application of the devices and how to position the residents under their care. An interview conducted with the Registered Nurse- Unit Manager on 0[DATE]20 at 10:43 AM revealed that the photographs were supposed to be inside the closet doors and not displayed outside where they were visible to all who enter the room. An interview was conducted with the Rehabilitation Director on 0[DATE] at 10:55 AM who stated that the positioning profiles should have been placed inside the closet doors and not on the outside. 415.3 (d)(1)(ii)

Based on observation, record review and interview conducted during the most recent recertification survey and an abbreviated survey (# NY 956), the facility did not: A. Implement a person centered care plan for 1 of 7 residents (#49) reviewed for accidents, 1 of 4 residents (#[AGE]) reviewed for positioning and 1 of 5 residents reviewed for nutrition (#199). Specifically, 1.) hip protectors were not applied as per the care plan for Resident #49; 2.) wheelchair leg rests were not applied as per the care plan for Resident #[AGE]; and 3) weekly weights were not done for the first 4 weeks after admission for Resident #199. B. Develop a care plan for 2 of 2 residents (#49 and #48) reviewed for incontinence. Specifically, a care plan with measureable goals and timetable was not developed to address increased bladder incontinence for Resident #49; and a care plan to address bowel incontinence was not developed to address bowel incontinence for Resident #48. The findings include, but are not limited to the following: 1. Complaint # NY 956: Resident # 49 was admitted to the facility with [DIAGNOSES REDACTED]. The 7/18/19 Admission MDS (Minimum Data Set: an assessment tool) revealed Resident #49 had severe cognitive impairment, received extensive assist with transfers, and had no falls. The 10/12/19 Quarterly MDS revealed Resident #49 received supervision with transfers and had a fall without injury. The 7/12/19 ADL (activities of daily living) needs care plan revealed an intervention for the use of hip protectors at all times. The 11/10/19 Incident and Accident (A/I) report revealed that the resident was observed at 8:05AM lying on the floor on her right side. The resident was sent to a local hospital and was admitted with a right [MEDICAL CONDITION]. The investigative report of this incident revealed the resident was not wearing a hip protector at the time of the incident. The unit Licensed Practical Nurse (LPN #1) was interviewed on 1/9/20 at 11:20 AM and stated the resident was supposed to wear hip protectors at all times. The Certified Nursing Assistant (CNA #1) was interviewed on 1/9/20 at 11:30AM and stated that on the morning of the fall she had gotten the resident out of bed at 6:30AM. She further stated she knew the resident was supposed to use hip protectors but did not apply them because they were not available. 2 .Resident # [AGE] had [DIAGNOSES REDACTED]. The 10/26/19 Annual MDS revealed that Resident #[AGE] was cogntively intact, received extensive assist for completion of ADL's and had bilateral lower extremity impairment. The 4/27/19 care plan for developing limitation in ROM (range of motion) related to decreased mobility of both legs and the 4/28/19 ADL self performance deficit care plans included an intervention for the use of leg rests when in the wheelchair. Observations on 1/3/20 at 12:00 PM and 1/7/20 at 10:00 AM revealed that leg rests were not being used. On 1/7/20 at 1:17 PM Resident #[AGE] was being wheeled from the main dining room to the unit and no leg rests were present. The resident was wheeled with his feet elevated approximately one inch above the floor. CNA#2 who was observed pushing the resident's wheelchair was interviewed on 1/7/20 at 1:24PM. She stated she had asked the resident to keep his feet up and off the floor before she began pushing the wheelchair. She stated if the resident dropped his feet when being pushed in the wheelchair he could fall. The Unit Manager (RN #2) was interviewed on 1/9/20 at 5:15 PM. She stated the resident was very tall and needed to be pushed in the wheelchair. She further stated the resident did not self propel the wheelchair. 3. Regarding bladder incontinence for Resident # 49, the 7/12/19 Bladder Assessment revealed that the resident was always continent. The 7/18/19 Admission MDS revealed Resident #49 received extensive assist with transfers and toilet needs, and was occasionally incontinent of bladder. The 10/12/19 Quarterly MDS revealed Resident # 49 received supervision with transfers and extensive assist with toileting and was frequently incontinent of bladder. The 7/12/19 activities of daily living (ADL) care plan was updated on 12/31/19 to indicate occasional incontinence, with the following interventions: on 11/14/19 check and change every 2 hours, and on 11/15/19 toilet every 3 hours. Review of the Bladder Record revealed the resident had the following incontinence episodes: July 2019 - 8 episodes, October 2019 - 44 episodes, and December 2019 - 71 episodes. After reviewing the resident's care plan it was determined the resident had no care plan that included measureable goals and interventions to address the type of bladder incontinence and attempts to decrease the frequency of bladder incontinence. The unit Nurse Manager (RN #2) was interviewed on 1/7/19 at 1:45 PM. She stated she was responsible for the development of care plans. After reviewing the medical record she stated a care plan had not been developed to address the resident's incontinence status. The resident had occasional incontinence, occurring mostly during the night shift. 4. Resident #48 is a [AGE]- year-old male with the [DIAGNOSES REDACTED]. The annual MDS dated [DATE] showed that the resident had no significant cognitive impairment, had hearing impairment with no hearing aid, had unclear speech, was occasionally incontinent of bowel (that is, during the past 7 days there was only one episode of bowel incontinence) and required supervision for toileting. The 10/12/19 quarterly MDS showed that the resident had no cognitive impairment and was frequently incontinent of bowel (2 or more episodes of incontinence and at least one episode of continence). The care plan revealed no mention of the cause of the bowel incontinence and no measureable goals and interventions to address bowel incontinence. The acting Unit Manager (AUM) Licensed Practical Nurse, was interviewed on 1/9/20 at 11:35 AM. This interview revealed that the resident was still frequently incontinent of bowel, which was probably related to the loose consistency of his stools secondary to the use of a medication (Allopurinal) used to treat gout. (This was initially documented by the Nurse Practitioner on 9/17/19). The AUM further stated that the Registered Nurse (who was not available) was responsible for the development of the care plan. On 1/9/20 the nurse aide (CNA #3) assigned to the resident on the day shift was interviewed at 12:07 PM. She stated that the resident was sometimes incontinent and it was mostly of bowel. 415.11(c)(1)

Based on interview and record review, the facility did not ensure that residents were provided adequate supervision to prevent resident to resident alteration that could possibly result in injury. Specifically, a cognitively impaired resident (Resident #106) threatened to harm another resident (Resident #23) and this threat was not promptly investigated and measures were not put in place promptly to prevent reoccurrence. The findings are: Resident #23 was a [AGE] year-old, non-ambulatory female with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for rehabilitation services. On 1/6/20 at 10:56 AM Resident #23 informed the surveyor that a few days prior a confused resident residing close to her room came into her room and threatened to kill her at about 10:00 PM. This made her very upset. The resident (later identified as Resident #106) entered her room on another day around the same time. Immediately following the interview with Resident #23 a Licensed Practical Nurses (LPN #2) identified Resident #106 as the resident who had entered Resident #23's room. Resident #106 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the initial Minimum Data Set (MDS-an assessment tool) dated 11/7/19, Resident #106 had severe cognitive impairment and behavior problems to include verbal and physical behaviors that significantly disrupted the environment. On 12/31/19 the Social Worker (SW) revised the resident's plan of care, noting that the resident had the potential to be verbally aggressive related to dementia evidenced by threatening staff, residents and visitors. The goal was for the resident to accept staff redirection when agitated as evidenced by lessened verbal aggressive outbursts towards others. The interventions to achieve this goal included: analyze key times, places, circumstances, triggers and what de-escalates behavior and document; assess resident's coping skills and support system; give the resident as many choices as possible about care and activities; monitor behaviors each shift; document observed behavior and attempted interventions; provide positive feedback for good behavior and emphasize the positive aspects of compliance. The triggers for verbal aggression were his family, attempting to relocate resident for de-escalation, and not giving resident undivided attention. Interview with the Unit manger/Registered Nurse (RN #3) on 1/7/20 at 12:45 PM revealed that she was not aware of Resident #106 wandering into Resident #23's room. The evening shift Nursing Supervisor (RN #4) was interviewed on 1/7/20 at 3:44 PM. She stated that she was aware of an incident involving both residents and was aware that Resident #106 had entered the room of Resident #23 and this made Resident #23 feel uncomfortable. RN #3 denied that she was told that Resident #106 threatened to harm Resident #23. RN #3 also stated that Resident #106 previously did not wander into other resident rooms. A follow-up interview with Resident #23 on 1/8/20 at about 10:45 AM revealed that she had reported to her husband of both incidents of Resident #106 wandering into her room. The surveyor then contacted the resident's husband via telephone at 10:55 AM on 1/8/20. This interview revealed that Resident #23 called the husband on 1/1/20 to report that a male resident close to her room had threatened her at about 10:00 PM. The husband called the supervisor to report that the male resident had wandered into Resident #23's room. The supervisor stated that she would take care of it. The husband stated that he could not recall if he had told the supervisor about the threat but she said that she would take care of the problem. The husband further stated that he called the facility back the following day and reported to a nurse on the day shift, identified as LPN #2 that Resident #106 had threatened to harm his wife, Resident#23. LPN #2 told him that Resident #23 had told her of the threat. The surveyor interviewed LPN #2 on 1/8/20 at 11:05 AM. She stated that she was aware of the incident and had reported it to the Social Worker. During an interview with the SW and the surveyor on 1/8/20 at 11:50 AM, the SW denied having any knowledge of Resident #106 wandering into Resident #23's room. The surveyor asked the SW what had prompted her to revise the plan of care for Resident #106 on 12/31/19. The SW stated that the revision was done because when she was on her way out of the facility on 12/30/19 at 5: 00 PM, after saying good-bye to Resident #106, he threatened to blow off her head. A review of the medical records for Resident #23 and Resident #106 revealed that there was no mention of the incidents from 1/1/120 to 1/5/20 and that no measures were in place to address the safety of Resident #23. After surveyor inquiry on 1/6/20, a note in the medical record for Resident #106 revealed that he was transferred to another unit for the safety of other residents. Also, there was no documented evidence in Resident# 106's medical record of specific behavioral interventions to address his potential for wandering into the rooms of other residents during the hours of sleep on this new unit. The nurse aide (CNA#4) assigned to Resident #106 on the new unit was interviewed on 1/9/20 at about 3:25 PM. She stated that she was not aware of the resident's wandering behavior into other resident rooms. 415.12(h)(2)

Based on interviews and record review conducted during the most recent recertification survey, the facility did not ensure that 2 of 2 residents reviewed for bowel and/or bladder incontinence were provided the necessary treatment or services to restore continence to the extent possible. Specifically: 1.) For Resident #48, no person-centered goals and interventions were put in place to address bowel incontinence and no measures addressing voiding patterns, use of diuretic and supplies to promote urinary continence were identified in the resident's plan of care to ensure implementation across all shifts. 2.) For Resident #49, specific measures were not put in place to attempt to decrease the frequency of urinary incontinence. The findings are: 1. Resident #48 is a [AGE]- year-old male with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS, an assessment instrument) dated 5/3/19 showed that the resident had no significant cognitive impairment, had hearing impairment with no hearing aid, had unclear speech, was occasionally incontinent of bowel and bladder (that is, during the past 7 days there was only one episode of bowel incontinence and less than 7 episodes of urinary incontinence), and required supervision for toileting. The 10/12/19 quarterly MDS showed that the resident had no cognitive impairment, was frequently incontinent of bowel (2 or more episodes of incontinence and at least one episode of continence) and continent of bladder. The resident's current medication regimen included a diuretic, [MEDICATION NAME] 20 mg daily, for [MEDICAL CONDITION] (given at 8:30 AM), which put the resident at risk for urinary incontinence. The current comprehensive care plan (CCP) revealed that the resident had urge incontinence related to [MEDICAL CONDITION]. The goal was for the resident's risk for [MEDICAL CONDITION] (infection of the blood) to be minimized/prevented via prompt recognition and treatment of [REDACTED]. The interventions to achieve this goal included clean peri area with each incontinent episode, encourage fluids during days to promote voiding responses; ensure unobstructed pathway to bathroom; and monitor for signs and symptoms of UTI. The CCP revealed no mention of the cause of the bowel incontinence, no specific input from the resident in the formulation of the goals and interventions, no reference to monitoring voiding patterns (such as frequency, volume, nighttime or daytime,), use of incontinence supplies (such as urinals and type of underwear) and the type of prompting needed to encourage urination and defecation and the time for offering of fluids in light of the use of a diuretic. According to documentation by the Certified Nurse Aides (CNAs) assigned to the care of the resident, the number of urinary incontinent episodes were recorded for the past three months as follows: November 2019 - 13 December 2019 - 06 January 2020- 05 (to date) Thirteen of all these urinary incontinent episodes (total of 24) occurred between 9:00 PM and 3:00 AM. There was no monitoring of the bowel movements. The computerized electronic medical record was not programmed to prompt the CNA to record the number of incontinent and continent episodes for bowel. The information given to the CNAs on the incontinence record was not updated to reflect the change in the resident's level of bowel incontinence. The information noted that the resident was occasionally incontinent of bladder and always continent of bowel. The acting Unit Manager (AUM), Licensed Practical Nurse, was interviewed on 1/9/20 at 11:35 AM. This interview revealed that the resident was still frequently incontinent of bowel, which was probably related to the loose consistency of his stools secondary to use of a medication (Allopurinal) used to treat gout. (This was initially documented by the Nurse Practitioner on 9/17/19). The AUM further stated that she updates the care plans after they are developed by the Registered Nurse. On 1/9/20 the nurse aide (CNA #3) assigned to the resident on the day shift was interviewed at 12:07 PM. She stated that the resident was sometimes incontinent and it was mostly of bowel. On 1/9/20 at 2:50 PM the surveyor made an attempt to interview the resident with the assistance of the AUM. The surveyor terminated the interview due to difficulty in communicating with the resident and his denial that he was incontinent of urine. 2. Resident # 49 was admitted with [DIAGNOSES REDACTED]. The 7/18/19 Admission MDS revealed Resident #49 had severe cognitive impairment, received extensive assist with transfers, and toilet needs, and was occasionally incontinent of bladder. The 10/12/19 Quarterly MDS revealed Resident # 49 received supervision with transfers, and extensive assist with toileting, and was frequently incontinent of bladder. The 7/12/19 Bladder Assessment revealed Resident #49 was always continent. The 7/12/19 Dependence on staff meeting ADL (activities of daily living) needs care plan noted that the resident was to be toileted every 3 hours. This plan was updated; 11/14/19 to check and change every 2 hours; 11/15/19 to toilet every 3 hours and on 12/31/19 to indicate occasional incontinence. Review of the Bladder Record revealed the resident had the following incontinence episodes: July 2019 - 8 episodes, October 2019 - 44 episodes, and December 2019 - 71 episodes. The was no documented evidence in the resident's record as to why the resident was incontinent of urine or what type of incontinence the resident experienced. After reviewing the resident's care plan it was determined the resident had no interventions in place that addressed the type of bladder incontinence, voiding patterns and attempts to restore normal bladder function to the extent possible. The unit Nurse Manager was interviewed on 1/7/19 at 1:45PM she stated the resident had occasional incontinence, occurring mostly during the night shift. She stated a discussion with the CNA revealed the resident had episodes of incontinence (damp undergarments) at times. The unit CNA (CNA #5) was interviewed on 1/7/19 at 1:59 PM, she stated the resident was toileted every 3 hours and was normally continent. 415.12(d)(1) 415.12(d)(2)

Based on observation, interview and record review conducted during the recertification survey, it was determined that for 3 of 7 residents (Residents #166, #199 and #216) reviewed for Nutrition and Hydration the facility did not ensure that each resident was provided the necessary care to either maintain, to the extent possible, acceptable body weight or proper hydration. Specifically, for Resident #199 there was a lack of weekly weight monitoring for the first 4 weeks following admission as indicated in the facility's weight policy and the plan of care; and for Residents #166 and #216, there was a lack of adequate monitoring of daily fluid intake to assess the adequacy of daily fluid consumption. The findings are: 1. Resident #199 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS- an assessment tool) completed on [DATE]19 showed that the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 00 out of a possible 15, which indicated impaired cognitive status and weighed 178 lbs. A review of Physician orders [REDACTED]. The Nutrition Care Plan initiated on 12/3/2019 indicated inadequate protein intake and increased nutrient needs. The goal was to improve oral intake to greater or equal to [AGE]% of meals. The interventions to achieve this goal included: to provide diet as ordered, monitor weight weekly for 4 weeks, then once per month and Carnation shake daily. The resident's weight chart showed the following weights: 1[DATE]19- 1[AGE].9 Lbs, 12/11/19 -178.0 Lbs, and 12/25/19 -150.4 Lbs. These weights represented a loss of 15.46% in approximately 4 weeks. There was no documented evidence of weights for the weeks of 12/1/19 to 12/7/19 and 12/15/19 to [DATE]. On 1/7/2020 at 4:00 PM Unit Manager (RN #3) was interviewed and she stated that routinely residents are weighed weekly for 4 weeks on admission, then monthly as per facility policy. Also, the facility's electronic medical record has a system in place for when there is a weight loss of 3 Ibs. or more the system alerts staff for possible intervention which is mostly for a re-weigh. This interview also revealed that the Unit Manager was not aware of the weight loss until the surveyor brought it to her attention. The resident's plan of care and the facility's weight protocol were not followed to prevent significant unplanned weight loss. 2. Resident #166 has [DIAGNOSES REDACTED]. The annual MDS dated [DATE] showed that the resident had severe cognitive impairment, required supervision with eating and weighed 126 lbs. The Care Area Assessment summary, an extension of the MDS, noted that the resident had inadequate intake and was at risk for weight loss. The most recent physician's orders [REDACTED]. A review of the comprehensive care plan revealed no specific goals for hydration/sufficient fluids. The nutrition care plan revealed goals for the resident's intake to be greater than or equal to [AGE] percent. The intervention to achieve this goal included: extra sandwich at lunch and dinner, monitor food intake, encourage intake greater than or equal to [AGE]%, and evaluate labs as ordered. A review of the CNA documentation revealed that the resident's total intake at meal times for the past 30 days was as follows: 00 to 25% - 11 times 26 to 50% - 33 times 51 to [AGE]% - 24 times 76 to 100% - 11 times The amount of fluids consumed was not distinguished or separated from the amount of solids consumed. Therefore, amount of fluids being consumed could not be determined. A review of the medical record revealed no laboratory values indicative of the resident's hydration status. Two meal observations showed the following: - 01/03/20 at 12: 57 PM the resident refused the meal offered. - 0[DATE] at 12:26 PM the resident was served 8 oz tea, 6 oz milk, pork, sauerkraut, baked beans, and a peanut butter & jelly sandwich. She ate all the beans, refused the additional solids, drank all the tea and took a few sips of milk. The Registered Dietitian (RD) assigned to the resident was interviewed on 1/9/20 at 3:40 PM. He was asked to address how the adequacy of the resident's daily fluid intake was being addressed in light of consumption of meals noted to be usually 50% or less most of the time, the ongoing use of a diuretic, the use of three medications for constipation, and the fact that there was no distinction between the amount of food and fluids consumed at meal times. The RD stated that this should have been done by nursing and that he would put a plan in place. 3. Resident #216 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] showed that the resident was feeling depressed, had cognitive impairment and reported frequent moderate pain. The CCP dated 12/26/19 addressed [MEDICAL CONDITION], RI and hydration. The [MEDICAL CONDITION] care plan noted that the resident's fluid intake would be monitored and the hydration care plan noted that the goal for the resident was to be adequately hydrated. The interventions to achieve this goal included: evaluate labs as available, ensure access to fluids, food service to provide 15[AGE]-1[AGE]0 fluids, and nursing to offer 240 ml with medication pass. A note written by a social worker on 12/26/19 stated that over the past 2 weeks the resident had felt very depressed due to physical decline and that she had a poor appetite with no desire to eat. According to the Medication Administration Record, [REDACTED]. Two diuretics, [MEDICATION NAME] 25 mg and [MEDICATION NAME] 40 mg were administered from 1[DATE] to 12/30/19. On 12/29/19 nursing documented that the resident had low blood pressure and unresponsive episodes. The recommendation was to send the resident to the hospital. On 12/30/19 nursing documented that the hospital called to report that the resident was admitted to the intensive care unit for the treatment of [REDACTED]. (The resident was not readmitted to the facility.) In light of the [DIAGNOSES REDACTED]. There was no documented evidence that the amount of fluids consumed between meals was monitored. Also, the CNA documentation showed no evidence that the resident's fluid intake at meal times was being monitored daily as planned in the renal care plan mentioned above. The CNA documentation showed that meal consumption was recorded for only one meal daily from 12/26/19 to 12/29/19 and was as follows: 12/26 at 22:51 - 0 to 25% 12/27 at 21:02 - 26 to 50% 12/28 at 22:14 - 26 to 50% 12/29 at 20:59 - refused The Unit Manager (RN #3) and a unit Licensed Practical Nurse (LPN #3) were interviewed on 1/8/20 at 1:25 PM. This interview revealed that the CNAs were not instructed to monitor the resident's fluid intake and that this should have been done by the Admission Nurse. 415.12(i)(1)(j)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 2 residents (#216) reviewed for dignity that care was provided in a manner to maintain dignity. Specifically, the resident's urinary (Foley) catheter tubing and drainage collection bag were not concealed to prevent direct observation by other residents and their families to maintain dignity and privacy. The findings are: Resident #216 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) of 1/8/18 indicated that the resident has severely impaired cognition; required extensive assistance of two people for most aspects of activities of daily living; and has an indwelling urinary catheter in place. The resident was observed on the following dates and times: -2/2/18 at 2:45 PM the resident was sitting in a wheelchair in the main dining area with the Foley bag without a cover resting on the wheelchair's foot rest and was visible to other residents and their family members present; -2/6/18 at 11:10 AM, the resident was in bed with the Foley catheter bag hooked to the foot part of the bed frame with no cover and could be seen from the hallway; -2/6/18 at 1:50 PM, the resident was up in a wheelchair in his room with his roommate present and the Foley bag was placed on the leg rests of the wheelchair without a cover in place and could be observed in the hallway; -2/8/18 at 12:15 PM, the resident was in his room sitting in his wheelchair with the Foley catheter bag exposed and was hanging on the side of the wheelchair facing the door; and on -2/9/18 at 1:30 PM, the resident was in his room sitting in his wheelchair with the Foley catheter bag hanging on the side of the wheelchair facing the door with no privacy bag in place. The resident's roommate was in the room with his wife. Review of the Certified Nursing Assistant (CNA) Care Guide (a record that provides instructions for CNAs of the type of care to provide the residents) revealed no documented evidence of directions or instructions given to the CNAs on how to maintain privacy of the Foley bag. The assigned CNA #2 was interviewed on 2/9/18 at 1:45 PM and stated that the indwelling urinary catheter drainage bag should have been placed in a blue bag. The Licensed Practical Nurse (LPN #2) was interviewed on 2/9/18 at 1:40 PM and stated the resident's urine drainage bag should have been covered to maintain privacy and dignity. LPN #2 stated that she did not know the reason why the bag was uncovered. 415.5 (a)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents were free from physical restraints. It was determined for 1 of 1 resident (#110) reviewed for physical restraints that, (1) thorough assessment and re-evaluation were not conducted to address the ongoing use of devices including wheelchair seatbelt, seatbelt alarm, and tray table that may possibly restrict the resident's movement, and (2) the physician's orders [REDACTED]. The facility policy and procedure for Restraints, revised on December 2010, stated that prior to application of a restraint, other alternatives will have been explored and/or tried, and only after documentation as to why these measures are ineffective or inappropriate will the least restrictive restraint be ordered and utilized. It further stated that the facility's interdisciplinary plan team will follow a systematic process of evaluation and care planning prior to using restraints. The policy and procedure further stated that the physician's orders [REDACTED]. meeting for all residents who utilize restraints. The findings are: Resident #110 has [DIAGNOSES REDACTED]. According to the Annual MDS of 11/22/17, the resident has severe cognitive skills; required extensive assistance of two staff members with most aspects of activities of daily living; and uses a wheelchair. This MDS further documented that the resident does not use any type of physical restraints including the use of any chair, bed, or other alarms. Observations were made on the following dates and times and showed that the resident was using a wheelchair seatbelt, seatbelt alarm and a tray table simultaneously: - on the morning of 2/2/18, the resident was in the unit's common area sitting in her wheelchair with a seatbelt, seat belt alarm and a tray table in place and at 12:45 PM of the same date, revealed the resident was at lunch in the unit dining room being assisted by a staff member with a wheelchair seatbelt, seatbelt alarm, and tray table in place during this meal. The resident was observed to be calm. - further observations were made during lunch on 2/6/18, 2/7/18, and on 2/8/18 between 12:00 PM and 12:45 PM and revealed the resident to be in the unit dining room being assisted by a CNA and the wheelchair seatbelt, seatbelt alarm, and tray table remained in place during these meals. The resident was observed earlier during the day on 2/8/18 at 10:00 AM to be in the common area sitting in her wheelchair with a wheelchair seatbelt, seat belt alarm, and a tray table and was calm. CNA #1 was interviewed 2/8/18 at 12:45 PM and she stated that the seatbelt, seatbelt alarm and tray table were never removed including during meals because the resident has [MEDICAL CONDITION]. The assigned Licensed Practical Nurse (LPN#1) was interviewed on 2/8/18 at 1:05 PM and stated that she has not observed the seatbelt, tray table and seatbelt alarm removed during meals. When asked how they identify residents who use these devices, LPN #1 stated there is a white folder and task list for the unit that provides a quick reference for anyone that is new to the unit. Additional observations were made on 2/9/18 between 12:00 PM and 12:45 PM and revealed the resident at lunch in the unit dining room being assisted by a CNA and had a wheelchair seatbelt, seatbelt alarm, and tray table in place. A review of the February 2018 CNA care guide and the Task List Assignment (a record used by nursing aides to obtain information about the type of care the residents need and where they document completion of the tasks provided) did not include the use of a tray table, seatbelt or seatbelt alarm. There were no instructions for the aide to follow as to when to apply and when to remove the said devices, including other care related areas while these devices were being used by the resident. Review of the resident's clinical record revealed that rehabilitation (rehab) screenings were conducted on 5/19/17 and 9/13/17 for use of the seatbelt and on 11/15/17 for positioning. (Rehab screening is used to identify long-term needs of the resident for possible rehab potential; orders and initial evaluation will then be conducted if rehab is possible). A Therapy Screening Form dated 1/16/18, indicated that the resident was referred to rehab for positioning and to re-evaluate the use of the tray table on her wheelchair. The screening notes revealed that nursing staff reported that it appears to be working well. The resident was found to be holding onto the tray and moving back and forth and appeared to be performing her own sensory stimulation. There were no further assessments conducted/documented to address the use of the seatbelt and the seatbelt alarm. Further review of the resident's clinical record including, but are not limited to, the comprehensive care plan, physician orders, and CNA Care Guide revealed no documented evidence for the use of the seatbelt alarm, seatbelt alarm, and tray table. Interviews were conducted on the following dates and times regarding the use of the above devices: - 2/8/18 at 1:15 PM, RN #1 unit manager stated that the care plan to address the use of these devices was not done because he was waiting for therapy to give him a directive which was a typical protocol prior to application of these devices. He stated that the tray table was put on recently when the Speech Therapist was evaluating the resident. The resident was dropping food on the floor and on herself and the table gives her room. He said that the tray table was used because of a recent [MEDICAL CONDITION], it gives her room and helps with positioning. RN #1 stated that the seatbelt did not prevent her from getting up because she does not walk and was originally placed as a positioning device which would not cause restriction. He said the seatbelt alarm was supposed to be discontinued and he thought it was removed. - 2/8/18 at 1:25 PM, Licensed Practical Nurse (LPN #2) was asked how often and under what conditions are the seatbelt, seat-belt alarms, and tray tables applied and removed. LPN #2 stated they should be removed every two hours and for cares, and that the nurses are responsible for making sure they are removed. - 2/8/18 at 3:00 PM, the director of rehabilitation stated the resident does a lot of moving, scooting around in her chair, and leans at the trunk. She said that the therapy screen was done with recommendations on 1/15/18 after occupational therapy evaluated the resident for the use of the tray table. She said that nurses should enter the orders for its use and create or update the care plans. She said that during care plan meetings the restraint/positioning is usually reviewed and signature sign sheet is completed. She further stated at this time that she'll review her records to see if any assessments were conducted. - 2/12/18 at 1:50 PM, the director of rehab stated she could not find any documentation that an actual assessment was done with regards to the use of the wheelchair seatbelt and seatbelt alarm. She stated she does not know where the seatbelt originated from. The director of rehab further stated that the Interdisciplinary Rehabilitation Screen Form is only used as a communication form and not an assessment. -2/13/18 at 12:40 PM, CNA #3 was asked where she gets instruction for the resident's daily care. CNA #3 stated she checks the task sheet or she asks the nurse. She said that during training she was shown how to apply the seatbelt and the seatbelt alarm to this resident daily. She said that when she did not find any directions or instructions for the use of the wheelchair seatbelt, seat-belt alarm and tray table listed on the CNA Tasks Completed Form. CNA #3 further stated that she should have clarified with the nurse manager about their use but she did not. She said that in the future she will read the task sheet daily and will pay better attention to the directions it gives. -2/13/18 at 12:45 PM, CNA #2 stated she reads the CNA Task Completed Form daily before starting work on her shift. CNA #2 was unable to show in this form where she was directed to use a wheelchair seatbelt, seatbelt alarm or tray table for this resident. She stated that since working on this unit back in May 2017, the resident has had a seatbelt on the wheelchair with a seatbelt alarm in place. She said that after having a [MEDICAL CONDITION] in January she also has a tray table in place. She said the resident always tried to get out of the seatbelt in the past. When asked to explain why she applied the seatbelt and seatbelt alarm when there was no instruction to do so, she stated she puts them on because they were on the resident's chair. CNA #2 further stated she never alerted the nurse or the nurse manager about the CNA task sheet not providing directions for the use of these devices. -2/13/18 at 1:15 PM, RN #1 was asked if he coded the resident's MDS regarding the use of restraints. He said he did and did not check off the use of physical restraints because he did not feel that these devices were restraints and that they were placed for positioning. RN #1 stated he does not have any documentation to back up the use or the reasons for the use of these devices. -2/13/18 at 2:30 PM, the Medical Director was asked about the use of these devices. He stated that the facility has systems in place for the use of restraints and positioning devices. The decision to initiate their use involves the nurse managers, the attending physicians, and the physical therapists. 415.4(a)(2-7)