Every finding on record at The Hamlet Rehabilitation and Healthcare Center at

Based on observation, record review, and interviews during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practices, to promote healing and prevent infections. This was identified for one (Resident #11) of four residents reviewed for Pressure Ulcer/Injury. Specifically, Resident #11 had a Stage 4 Pressure Ulcer (full-thickness tissue loss that exposes bone, tendon, or muscle) on the left buttock and sacrum (bottom of the spine). Resident #11 had a Physician's order to cleanse the wound with Dakin's solution (a diluted bleach solution, used as antiseptic to clean and treat wounds); however, the Wound Care Nurse used sodium chloride solution (normal saline) to clean Resident #11's left buttock wound during the wound care observation. The wound care team recommended to cleanse the wound with normal saline instead of Dakin's solution on 2/14/2025; hoewever, there was no documented evidence the recommendation was implemented until 2/18/2025. The finding is: The facility's policy titled Pressure Injury, last revised on 6/2024, documented the medical provider will authorize pertinent orders related to wound care treatments, including wound cleansing and debridement approaches, dressings (occlusive, Absorptive, etc.), and application of topical agents if indicated for the type of skin alteration. Upon written receipt of recommendations made by the wound care provider/consultants, the primary care providers will review and address the recommendations within 48 hours. Resident #11 was admitted with diagnoses including Multiple Sclerosis (a disease that causes a breakdown of the protective covering of nerves), Stage 4 Pressure Ulcer of the Left Buttock and Sacrum (bottom of the spine), and Osteoarthritis. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, which indicated Resident #11 had moderately impaired cognition. Resident #11 had unhealed pressure ulcers and used a pressure-reducing device for the chair and bed. A Comprehensive Care Plan titled Left Buttock and Sacrum Unstageable Wound last revised on 2/15/2024 documented interventions including the use of a pressure reduction bed mattress, a cushion to wheelchair, administration of pain medication 60 minutes before treatment, turning and positioning every 2 hours, wound care consultations, and treatments as per the Physician's orders. A Physician's order dated 1/30/2025 documented to apply Santyl (medication that removes damaged tissue from skin ulcers) External Ointment of 250 units per gram to the left gluteus (buttock) and sacral wound topically every day shift for wound care. Clean with quarter-strength Dakin's solution (a diluted bleach solution used as an antiseptic to clean and treat wounds), pat dry, apply Santyl followed by normal saline moistened gauze, Zinc Oxide to peri-wound, and cover with a silicone foam dressing daily and as needed. A wound care consultation progress note dated 2/14/2025, written by the Wound Care Nurse Practitioner, documented the left buttock Stage 4 pressure ulcer measuring 5.7 centimeters in length, 10.2 centimeters in width, and 0.2 centimeters in depth. The recommendations included cleansing the wound with normal saline, applying Santyl to the wound, and loosely packing it with saline moist gauze covered with bordered gauze daily and as needed. The Sacral Stage 4 pressure ulcer measurements were 1.2 centimeters in length, 1.2 centimeters in width, and 1 centimeter in depth. The recommendations included cleansing the wound with normal saline, protecting the peri-wound with zinc oxide, applying Santyl to the wound, and loosely packing the wound with saline moist gauze covered with bordered gauze daily and as needed. The Physician's order for the left buttock wound and sacral wound was not changed to indicate the wound care team's recommendation on 2/14/2025 to cleanse the wound with normal saline instead of Dakin's solution. During a wound care observation on 2/18/2025 at 1:15 PM, the Wound Care Nurse was assisted by Licensed Practical Nurse #3 and the Nurse Manager for positioning Resident #11 during the wound care treatment. The Wound Care Nurse started cleaning Resident #11's left buttock wound with 0.9 percent sodium chloride (normal saline). Upon inquiry by the surveyor, the Wound Care Nurse stopped and reviewed the Physician's order for Resident #11 and stated the Physician's order indicated that the wound should be cleansed with a quarter-strength Dakin's solution. During an interview on 2/18/2025 at 1:22 PM, the Wound Care Nurse stated that on 2/14/2025, the Wound Care Nurse Practitioner recommended discontinuing the use of the quarter-strength Dakin's solution and using the normal saline for cleansing the left buttock and sacral wounds. The Wound Care Nurse stated that they (the Wound Care Nurse) should have discontinued the quarter-strength Dakin's solution and started normal saline for cleaning as per the recommendations because there were no signs of wound infection. The Wound Care Nurse further stated they should have checked the Physician's orders prior to the start of the treatment and should have obtained a Physician's order prior to use the normal saline. During an interview on 2/18/2025 at 2:48 PM, Licensed Practical Nurse #1 stated when they provided wound care treatment for Resident #11, they followed the Physician's orders and used the quarter-strength Dakin's solution for cleaning the wound. Licensed Practical Nurse #1 stated they had never received any order to change Dakin's solution to normal saline. During an interview on 2/19/2025 at 9:10 AM, Licensed Practical Nurse #2 stated they provided wound care treatment on 2/13/2025 and 2/14/2025 for Resident #11. Licensed Practical Nurse #2 stated the Wound Care Nurse Practitioner was present and assessed the wounds with the Wound Care Nurse on 2/14/2025, but they (Licensed Practical Nurse #2) did not receive any orders to change the quarter-strength Dakin's solution to normal saline for cleaning Resident #11's wounds. Licensed Practical Nurse #2 stated they were using Dakin's solution to cleanse Resident #11's wound per the Physician's order. During an interview on 2/19/2025 at 9:22 AM, the Wound Care Nurse Practitioner stated they assessed Resident #11 on 2/14/2025. The Wound Care Nurse Practitioner stated Resident #11's wounds had no sign of infection. The Wound Care Nurse Practitioner stated they recommended discontinuing the quarter-strength Dakin's solution and using normal saline to cleanse Resident #11's wounds instead. The Wound Care Nurse Practitioner stated prolonged use of Dakin's solution can damage skin. The Wound Care Nurse Practitioner further stated they expected the nurses to relay recommendations to the primary Physicians within 24-48 hours. During an interview on 2/19/2025 at 1:27 PM, the Nurse Practitioner stated they were notified of the recommendation to discontinue the Dakin's solution for Resident #11's wound care by the Wound Care Nurse on 2/18/2025. The Nurse Practitioner stated they expected to be notified of recommendations within 24-48 hours of any consultation. The Nurse Practitioner stated they agreed with the Wound Care Nurse Practitioner's recommendation and the Physician's order was updated on 2/18/2025. During an interview on 2/19/2025 at 2:01 PM, the Director of Nursing Services stated they (the Director of Nursing Services) did not know why the Wound Care Nurse did not document the new treatment order for Resident #11 until 2/18/2025. 10 NYCRR 415.12(c)(1)

Based on observation, record review and interview during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure care and services for the provision of parenteral fluids were consistent with the professional standard of practice for each resident. This was identified for one (Resident #323) of two residents reviewed for Hydration. Specifically, Resident #323 was admitted on [DATE] with a Peripherally Inserted Central Catheter (a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) inserted to the left upper arm. There was no documented evidence the external length of the catheter was routinely measured to prevent migration and the care plan was not updated to include the measurement of the external length of the catheter. The Physician's order did not include monitoring the catheter site for signs and symptoms of infection and measuring the external length of the catheter with each dressing change The finding is: The facility policy titled Peripherally Inserted Central Catheter and revised on 6/2024 documented to measure the length of the external access device with each dressing change or, if catheter dislodgement is suspected, compare with the length documented on initial assessment upon insertion. Healthcare providers should regularly assess the site for signs of infection, complications or dislodgement. Resident #323 was admitted with diagnoses that included Malignant Neoplasm (Cancer) of the Bone, Anemia, and Malignant Neoplasm of the Kidney. A Minimum Data Set assessment was not available because the resident was recently admitted . The hospital record dated 2/4/2025 documented a Peripherally Inserted Central Catheter was inserted into Resident #323's left Basilic vein. A Physician's order dated 2/6/2025 documented to change the catheter site dressing for Resident #323's Peripherally Inserted Central Catheter to the left upper extremity every 72 hours and as needed with transparent dressing, on the day shift every Monday and Thursday. The Physician's order also included to flush the Peripherally Inserted Central Catheter with 10 milliliters of Normal Saline before and after every intravenous medication use. The Physician's order did not include monitoring the catheter site for signs and symptoms of infection and measuring the external length of the catheter with each dressing change. A review of the resident Medication Administration Record and Treatment Administration Record for February 2025 revealed there was no documented evidence of external length measurements of the catheter or monitoring the catheter site for signs and symptoms of infection from 2/6/2025 to 2/14/2025 and 2/18/2025 to 2/19/2025. The resident was hospitalized from 2/14/2025 to 2/18/2025. During an observation on 2/12/2025 at 9:30 AM, Resident #323 was observed resting in bed with a Peripherally Inserted Central Catheter in the left upper arm. The site appeared to be intact. A Comprehensive Care Plan dated 2/13/2025 documented the resident had a Peripherally Inserted Central Catheter for the administration of medication. Interventions included assessing the insertion site of the Peripherally Inserted Central Catheter for any redness, tenderness, or swelling, as well as checking that the dressing is clean, dry, and intact. The Nursing Re-Admission Evaluation dated 2/18/2025 documented the dressing for the Peripherally Inserted Central Catheter line to the left upper arm was clean, dry and intact. The resident denied pain at the site. The evaluation did not include the external length measurement of the catheter. During an interview on 2/19/2025 at 4:22 PM, the Assistant Director of Nursing Services stated the Registered Nurses were responsible for flushing the Peripherally Inserted Central catheter and monitoring for blood return, pain, and signs of infection at the catheter site. The Assistant Director of Nursing Services stated they did not know if the facility policy included monitoring the catheter for migration and to measure the external length of the catheter. During an interview on 2/20/2025 at 9:45 AM, Registered Nurse #1 stated during each shift, the Peripherally Inserted Central Catheter line should be monitored to ensure the circumference of the resident's arm does not increase in size. The catheter should also be flushed and the external length should be measured with every dressing change. Registered Nurse #1 stated the Registered Nurses should document their assessment of the site and measurement of the catheter in the Medication Administration Record. Registered Nurse #1 stated upon admission and readmission, the Registered Nurse who completed the assessments should have obtained orders to monitor for signs and symptoms of infection and measure the external length of the catheter. During an interview on 2/20/2025 at 10:09 AM, the Director of Nursing Services stated the medical team, including the resident's medical provider, was responsible for entering and reconciling the orders in the Electronic Medical Record upon admission. The Director of Nursing Services stated after the Physician enters the orders in the medical record, the admitting nurse should ensure all orders are correct. The Director of Nursing Services stated the Registered Nurses were responsible for the dressing change of the Peripherally Inserted Central Catheter, which included measuring the external length of the catheter and checking for signs and symptoms of infection at the catheter site. The Director of Nursing Services stated there were no Physician's orders in place that addressed assessing the site for signs of infection and measurement of the external length of the catheter. The Director of Nursing Services further stated there should have been Physician's orders to monitor Resident #323's catheter for migration and to measure the external length of the catheter. During an interview on 2/20/2025 at 12:28 PM, Physician #1 stated upon admission, the medical team should have ensured that orders were in place for the care of the Peripherally Inserted Central Catheter, including to measure the external length of the catheter. 10 NYCRR 415.12(k)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #7) of three residents reviewed for Respiratory care. Specifically, Resident #7, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had a Physician's Order to administer oxygen therapy at 2 liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen) as needed. The resident complained of feeling short of breath and was trying to place the nasal cannula to receive supplemental oxygen from the oxygen tank; however, the oxygen tank was empty. The finding is: The Oxygen Administration Policy dated 1/28/2025 documented oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The Policy did not include who was responsible for maintaining and/or monitoring the oxygen tanks. Resident #7 was admitted with the diagnoses of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The Minimum Data Set documented the resident utilized oxygen therapy. The Physician's Order dated 1/7/2025 documented to administer Oxygen therapy via nasal cannula at 2 liters per minute as needed for shortness of breath. The Comprehensive Care Plan for cardiac decompensation related to Hypertension dated 10/16/2024 documented interventions including administering oxygen therapy as ordered by the Physician. During an observation on 2/12/2025 at 11:35 AM, Resident #7 was observed in their bed and was attempting to put the nasal cannula in their nose. The resident stated they felt short of breath and were trying to fix the tubing. The oxygen tubing was attached to the oxygen tank which was placed by the door. The gauge needle was at the red line indicating the tank was empty. The Director of Nursing Services was alerted to check the resident's oxygen saturation level. The Director of Nursing Services came to the resident's room and checked the resident's oxygen saturation level, which was between 88 percent to 91 percent (normal range above 95 percent). The Director of Nursing Services stated the oxygen tank was empty. A new oxygen tank was subsequently connected, and the resident's oxygen saturation level went up to 92 percent. During an interview on 2/12/2025 at 11:48 AM, the Director of Nursing Services stated the resident should use a concentrator for oxygen; however, when the concentrator was broken, the staff used an oxygen tank to administer oxygen therapy. The Director of Nursing Services stated the oxygen tank should have enough oxygen available. Resident #7 is alert and can use the call bell to call for staff assistance. During an interview on 2/13/2025 at 1:38 PM, Licensed Practical Nurse #4 stated Resident #7 has a Physician's Order for oxygen therapy as needed. Licensed Practical Nurse #4 stated the resident had been utilizing an oxygen tank since the morning. At 9:00 AM, there was a quarter full of oxygen remaining in the tank. The resident made their needs known and had no concerns. Licensed Practical Nurse #4 stated they got busy and did not check the oxygen tank after 9:00 AM. Licensed Practical Nurse #4 stated they should have checked the oxygen tank to ensure there was enough oxygen available. During an interview on 2/20/2025 at 11:57 AM, Nurse Practitioner #1 stated they expected the nursing staff to follow the Physician's Orders related to oxygen therapy. Resident #7 has significant Chronic Obstructive Pulmonary Disease, and if they did not receive oxygen therapy as needed, there could be a risk of respiratory distress and Hypoxia (lack of oxygen to body tissues). 10 NYCRR 415.12(k)(6)

Based on record review, and interviews during an abbreviated survey (NY00321603), the facility failed to prevent and protect an incident of verbal abuse for one (Resident #1) out of three residents reviewed for abuse. Specifically, the facility failed to immediately remove Certified Nursing Assistant #1 from Resident #1's room when Certified Nursing Assistant #1 was verbally abusive and displaying signs of physical aggression towards Resident #1. The incident was captured on a video recording made by Resident #1. The facility's census was 221. This resulted in harm that was not immediate jeopardy. The facility's abuse policy revised on 07/2023 documented in pertinent part Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Resident #1 was admitted with diagnosis including Type 2 diabetes mellitus, Respiratory bronchiolitis interstitial lung disease (inflammatory lung disease) and Pleural effusion (accumulation of fluid between the lung and chest wall). According to the 5-day Minimum Data Set (MDS), Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #1 required extensive assistance of two staff with most activities of daily living. Resident #1's care plan initiated on 07/07/2023 documented that the resident had a behavior problem related to the resident frequently ringing their call bell every 30 minutes, and the resident also yelled out at times. The intervention to the identified behaviors documented in part, (1) Intervene as necessary, approach/speak in a calm manner, divert attention as needed; (2) When the resident becomes agitated, intervene before agitation escalates as needed, engage calmly in conversation, if response is accusatory, staff to provide emotional support as able and approach later as needed. The special instruction portion of the care plan documented Resident #1 was a 2-person approach. The care plan initiated on 07/19/2023 and last revised on 09/14/2023 documented Resident #1 was at risk for potential abuse/ neglect related to the resident's dependence on others for activities of daily living care. Part of the intervention was to provide support and ensure resident is free from abuse and/or neglect. A copy of the video footage recorded by Resident #1 of the verbal abuse incident was provided by Resident #1 on 03/14/2024 at 12:46 PM. The three minutes and thirty-five seconds long video footage was reviewed with the facility's administration. The facility's administration transcribed the said video as follows: At approximately 41 seconds into the recording, Certified Nursing Assistant #1 walked into Resident #1's room with their phone up and the camera portion of the phone turned towards Resident #1. Certified Nursing Assistant #1 could then be heard telling Resident #1 in a screaming voice to stop ringing their call bell citing that nursing staff were well aware. Certified Nursing Assistant #1 was captured screaming the statement as they simultaneously reached to the wall on the left corner of Resident #1's room to deactivate Resident #1's call bell. The video revealed that after Certified Nursing Assistant #1 deactivated Resident #1's call bell, they stood in Resident #1's room with their phone still up as described above. Resident #1 was then heard telling Certified Nursing Assistant #1 to get out of Resident #1's room. In response, Certified Nursing Assistant #1 was captured asking if Resident #1 would stop being belligerent. Resident #1 was again heard asking Certified Nursing Assistant #1 to leave their room. In their response, Certified Nursing Assistant #1 was captured telling Resident #1 that Resident #1 needed to stop ringing the call bell. Certified Nursing Assistant #1 was also captured swinging their left hand while they held their phone up with their right hand in the position described above. Certified Nursing Assistant #1, in addition to swinging their left hand, could be heard telling Resident #1 that I didn't tell you, you could record me. The video revealed that at approximately 58 seconds into the recording, a staff later identified as Registered Nurse #1 was outside Resident #1's room. Registered Nurse #1 made no attempt to remove Certified Nursing Assistant #1 from Resident #1's room. Resident #1 was then heard asking that Registered Nurse #1 call a nurse manager. Registered Nurse #1 could be heard in the background responding to Resident #1 that there was no nurse manager present. The video footage then recorded Certified Nursing Assistant #1 loudly telling Resident #1 to stop being belligerent and rude to the facility staff and for Resident #1 to stop screaming down the hallway. The video footage revealed Registered Nurse #1 entered Resident #1's room at approximately one minute twenty-six seconds into the recording to administer Resident #1's pain medication. Resident #1 was again heard telling Registered Nurse #1 that they needed to speak with a manager. In their response, Registered Nurse #1 told Resident #1 that there was no nurse manager around and that Registered Nurse #1 would let someone know that Resident #1 needed to talk to someone. At two minutes twenty-six seconds into the recording, Certified Nursing Assistant #1 was heard screaming loudly while telling Resident #1 to delete the video capturing the incident. The video recording showed Registered Nurse #1 as they left Certified Nursing Assistant #1 alone in the room with Resident #1 while Certified Nursing Assistant #1 was actively engaging and displaying signs of physical aggression (hand swinging) towards Resident #1. The final moment of the video recording captured Certified Nursing Assistant #1 used the F-word (profanity) towards Resident #1. A review of Resident #1's Psychologist progress note dated 08/22/2023 revealed the chief complaint/reason for the psychologist consult was because Resident #1 was having anxiety, and depressed mood. The Psychologist documented that Resident #1 exhibited symptoms including anxiety/fear, hopelessness / helplessness, irritability, negative statements, sad and worried expression during the psychologist session with the resident. A review of the facility's document titled Summary of Investigation dated 08/08/2023 documented that at approximately 12:05 pm on 08/07/2023 Resident #1 informed a unit manager (did not identify) that the resident had a video of an interaction with a Certified Nursing Assistant (did not identify) and that the said Certified Nursing Assistant was yelling at the resident. The Summary of Investigation further documented the Director of Nursing Services reviewed the video footage and interviewed Resident #1. The Summary of Investigation documented the video footage confirmed the Certified Nursing Assistant was not using customer service skills and said unidentified Certified Nursing Assistant was also documenting the interaction with their personal cellphone, despite having been educated on Health Insurance Portability and Accountability Act, the facility's social media policy as well as abuse, neglect, and mistreatment. Furthermore, the Summary of the Investigation identified Certified Nursing Assistant #1 as the perpetrator and documented they were removed from the schedule and later terminated for cause. The Summary of Investigation concluded that there was cause to believe that the alleged Resident abuse, mistreatment, or neglect regarding Resident #1 occurred. During a telephone interview on 03/14/2024 at 12:03 PM, Resident #1 stated that the event which led to the verbal abuse incident started after Resident #1 rang their call bell to ask for their pain medication. Resident #1 stated nursing staff profiled them as abusing the call bell, however Resident #1 was completely dependent on staff for everything. Additionally, Resident #1 stated nursing staff made derogatory comments towards Resident #1 each time nursing staff responded to Resident #1's call bell (did not cite an example). Resident #1 stated they had complained to the facility administration about the situation and each time they made the complaint, the facility administration downplayed Resident #1's concern on the account that nursing staff denied the allegation. Resident #1 decided to record their encounter each time they rang their call bell. Resident #1 stated Certified Nursing Assistant #1, who was captured on the video verbally abusive towards Resident #1, was not assigned to them and Certified Nursing Assistant #1's only intention of being in Resident #1's room was to threaten, bully and to act demeaning towards Resident #1. Resident #1 stated Certified Nursing Assistant #1 came into their room and told Resident #1 to stop ringing their call bell. Resident #1 stated Certified Nursing Assistant #1 was in their room for several minutes displaying threatening behaviors both verbally and physically. Resident #1 stated the encounter made Resident #1 very fearful and humiliated. Resident #1 stated they felt they were at risk of being attacked and injured by Certified Nursing Assistant #1. Resident stated they were bed ridden and were defenseless should Certified Nursing Assistant #1 decide to attack them. Resident #1 could be heard sobbing, moaning, and sniveling while they narrated the encounter. Resident #1 stated the incident kept flashing back in their memory and made them cry each time they remembered. Resident #1 stated it was not until the nursing staff who worked the morning shift came in that they were able to talk to someone about their encounter. During an interview on 03/14/2024 at 12:17 PM, Licensed Practical Nurse #1 stated they were the floor nurse assigned to Resident #1 on the morning shift (7:00 AM through 3:00 PM) on 08/07/2023. Licensed Practical Nurse #1 further stated they were not at the facility at the time of the verbal abuse incident, however, when they arrived at the facility on the morning of 08/07/2023, Resident #1 reported to them Certified Nursing Assistant #1 yelled at Resident #1. Licensed Practical Nurse #1 stated Resident #1 did not say much as the resident appeared to be upset when narrating their encounter. Licensed Practical Nurse #1 stated they reported Resident #1's complaint to Registered Nurse Supervisor #2 who advised them the night shift supervisor (Registered Nurse Supervisor #1) and the unit Nurse (Registered Nurse #1) had been made aware of the situation and Registered Nurse Supervisor #2 was waiting for Administration to arrive at the facility. During an interview on 03/14/2024 at 2:10 PM, Certified Nursing Assistant #1 stated Resident #1 was harassing staff members at the facility and Certified Nursing Assistant #1 believed someone needed to address Resident #1's behavior. Certified Nursing Assistant #1 stated they were not assigned to Resident #1 but responded to Resident #1 while the aid assigned to the resident was either on break or helping another resident. Certified Nursing Assistant #1 stated they were aware Resident #1 was a 2-person approach, but they went in Resident #1's room alone. Certified Nursing Assistant #1 stated they reacted during their encounter with Resident #1 because they walked in on Resident #1 recording them. Certified Nursing Assistant #1 stated after the encounter with Resident #1, they returned to their original assignment but were not instructed to not have any contact with Resident #1. Certified Nursing Assistant #1 stated they worked every other weekend and were invited to the facility by the Director of Nursing Services to provide a written statement on 08/08/2023 (Certified Nursing Assistant #1's day off). Certified Nursing Assistant #1 stated they were fired the same day they gave their report. Certified Nursing Assistant #1 stated they were verbally inappropriate with Resident #1 and had apologized to the Director of Nursing Services. During an interview on 03/14/2024 at 2:30 PM, Registered Nurse #1 stated they were the floor nurse on the evening shift (11:00 PM through 7:00 AM) on 08/06/2023. Registered Nurse #1 stated that Resident #1 had rang their call bell to ask for pain medication and were simultaneously screaming for their pain medication instead of waiting for nursing staff to respond to their call bell. Registered Nurse #1 stated Certified Nursing Assistant #1's attention was drawn to Resident #1's room in response to the resident screaming. Registered Nurse #1 stated Certified Nursing Assistant #1 was the aggressor, and Resident #1 was the victim. Registered Nurse #1 stated they stood in between Resident #1 and Certified Nursing Assistant #1 and called for help. When advised about the video evidence, Registered Nurse #1 stated they had to multitask by addressing the resident's pain whilst also trying to protect the resident from the aggressor. Registered Nurse #1 stated they reported the incident to the nurse supervisor (Registered Nurse Supervisor #1) on the shift. Registered Nurse #1 stated they did not report the incident in Resident #1's medical record as abuse because they did not witness the entire interaction between Resident #1 and Certified Nursing Assistant #1. Registered Nurse #1 stated they were re-trained on abuse after the incident. Registered Nurse Supervisor #1 was no longer employed at the facility for reason unrelated to the incident and were not available for interview despite multiple attempts. During an interview on 03/29/2024 at 4:35 PM Resident #1's Psychologist stated they received a referral to see Resident #1 following a verbal abuse incident the resident had with a nursing staff of the facility. Resident #1's Psychologist stated their scheduled assessment session dated 08/07/2023 immediately following the verbal abuse incident with Resident #1 did not hold because Resident #1 declined to be assessed for any psychosocial aftermath of the resident's interaction with the nursing staff. Resident #1's Psychologist stated that they had a subsequent assessment session dated 08/22/2023 with Resident #1. Resident #1's Psychologist stated Resident #1 did not express any concern about the abuse incident and the Psychologist's assessment which cited Resident #1 exhibited symptoms of anxiety/fear, hopelessness /helplessness, irritability, negative statements, sad and worried expression were not related to Resident #1's verbal abuse incident but resulted from Resident #1's upcoming discharge at the time pertinent to the Psychologist's assessment. Resident #1's Psychologist however clarified their note did not specifically delineate the listed symptoms were exclusively related to those exhibited by Resident #1 in anticipation of the resident's discharge from the facility. Resident #1's Psychologist stated the disposition about what potential the verbal abuse incident had and/or could have on Resident #1 was subjective and the Psychologist could not speak to what impact the verbal abuse incident had for Resident #1. During an interview on 03/29/2024 at 5:06 PM, the Director of Nursing Services stated Resident #1 made the facility administration aware of the verbal abuse incident on 08/07/2023. The Director of Nursing Services stated Resident #1 made a video of their interaction with the nursing staff whom the Director of Nursing Services identified as Certified Nursing Assistant #1. The Director of Nursing Services stated they only watched a partial portion of the video initially and concluded that Certified Nursing Assistant #1's (the perpetrator nursing aid identified in the video) interaction with Resident #1 was appalling, inappropriate, and was not reflective of the core value of an abuse free environment the facility stood for. The Director of Nursing Services stated they immediately terminated Certified Nursing Assistant #1's employment and then conducted a facility wide training on abuse. The Director of Nursing Services stated the survey was their first opportunity to review the complete video footage from Resident #1's recording and their review of the complete video unveiled what they considered disturbing. The Director of Nursing Services stated their complete review of the video identified that Registered Nurse #1 was a co-conspirator in the verbal abuse incident against Resident #1. The Director of Nursing Services stated Registered Nurse #1 watched on as Certified Nursing Assistant #1 continued to alter verbally inappropriate conversation towards Resident #1. The Director of Nursing Services stated Registered Nurse #1 did not timely intervene and/or attempt to remove Certified Nursing Assistant #1 from Resident #1's room. The Director of Nursing Services stated Registered Nurse #1 should not have left Certified Nursing Assistant #1 to be alone with Resident #1 while Certified Nursing Assistant #1 was actively directing verbally inappropriate words and showing signs of physical aggression towards the resident. The Director of Nursing Services stated based on their complete review of the video footage from Resident #1's recording, they terminated Registered Nurse #1's employment. During an interview on 03/29/2024 at 5:17 PM, The Nursing Home Administrator stated they had not personally reviewed the video recording made by Resident #1 of the resident's interaction with Certified Nursing Assistant #1 prior to survey as they relied on nursing leadership to take charge of the investigation. The Nursing Home Administrator stated their review of the video recording concluded that Certified Nursing Assistant #1's interaction with Resident #1 was egregious and unacceptable. The Nursing Home Administrator reiterated the facility's administration complete review of the video recording made by Resident #1 was not until the time of survey, and it drove the facility's conclusion that Registered Nurse #1 did not intervene as expected. The Nursing Home Administrator stated Registered Nurse #1 should have intervened by making the aggressor (Certified Nursing Assistant #1) leave Resident #1's room sooner. Register Nurse #1 should not have left Certified Nursing Assistant #1 to be alone with Resident #1 while Certified Nursing Assistant #1 was actively displaying sign of physical aggression verbally inappropriate words. Certified Nursing Assistant #1's behavior did not conform with the facility's directed customer service towards Resident #1. The Nursing home Administrator stated based on the new and complete information from the video, the facility terminated Registered Nurse #1. The Nursing Home Administrator reiterated that the facility conducted a facility wide training on abuse including, prevention, identification, and reporting of abuse immediately after they were made aware of the incident. During an interview 0n 03/29/2024 at 5:30 PM, the facility's Medical Director stated upon receiving Resident #1's verbal abuse complaint incident perpetrated by Certified Nursing Assistant #1 the facility invited them to assess Resident #1. The Medical Directors stated responses to situations such as the verbal abuse interaction against Resident #1 can be varied. The Medical Director stated their assessment of Resident #1 did not identify any psychologic and/or psychiatric symptoms. NYCRR 415.4(b)(1)(i), 415.12(h)(2)

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY00326793) initiated on 11/16/2023 and completed on 11/22/2023, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed or implemented that included measurable objectives and time frames to meet the resident's current needs. This was identified for one (Resident #391) of two residents reviewed for Urinary Catheter, one (Resident #81) of 2 residents reviewed for physical restraints and for one (Resident #130) of two residents reviewed for communication. Specifically, 1a) Resident #391 was readmitted on [DATE] with a Peripherally Inserted Central Line (PICC) for Antibiotic Therapy. On 6/5/2023 the PICC line was changed to the right arm and there was no documented evidence that a care plan was developed for the use and care of the PICC line. 1b) Resident #391 was assessed for the use of an indwelling Foley catheter due to Urinary Retention on 6/1/2023 and there was no documented evidence that a care plan was develop for the indication and use of the indwelling Foley catheter. 2) Resident #81 was observed wearing a self-release seatbelt while seated in a motorized wheelchair. There was no documented evidence of a Physician's order, an assessment, or a Comprehensive Care Plan (CCP) developed for the use and monitoring of the self-release seatbelt. 3) Resident #130 was admitted with bilateral hearing aids. There was no Comprehensive Care Plan developed for the use of the hearing aids. The findings are: The facility's policy and procedure titled Comprehensive Care Plans, dated 5/18/2023 documented the comprehensive, person-centered care plan is developed within seven days of completion of the required MDS assessment and no more than twenty-one days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1a) Resident #391 was admitted with diagnoses that includes Sepsis, Urinary Tract Infection, and Unspecified B-Cell Lymphoma. The MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident required extensive assistance of two staff members for bed mobility, transfers, toileting and was always incontinent of bowel and bladder. The MDS further documented the resident received antibiotic medication for four days during the look back period. A Hospital Discharge Summary dated 5/26/2023 documented to administer Ceftriaxone (Antibiotic medication) 2 Grams (gm) via the Intravenous piggy back (IVPB) every 24 hours for 42 days via a PICC line, complete on 7/6/2023. The Admission Evaluation form dated 5/26/2023 did not include that the resident had a PICC line catheter in place. A Physician's order dated 5/27/2023 documented to administer Vancomycin HCl (Antibiotic) Intravenous Solution Reconstituted 750 milligram (mg) intravenously one time a day for Sepsis until 7/6/2023. A Physician's order dated 5/27/2023 documented to administer Ceftriaxone Sodium in Dextrose Intravenous Solution 2 gm Intravenously one time a day for Sepsis until 7/6/2023. The Physician's order dated 5/27/2023 for the administration of the Antibiotic did not include use and care of the PICC line. The Medication Administration Records (MAR) dated 5/2023 and 6/2023 documented that the resident was administered Ceftriaxone Sodium-Dextrose Intravenously Solution 2 gm and Vancomycin HCl Intravenous Solution Reconstituted 750 mg intravenously one time a day for Sepsis starting 5/27/2023 through 6/11/2023. The resident was discharged from the facility on 6/12/2023. The MAR dated 5/2023 and 6/2023 was reviewed and lacked documented evidence that the PICC line catheter was flushed before and after the antibiotic therapy or that the PICC line dressing was changed. The nursing progress notes from 5/26/2023 to 6/4/2023 were reviewed. There was no documented evidence of the presence of a PICC line catheter site prior 6/4/2023. A Nursing progress note dated 6/5/2023 documented the resident's PICC line was observed leaking. An order to replace the PICC line was obtained and a new PICC line was placed in the right arm. RN #3 was interviewed on 11/21/2023 at 4:15 PM and stated that the resident was readmitted from the hospital with a PICC line. RN #3 stated that they had reviewed the hospital records for documentation regarding placement, and the type of PICC line catheter that was in place. RN #3 stated that they should have obtained Physician orders to monitor the PICC line site; for weekly dressing changes; and for flushing the PICC line before and after Antibiotic therapy. RN #3 stated that a CCP should have been initiated to include the use and indication for the PICC line. 1b) A Nurse Practitioner (NP) note dated 6/1/2023 documented the resident was assessed and noted with abdominal distention and bladder distention. The resident was catheterized and 2300 milliliters (ml) of urine was drained. An Abdominal x-ray revealed evidence of a distended bladder. The resident remained with the Foley catheter at this time with positive urine drainage. A Physician's order dated 6/1/2023 documented to obtain an abdominal Ultrasound and a Pelvic Ultrasound. A Nursing Progress note, created on 6/2/2023 at 9:10 AM for 6/1/2023, documented the resident complained of abdominal pain and was immediately seen by the Physician who was present in facility at the time. The medical record did not include a Physician's order for the use of a Foley catheter. The Bowel and Bladder Evaluation form dated 6/6/2023 documented the resident was incontinent of urine and has a Foley catheter due to Urinary Retention. The Director of Nursing Services (DNS) was interviewed was on 11/20/2023 at 4:43 PM. The DNS stated that on admission the admitting nurse should have documented on the admission assessment that the resident was admitted with a PICC line. The DNS stated the admitting Registered Nurse (RN) #3 should have obtained a Physician's order to flush the PICC line before and after Antibiotic use and for care of the PICC line, which should have included weekly dressing changes. The DNS stated that there should have been Physician's order for the use and care of the Foley catheter. The DNS further stated there should have been a CCP developed for the use of the PICC line and for the use of the indwelling Foley catheter. Licensed Practical Nurse (LPN) #7 was interviewed was on 11/22/2023 at 12:06 PM. LPN #7 stated they inserted a Foley catheter on 6/1/2023 as per the Physician's verbal orders. LPN #7 stated that once they had conducted the bladder scan the results were reported to the Physician and a Foley catheter was inserted based on the Physician's verbal orders. LPN #7 stated all procedures completed for the resident require a Physician's order. LPN #7 stated they were not responsible to enter the Physician's orders in the Electronic Medical Record (EMR), that responsibility belonged to the NP, Physician, or the unit Nurse Manager. LPN #7 further stated that the Registered Nurse (RNs) were responsible for initiating the CCP for the use of the Foley Catheter. Nurse Practitioner (NP) #1 was interviewed on 11/22/2023 at 12:38 PM. NP #1 stated that when a resident has a PICC line there should have been a Physician's orders in place for the use of the PICC line; flushing the PICC line before and after use; and for weekly PICC line dressing changes. The NP stated that it was an oversight that orders were not initiated for the use and care of the PICC line. NP #1 stated that they were in the facility on 6/1/2023 and examined the resident due to bladder distension. NP #1 stated the resident failed voiding and they ordered a straight catheterization then insertion of the indwelling Foley catheter and documented their plan in the medical progress notes; however, it was an oversight that they did not initiate an order for the Foley Catheter. The Medical Director was interviewed on 11/22/2023 at 1:16 PM and stated that a Physician's order should be in place from the hospital for the PICC line care. The Medical Director stated that the two basic orders that should be obtained from the Physician by the admitting nurse were the PICC line dressing changes weekly and as needed, and to flush the PICC line before and after each use. The Medical Director stated that when the PICC line dressing changes are not performed timely there is a potential for infection at the PICC line site. The Medical Director stated that if the PICC line catheter was not flushed then there is a potential for the PICC line malfunction. Additionally, the Medical Director further stated that when a Foley catheter is inserted there should be a Physician's order including the indication for the use of the Foley Catheter. 49245 2) Resident #81 was admitted with diagnoses that include Hemiplegia and Hemiparesis with Cerebral Infarction and Polyarthritis. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident was cognitively intact. Resident #81 required extensive assistance of two persons for all Activities of Daily Living (ADLs) which includes toileting, bed mobility, and personal hygiene. The resident utilized a motorized wheelchair for mobility. The Comprehensive Care Plan (CCP) for Impaired Mobility/Positioning Device dated 6/19/2023 and last updated on 9/3/2023 documented interventions including the use of a motorized wheelchair with a joystick and a right arm trough for improved positioning. The CCP did not include the use of a seat belt. The Physician's orders dated 11/8/2023 to utilize a motorized wheelchair; however, the order did not include the use of a self-release seat belt. Resident #81 was observed on 11/16/2023 at 11:30 AM wearing a self-release seat belt while using a motorized wheelchair. Resident #81 was interviewed on 11/20/2023 at 2:26 PM and stated that they always use a seat belt with the motorized wheelchair because they do not want to fall. Certified Nursing Assistant (CNA) #1 was interviewed on 11/21/2023 at 11:52 AM and stated that Resident #81 always uses the self-release seat belt when they are using the motorized wheelchair. The Director of Rehabilitation Services was interviewed on 11/20/2023 at 3:18 PM and stated that residents who use self-release seat belts should have an evaluation completed and a care plan developed for the use of the seat belt even if the wheelchair came with the resident from their home. MDS Coordinator #1 was interviewed on 11/22/2023 at 10:12 AM and stated that Resident #81 obtained the motorized wheelchair themselves. MDS Coordinator #1 stated they were responsible for updating the CCP. MDS Coordinator #1 stated they did not update Resident #81's CCP to include the use of the self-release seat belt because the resident did not use the seat belt all the time. The Director of Nursing Services (DNS) was interviewed on 11/22/2023 at 9:40 AM and stated that Resident #81 has a motorized wheelchair, and the self-release seat belt is a part of the motorized wheelchair. The self-release seat belt care plan was supposed to be developed when the motorized wheelchair was first used. 41051 3) The facility's policy and procedure titled Care of Hearing Aids last revised February 2018 documented the purpose of the procedure is to maintain the resident's hearing at the highest attainable level. Resident #130 was admitted with diagnoses of lumbar vertebra (a bone in the lower back) fracture, Dementia and Anemia. The 5-day Minimum Data Set (MDS) assessment dated [DATE] documented Resident #130 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The MDS documented Resident #130 had adequate hearing and there were no hearing aids or other hearing appliances used. On 11/17/2023 at 9:20 AM Resident #130's television could be heard from down the hallway. Resident #130 was in their room watching television. Resident #130 was not able to engage in a conversation despite the surveyor speaking with an louder volume. On 11/20/2023 at 4:53 PM Resident #130 was observed in their room watching television. Resident #130 responded appropriately to questions asked at a normal volume. Resident #130 stated they wear hearing aids in both ears. Resident #130 stated they had the hearing aids since they (Resident #130) were admitted to the facility, and they keep the hearing aids in their nightstand. Resident #130 stated they put them in the hearing aids in the morning by themselves and take them out before bed. Resident #130 stated they do not have a problem hearing people or the television when they are using the hearing aids. Resident #130's Baseline Care Plan dated 10/2/2023 documented Resident #130 used bilateral hearing aids. Review of the Comprehensive Care Plan revealed no care plan was developed for the use of the hearing aids. Review of the Documentation Survey Report (Certified Nursing Assistant (CNA) accountability record) for the month of September, October and November 2023 revealed no documentation regarding the resident's bilateral hearing aids until 11/21/2023. CNA #9 was interviewed on 11/21/2023 at 10:53 AM and stated they have worked with Resident #130 since the resident was admitted to the facility. CNA #9 stated Resident #130 cannot hear without their hearing aids and has been using hearing aids since they (Resident #130) were admitted . RN #2, the unit charge nurse, was interviewed on 11/21/2023 at 3:49 PM and stated they were not aware that Resident #130 wore hearing aids. RN #2 stated they were informed by CNA #9 on the morning of 11/21/2023 that Resident #130 used hearing aids. The MDS Coordinator was interviewed on 11/21/2023 at 4:03 PM. The MDS Coordinator stated the unit charge nurse completed the admission evaluation and baseline care plan that indicated Resident #130 wore bilateral hearing aids on 9/9/2023. The MDS Coordinator stated the resident did not have an issue hearing them (MDS Coordinator) when they (MDS Coordinator) completed the MDS assessments on 9/15/2023 and 10/6/2023. The unit charge nurse who completed the admission evaluation and the baseline care plan for Resident #130 was unavailable for an interview. The Director of Nursing Services (DNS) was interviewed on 11/22/2023 at 2:46 PM. The DNS stated the Hearing Aid Care Plan was not developed because the MDS Coordinator did not find the resident's hearing to be an issue. Prior to the recertification survey there was no evidence of the resident requiring hearing aids. 10 NYCRR 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00326793) initiated on 11/16/2023 and completed on 11/22/2023 the facility did not ensure that medical care of each resident was supervised by a Physician and included Physician's orders for the resident's immediate care and needs. This was identified for one (Resident #391) of two residents reviewed for Urinary Catheter use. Specifically, a) Resident #391 was readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) Line for Antibiotic Therapy. There were no physician's orders in place upon admission on 5/26/2023 for the use of the PICC line for antibiotic therapy; for monitoring of the PICC line site, nor for dressing changes of the PICC line. b) On 6/1/2023 Resident #391 was assessed by a Nurse Practitioner (NP) #1 for the use of an indwelling Foley catheter due to a diagnosis of Urinary Retention. There was no physician's order obtained for the indication and use of the indwelling Foley catheter. The finding is: The facility's Physician's Orders Policy dated 5/19/2023 documented that each resident must be under the care of a Licensed Physician authorized to practice medicine in this state and current list of orders must be maintained in the clinical record of each resident. a) Resident #391 was admitted with diagnoses that includes Sepsis, Urinary Tract Infection, and Unspecified B-Cell Lymphoma. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident was always incontinent of bowel and bladder. The MDS further documented the resident received antibiotic therapy for 4 days during the look back period. A Physician's order dated 5/27/2023 documented to administer Vancomycin HCl (Antibiotic) Intravenous Solution Reconstituted 750 milligram (mg) intravenously and Ceftriaxone Sodium (Antibiotic) in Dextrose Intravenous Solution 2 Gram Intravenously one time a day for Sepsis until 7/6/23. The Medication Administration Records (MAR) dated 5/2023 and 6/2023 documented Ceftriaxone Sodium-Dextrose Intravenously Solution 2 gram intravenously one time a day and Vancomycin HCl Intravenous Solution Reconstituted 750 mg intravenously one time a day for Sepsis were administered starting 5/27/2023 through 6/11/2023. The resident was discharged from the facility on 6/12/2023. The MARs dated 5/2023 and 6/2023 were reviewed. Both the 5/2023 and 6/2023 MARs lacked documented evidence of dressing changes of the PICC line and that the PICC line was flushed prior to and after the antibiotic administration. A Nurse Practitioner (NP) note dated 6/1/2023 documented the resident Continued Vancomycin and Ceftriaxone until 07/06/2023 for Endocarditis. A Nursing progress note dated 6/5/2023 documented the resident's PICC line was observed leaking. An order to replace PICC line was obtained and a new line in the right arm was placed. PICC line patent, no complaint of pain or leaking at this time. b) The Bowel and Bladder Admission Evaluation form dated 6/6/2023 documented the resident was incontinent of urine and has a Foley catheter due to Urinary Retention. A Nurse Practitioner (NP) note dated 6/1/2023 documented the resident was assessed and noted with abdominal distention and bladder distention. The resident was catheterized and 2300 milliliters (ml) of urine was drained. An Abdominal x-ray revealed evidence of a distended bladder. The resident remained with the Foley catheter at this time with positive urine drainage. A review of the resident's medical record revealed there were no Physician's orders for the use of the foley catheter use nor an indication for the foley catheter. The Director of Nursing Services (DNS) was interviewed was on 11/20/2023 at 4:43 PM. The DNS stated that on admission the admitting nurse should have documented on the admission assessment that the resident was admitted with a PICC line. The DNS stated the admitting Registered Nurse (RN) #3 should have obtained a Physician's order to flush the PICC line before and after Antibiotic use and for care of the PICC line, which should have included weekly dressing changes. The DNS further stated that there should have been a Physician order for the Foley catheter and that a CCP should have been developed for the use of the PICC line and for the use of the indwelling catheter. Licensed Practical Nurse (LPN) #7 was interviewed was on 11/22/2023 at 12:06 PM. LPN #7 stated they inserted the Foley catheter on 6/1/2023 as per the Physician's verbal order. LPN #7 stated that once they had conducted the bladder scan the results were reported to the Physician and a Foley catheter was inserted based on the physician's verbal orders. LPN #7 stated all procedures completed for the resident require a Physician's order. LPN #7 stated they were not responsible to enter the Physician's orders in the Electronic Medical Record (EMR), that responsibility belonged to the NP, Physician, or the unit Nurse Manager. Nurse Practitioner (NP) #1 was interviewed on 11/22/2023 at 12:38 PM. NP #1 stated that when a resident has a PICC line there should have been a Physician's orders in place for the use of the PICC line; flushing the PICC line before and after use; and for weekly PICC line dressing changes. The NP stated that it was an oversight that orders were not initiated for the use and care of the PICC line. NP #1 stated that they were in the facility on 6/1/2023 and examined the resident due to bladder distension. NP #1 stated the resident failed voiding and they ordered a straight catheterization then insertion of the indwelling Foley catheter and documented their plan in the medical progress notes; however, it was an oversight that they did not initiate an order for the Foley Catheter. The Medical Director was interviewed on 11/22/2023 at 1:16 PM and stated that a Physician's order should be in place from the hospital for the PICC line care. The Medical Director stated that the two basic orders that should be obtained from the Physician by the admitting nurse were the PICC line dressing changes weekly and as needed, and to flush the PICC line before and after each use. The Medical Director stated that when the PICC line dressing changes are not performed timely there is a potential for infection at the PICC line site. The Medical Director stated that if the PICC line catheter was not flushed then there is a potential for the PICC line malfunction. Additionally, the Medical Director further stated that when a Foley catheter is inserted there should be a Physician's order including the indication for the use of the Foley Catheter. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 11/16/2023 and completed on 11/22/2023, the facility did not ensure that the Comprehensive Care Plan (CCP) for each resident was reviewed and revised by an interdisciplinary team to reflect the resident's current status. This was identified for one (Resident # 196) of five residents reviewed for Accidents and one (Resident #200) of four residents reviewed for Limited Range of Motion. Specifically, 1) Resident #196 had a physician's order, and a CCP developed, to utilize a Wanderguard bracelet due to wandering behavior. Facility staff were aware of the resident's behavior of removing the Wanderguard bracelet; however, the CCP was not updated to reflect the resident's behavior. Additionally, the Certified Nursing Assistant Accountability Record (CNAAR) was not updated to address the resident's behavior. 2) Resident #200 had a Physician's order to wear a Miami J collar (rigid collar applied to the neck) due to a cervical fracture. Resident #200 was observed on multiple occasions not wearing the Physician prescribed Miami J collar. The CCP was not revised to reflect the resident's behavior of removing the Miami J collar. The finding is: The facility's policy titled, Care Plans, Comprehensive Person-Centered dated 5/18/2023 documented assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team reviews and updates the care plan when the desired outcome is not met. 1) Resident #196 has diagnoses including Severe Dementia with Other Behavioral Disturbances, Anxiety Disorder, and Psychotic Disorder. The 9/20/2023 quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severely impaired cognition. Resident #196 requires one-person physical assistance with transfers and ambulation. A physician's order dated 9/07/2023 documented to apply the Wanderguard/Secure Care bracelet to the right ankle and to check the function of the Wanderguard bracelet every shift to ensure safety and minimize elopement risk. A CCP, initially developed on 12/10/2022 and last revised on 09/25/2023, documented the resident exhibits behavior symptoms such as wandering behavior; was identified as an elopement risk; was expressing desire to leave the facility, and had cognitive impairment. Interventions included but were not limited to checking the function of the Wanderguard and checking the placement of the Wanderguard bracelet each shift. The Treatment Administration Record (TAR) for November 2023 documented to check the function of the Wanderguard to the right ankle every shift for safety/elopement risk. The TAR included the initials of the nursing staff every shift. Resident #196 was observed sitting on the edge of the bed in their room on 11/17/2023 at 11:47 AM. The resident was observed not wearing a Wanderguard on their ankle. The 7 AM - 3 PM shift Certified Nursing Assistant (CNA) #6 was interviewed on 11/17/2023 at 11:47 AM. CNA # 6 stated they (CNA #6) were the assigned dayshift CNA for Resident # 196. The surveyor asked CNA#6 to check the placement of Resident #196's Wanderguard bracelet. CNA #6 checked the resident's upper extremities, followed by the lower extremities, but could not find the Wanderguard bracelet. CNA #6 then searched the resident's room, checking all the drawers. CNA #6 was not able to locate the Wanderguard. CNA #6 stated that the resident occasionally removes the Wanderguard bracelet. CNA #6 stated the nurses are responsible for checking and documenting that the Wanderguard is in place; the task of documenting the Wanderguard's placement is not specifically assigned to CNAs. CNA#6 stated they would notify a nurse if they noticed the wanderguard was not in place. Resident #196 was observed in the activity room on 11/20/2023 at 4:04 PM, engaged in an activity. Licensed Practical Nurse (LPN) #1 was present in the activity room and was asked to check the placement of Resident # 196's Wanderguard. LPN #1 stated the Wanderguard was not on the resident. LPN #1, the unit manager, was re-interviewed on 11/20/23 at 4:08 PM and stated that everyone is responsible for checking the Wanderguard's placement. LPN #1 further stated that Resident #196 frequently removes the Wanderguard. LPN #2 was interviewed on 11/20/2023 at 4:20 PM. LPN #2 stated that they checked Resident # 196's Wanderguard placement on 11/17/2023 and documented resident's Wanderguard was in place on TAR. LPN #2 stated that the resident frequently removes the Wanderguard. LPN #2 stated, It is hard plastic, I don't know how (the resident) takes it off. Resident # 196's Electronic Medical Record (EMR) was reviewed from 9/07/2023 through 11/20/2023. There was no documented evidence regarding Resident # 196 removing the Wanderguard bracelet. The Director of Nursing Services (DNS) was interviewed on 11/20/2023 at 4:35 PM and stated that Wanderguard placement is checked by nurses during each shift, and the overnight shift (11 PM - 7 AM) nurses assess the functioning of the Wanderguard on a weekly basis. The DNS reviewed the resident's CCP and acknowledged the absence of a care plan to address the resident's behavior of removing the Wanderguard. The DNS stated that the care plan for the Wanderguard should have been revised to address the resident's non-compliance to manage and address the behavior of the Wanderguard removal. 41051 2) The facility's policy titled, Assistive Devices and Equipment dated 5/19/2023 documented devices and equipment that assist with resident mobility, safety and independence are provided for residents. The policy documented the staff are required to demonstrate competency in the use of devices and equipment and are available to assist and supervise residents as needed. Resident #200 was admitted with diagnoses including a Nondisplaced fracture of the seventh cervical vertebra (bone in the spine at neck), Traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), and Chronic obstructive pulmonary disease. The 5-day Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of three indicating the resident had a severely impaired cognition. The resident was dependent on a helper to eat, complete oral hygiene, complete toileting hygiene, to shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and to complete personal hygiene. A Physician's (MD) order dated 10/17/2023 documented to wear the Miami J collar at all times, remove every shift for hygiene and skin checks. The Comprehensive Care Plan (CCP) for alteration in musculoskeletal status related to seventh vertebral fracture dated 10/18/2023 documented the resident would have no complications from the fracture. The interventions effective on 10/18/2023 included to wear the Miami J collar per MD orders. The CCP for Behavior dated 11/2/2023 documented the resident exhibits behavior symptoms such as: ambulating without assistance, wandering about the unit but has not attempted to leave interior of the building. The CCP was revised on 11/20/2023 to include the resident's behavior of removing the Miami J collar. A nursing progress note dated 11/7/2023 documented Resident #200 was observed removing their Miami J collar. A Nurse Practitioner (NP) progress note dated 11/10/2023 documented Resident #200 was noncompliant with wearing the Miami J collar. A nursing progress note dated 11/12/2023 documented Resident #200 refused to wear the Miami J collar. A nursing progress note dated 11/13/2023 documented Resident #200 was pulling off their Miami J collar. The NP progress note dated 11/16/2023 documented Resident #200 was to continue use of the Miami J collar; remove every shift with routine skin care. A nursing progress note dated 11/20/2023 documented Resident #200 was walking in their room without wearing the Miami J collar. A subsequent nursing progress note dated 11/20/2023 documented Resident #200's Miami J Collar could not be located. The NP progress note date 11/21/2023 documented Resident #200 was noncompliant with wearing the Miami J collar. The NP note dated 11/22/2023 documented Resident #200 was observed not wearing their Miami J collar. Resident #200 was to wear Miami J collar at all times until cleared by the Neurosurgeon. The following observations of Resident #200 were made: -On 11/17/2023 at 9:16 AM Resident #200 was observed sitting in their wheelchair in their room and not wearing their Miami J collar. The Miami J collar was observed on their nightstand. -On 11/20/2023 at 4:17 PM Resident #200 was observed sitting on their bed and not wearing their Miami J collar. When asked where their Miami J collar was Resident #200 pointed to their nightstand. The Miami J collar was observed on the nightstand. -On 11/21/2023 at 10:16 AM Resident #200 was observed in the resident lounge. Resident #200 was not wearing their Miami J collar. Certified Nursing Assistant (CNA) #8, the assigned 7 AM - 3 PM CNA, was interviewed on 11/20/2023 at 4:19 PM. CNA #8 stated Resident #200 has to wear the Miami J collar at all times, but the resident frequently removes the collar. CNA #8 stated they (CNA #8) informed the unit Licensed Practical Nurse (LPN) when Resident #200 removed the collar because the LPN was responsible for ensuring the placement of the collar. LPN #5 was interviewed on 11/21/2023 at 9:56 AM. LPN #5 stated the resident started to remove the Miami J collar after their (Resident #200's) tracheotomy tube was removed on 11/6/2023. LPN #5 stated they (LPN #5) ensured the placement of the collar at the start of each shift and when Resident #200 removed the collar they (LPN #5) offered verbal encouragement to reapply the collar. LPN #5 stated they (LPN #5) documented in their nursing notes that Resident #200 removed the collar. Registered Nurse (RN) #2 was interviewed on 11/21/2023 at 10:05 AM. RN #2 stated Resident #200 started to remove their Miami J collar when their tracheotomy tube was removed on 11/6/2023. RN #2 was re-interviewed on 11/21/2023 at 3:48 PM. RN #2 stated Resident #200's care plan should have been updated on 11/7/2023 when the resident first removed the collar. The Minimum Data Set (MDS) Coordinator was interviewed on 11/21/2023 at 4:13 PM. The MDS Coordinator stated they updated Resident #200's care plan on 11/20/2023 because they (MDS Coordinator) were informed of the issue of Resident #200 removing the Miami J collar on 11/20/2023. The MDS Coordinator stated updates on a resident's condition are reported to them (MDS Coordinator) via the morning report, through Electronic Medical Record (MAR) review or reports from the Unit RN. The MDS Coordinator stated they share the responsibility of creating and updating the care plan with other nurses and the rehabilitation therapy department. The Director of Nursing Service was interviewed on 11/22/2023 at 2:53 PM. The DNS stated a revision of the Comprehensive Care Plan should be completed within seven to fourteen days of a change in a resident's behavior. 10 NYCRR 415.11(c)(2)(i-ii)

Based on observations, record review and interviews conducted during a Recertification Survey initiated on 11/16/2023 and completed on 11/22/2023, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision to prevent accidents. This was identified for one (Resident #87) of five residents reviewed for Accidents. Specifically, Resident #87 was observed on 11/22/2023 with multiple medications in a medication cup on their bedside table with no staff member in the vicinity. The resident was not assessed to safely self-administer medications. The finding is: The facility policy for administering medication dated 5/19/2023 did not address protocols to be followed related to medications being left unattended at the resident's bedside. Resident #87 was admitted with diagnoses that included Depression, Right Breast Cancer, and Gastro-Esophageal Reflux Disease (GERD). A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented the resident received antidepressant medication for seven of seven days during the lookback period. A physician's order in place since 11/5/2021 through 11/22/2023 documented to administer Anastrozole 1 milligram (mg) 1 tablet by mouth one time a day for Breast Cancer. A Physician's order in place since 12/15/22 through 11/22/2023 documented to administer Loratadine (Claritin) 10 mg, 1 tablet by mouth one time a day for allergy symptoms. A Physician's order in place since 5/9/2022 through 11/22/2023 documented to administer Omeprazole 20 mg 1 tablet by mouth in the morning for acid indigestion. A Physician's order in place since 4/28/2021 through 11/22/2023 documented to administer Venlafaxine Hydrochloride (HCI) Extended Release (ER) 75 mg, 3 capsules by mouth one time a day for Depression. A Comprehensive Care Plan (CCP) dated 12/14/2020 and updated 7/5/2023 documented the resident has Anti-Estrogen medication-related Cancer. Interventions included but were not limited to give medications and treatments as ordered. A CCP dated 6/4/2020 and last updated 7/5/2023 documented the resident has GERD and was at risk for complications. Interventions included but were not limited to give medications as ordered. A CCP dated 6/4/2023 documented the resident uses antidepressant medication related to Depression. Interventions included but were not limited to give the antidepressant medications as ordered by the physician. During an observation on Nursing Unit 200 on 11/22/2023 at 9:20 AM Resident #87 was observed in bed. The resident was awake, alert and responded appropriately to greetings. A medication cup containing a capsule and 4 tablets was observed on the resident's bedside table. The resident stated that the cup contained their Antidepressant (Venlafaxine), Cancer (Anastrozole) tablet, their medication (Prilosec) for GERD, and Claritin (for allergies). Resident #87 stated they were not finished taking their pills. There was no staff member present in the resident's room. Licensed Practical Nurse (LPN) #8 was interviewed on 11/22/2023 at 9:25 AM. LPN #8 stated they gave Resident #87 their medications at 8:29 AM; however, they did not observe the resident taking all their medications because they had to leave the resident's room when they received an overhead page. LPN #8 stated that the resident receives a total of six medications in the morning and they had administered two of the six medications when they were paged. LPN #8 stated the other medications were left in a cup at the bedside. LPN #8 stated the process was for them to stay with the resident until all medications were taken. LPN #8 stated when they responded to the overhead page, they (LPN #8) should have taken the pills with them when they left the resident's room. LPN #8 stated that they intended to return to the resident but forgot. Physician #1, who was the resident's attending Physician, was interviewed on 11/22/2023 at 11:50 AM. Physician #1 stated Resident #87 did not request to self-administer their medication and therefore they did not initiate an order for self-medication Administration. Physician #1 stated that the medication should not have been left at the resident's bedside. The Director of Nursing Services (DNS) was interviewed on 11/22/2023 at 12:35 PM. The DNS stated LPN #8 should not have left the medications at the resident's bedside. The DNS further stated that LPN #8 should have taken the medications with them when they left the resident's room in response to the page. 10 NYCRR 415.12(h)(1)(2)

Based on record review and interview during an abbreviated survey (NY00323094), the facility did not have an effective system to monitor resident's bowel movements adequately. This issue was identified for one resident (Resident #1) out of the five residents reviewed. Specifically, Resident #1 was assessed to have constipation according to the Minimum Data Set (MDS). The Certified Nursing Assistant (CNA) records documented Resident #1 had no Bowel Movements (BM) or the bowel movement section was left blank on 15 days in [DATE]. There was no documented evidence that Resident #1's Physician or Nurse Practitioner were notified or that the facility implemented their bowel protocol. On [DATE], Resident #1 was diagnosed with a rectal fecal impaction based on an abdominal x-ray. Subsequently, on [DATE], Resident #1 was transferred to the hospital and expired on [DATE] due to septic shock related to stercoral colitis with perforation (which occurs when chronic constipation leads to fecal impaction causing holes in the colon wall). This resulted in immediate jeopardy and actual harm to Resident #1. The findings are: The facility policy and procedure titled Bowel Protocol, dated ,d+[DATE], documented the facility's policy to ensure that each resident has regular bowel movements (BM). The CNA is responsible for documenting bowel movements on the CNA accountability record, including the size. If a resident has not had a bowel movement for six shifts (2 consecutive days), Milk of Magnesia (MOM) (treatment for constipation) is to be administered per the Medical Doctor's (MD) order. If there is still no BM after the next shift, sorbitol (medication used to treat constipation) should be administered. If there is no BM by the end of the day, the steps must be repeated. Resident #1 was admitted with several diagnoses, including multiple fractures of right ribs, pneumothorax (collapsed lung), and gastroesophageal reflux disease (a common condition in which the stomach contents move up into the esophagus). The Minimum Data Set (MDS) dated [DATE] documented that the resident was cognitively intact and had constant bowel incontinence. The Activities of Daily Living (ADL) documentation stated that Resident #1 requires extensive assistance from two people for toileting and transferring. The MDS also documented the presence of constipation. The admitting medication orders included various medications, including Senna 8.6 milligrams (mg) (a medication for constipation). The comprehensive care plan documented that the resident had bowel incontinence related to immobility. The goal was for the resident to be continent during the daytime. Interventions included checking every 2 hours, providing a bedpan, peri care, monitoring and documenting any changes in mental status and bowel movement pattern each day. The August CNA accountability records identified 81 opportunities to document bowel movements from [DATE]-[DATE], and they were documented as follows: ,d+[DATE] documents showed no bowel movement. ,d+[DATE] were not documented (left blank). ,d+[DATE] documented a bowel movement with its size. ,d+[DATE] documented code 97 indicating not applicable. 9 episodes had six shifts without evidence of a bowel movement. The Certified Nursing Assistant (CNA) accountability record documented the resident had no Bowel Movements (BM) or the section for the bowel movement was left blank on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. The facility presented a High Alert Bowel monitoring form dated [DATE]-[DATE], where each shift was indicated as 0, S, M, or L, but this form was not consistent with the CNA accountability records. The form did not include initials or titles of staff who entered the information or a key defining the entries. LPN#1, who reportedly completed the form, works the day shift, and was noted to be off 15 days during this period. A nurse's progress note dated [DATE] documented the Nurse Practitioner (NP)#1 ordered a KUB (Kidney Ureter Bladder) x-ray and labs for abdominal pain. Radiology results dated [DATE] of the abdomen documented: There is a suggestion of a large rectal fecal impaction in rectum. A nursing progress note dated [DATE] at 3:47 PM documented Resident #1 received an enema as ordered by NP# 1. There was no documented evidence of the effectiveness of the enema. There was no documented evidence by the Primary Physician #1 (PP#1) or the Nurse Practitioner #1(NP #1) [DATE] regarding Resident #1's condition or whether they had an assessment. There was no documented evidence as to why the x-ray and labs were ordered. A nursing progress note dated [DATE] at 2:17 PM documented Resident #1 was lethargic. NP#1 was notified and ordered a chest x-ray, labs, and two different intravenous antibiotics. A nursing progress note dated [DATE] at 3:38 PM documented the intravenous line was infiltrated (not working). NP #1 was notified, and they provided orders for Resident #1 to increase their oral fluids. The [DATE] at 2:13 PM NP #2 note documented Resident #1's chest x-ray showed no acute cardio-pulmonary disease. The NP #2 general exam documented no acute distress but noted lethargy (a state of sleepiness or deep unresponsiveness). The note further documented Resident #1 was recently diagnosed with fecal impaction status post bowel regimen with positive effects. The note further documented Resident #1 was noted with increased weakness and lethargy. The [DATE] at 08:14 AM NP #1 note documented Resident #1 was diagnosed with a fecal impaction. Resident #1 is currently complaining of abdominal discomfort. A repeat abdominal x-ray and blood work ordered. A Nursing Change of Condition Note dated [DATE] at 1:38 PM Resident #1 was transported to Hospital via ambulance for increased lethargy. The hospital physician progress note dated [DATE] documented Resident #1 was found to be in septic shock related to stercoral colitis with perforation and multi organ failure with altered mental status requiring mechanical ventilation. Resident #1 expired. A telephone interview was conducted on [DATE] at 1:00 PM with CNA #1 who stated they do not remember Resident#1 having a bowel movement on their shift, only wet brief. CNA #1 documented only on the computer and does not remember anyone asking about the resident's bowel movement. A telephone interview was conducted on [DATE] at 1:15 PM with CNA #2 and stated they would report bowel abnormalities to the nurse. CNA #2 does not remember anyone asking about Resident #1's bowel movements. CNA #2 stated they are responsible for documenting what happens only on the assigned shift on the computer. An interview was conducted with LPN # 1 on [DATE] at 3:00 PM stated they work regular day shift on the same floor. LPN#1 stated they do not document resident BM. LPN #1 stated that the CNA's are responsible to document when residents have a BM. LPN#1 further stated resident was lethargic, pale and the blood pressure was low. LPN #1 stated it was reported that resident was not at baseline, but does not remember reporting the bowel movements to the Nurse Practitioner. LPN #1 further stated they did not follow up on the x-ray but were given a verbal order by the NP #1 for an enema. LPN#1 stated the order was entered in the computer but LPN#1 did not administer the enema. An interview was conducted with the Unit Manager on [DATE] and [DATE] who stated they would interview different staff members and complete the high alert bowel form for all shifts on the days they worked. The Unit Manager could not identify who reported bowel movements on any day. The Unit Manager further stated they did not know who completed the form on weekends or when they were off. An interview was conducted on [DATE] at 1:05 PM and at 5:29 PM with Director of Nursing Services (DNS), who stated CNAs document bowel movements in the CNA accountability record in the electronic medical records. The Unit Manager is responsible to check the CNA accountability record, and the CNAs let the Unit Manager know if the resident does not have a bowel movement. The DNS further stated Resident #1 was also being monitored using, the high alert bowel monitoring form which was completed by the Unit Manager. The DNS does not know who reported the findings to the Unit Manager or who completed the form in the absence of the Unit Manager. The DNS stated missed documentation on the CNA accountability record is a problem. The facility educates and disciplines CNA staff constantly. The DNS further stated residents without a BM will appear on an alert on the Unit Managers dashboard but does not know if it includes missing documentation or only the code for no BM. If an alert comes up the Unit Manager will talk to the patient or notify the medical staff for new orders. The DNS states the facility has a doctor or Nurse Practitioner on site daily, so they usually defer to them and not the protocol. The DNS stated vital signs are taken based on the physician orders. A nurse can take vital signs independently however the doctor would indicate how often a resident should be monitored. The DNS stated there is a group messaging used to communicate residents with changes in condition. The group messaging includes the medical doctor, the chief medical officer, all practitioners, and supervisors. On the phone application they discuss residents with changes in condition and all transfers to the hospital. Resident #1 was included on the chat on [DATE] when they were transferred out to the hospital. Resident #1 was not included prior to. as they were being treated in house. The DNS further stated the resident had elevated white blood count and was being treated with IV antibiotics and was scheduled for a chest x-ray before she went out. The DNS stated they were not able to identify the source of the infection causing the elevated white count. An Interview was conducted with the NP #1 on [DATE] at 3:00 PM who stated a nurse (does not remember who) verbally reported Resident #1 did not have a bowel movement in a week and was having abdominal pain, NP #1 provided a verbal order for initial labs and x-ray and a stat (a medical term meaning instantly or immediately) enema on [DATE]. NP#1 stated they did not document an assessment, or intervention. NP#1 stated they did not document on [DATE]. NP #1 reviewed the result of the KUB (Kidney Ureter Bladder- x-ray of abdomen) on the same day that the enema was ordered. NP#1 stated Resident #1's bowel pattern of is every 3 days from the aide and the nursing team verbally reported. The NP further states she did not document the assessment. A telephone interview was conducted on [DATE] at 1:48 PM with the Primary Physician (PP) #1 who stated an enema was ordered in response to the x-ray [DATE], and nursing staff should be monitoring for effectiveness. PP #1 stated they were aware Resident #1 continued to decline, and they were monitoring labs and treating with antibiotics. PP #1 stated Resident #1 was hypoxic (oxygen is not available or sufficient), and it was thought that the source of the infection was pneumonia. PP #1 stated prior to the x-ray it was not reported to that Resident #1 had no bowel movements. During an interview conducted with the Medical Director on [DATE] at 1:00 PM stated that the physicians practice independently. The MD stated that if a treatment plan is not effective and the resident is not stabilized or turn around in 48 hours staff should consider a higher level of acuity. The Medical Director stated if the resident had lethargy, vital signs should be monitored at least every shift. The Medical Director stated they were not involved in the resident's care and escalation was not made. [10 NYCRR 415.12]

Based on observations, record review, and interviews during the Recertification Survey completed on 7/22/2021, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This was identified for one (Resident #57) of two residents reviewed for ADLs. Specifically, Resident # 57, who required staff assistance to perform personal hygiene, was observed with untrimmed and soiled fingernails. The finding is: The facility's undated Nail Care policy documented fingernails are places where dirt and germs collect and should be cleaned every day. Nails are to be cut and filed regularly. The nails should be cut short and edges filed to make them smooth. If an injury occurs during nail care- notify the nurse. Resident #57 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severely impaired cognition. The resident required extensive assistance of 1 staff member for dressing and hygiene. The resident was observed on 7/15/2021 at 11:00 AM and 12:30 PM with a Band-Aid on their left pointer finger and stated that they (Resident #57) hurt their fingernail a couple of days ago and the nail bled a lot. The resident removed the band-aid. The resident's left pointer fingernail was broken with some dried blood and nail bed avulsion (Involves the nail and part of the nail bed pulling away from the rest of the nail bed, either partly or entirely). The nail was observed to be very long. The other fingernails were also long and had broken tips. The resident stated they have been asking for everyone to cut their fingernails The Certified Nursing Assistant (CNA) #8 was interviewed on 7/19/21 at 11:25 AM and stated they were the assigned CNA for Resident #57 and that CNAs are responsible for providing nail care weekly. CNA#8 stated it has been a while since they cut the resident's fingernail and could not recall when the nails were last cut . The Licensed Practical Nurse (LPN) # 3 was interviewed on 7/19/2021 at 11:30 AM and stated primarily the CNAs are responsible for providing nail care to the residents. However, at times the LPNs may provide nail care. LPN #3 stated they (LPN #3) never provided nail care to Resident #57. The Director of Nursing Services (DNS) was interviewed on 7/21/2021 at 2:00 PM and stated nail care is supposed to be completed daily by the CNAs and there is no system to log when nail care is provided by the CNAs. The Registered Nurse (RN) Nurse Manager #2 was interviewed on 7/21/2021 at 3:30 PM and stated that there is no specific documentation to document when nail care is provided. RN #2 stated that they did not know when nail care was last provided to Resident #57 and expected the CNAs to check the nails daily. 415.12(a)(3)

Based on observation, record review, and interviews during the Recertification Survey completed on 7/22/2021, the facility did not ensure that residents with limited ambulatory ability received appropriate services to maintain or improve their ambulatory ability for one (Resident #100) of 3 residents reviewed for Rehabilitation and Restorative services. Specifically, Resident #100 was discharged from skilled Physical Therapy (PT) services on June 1, 2021, with recommendations to start the Nursing Ambulation Program (NAP); however, the resident did not receive NAP services as recommended by the Rehabilitation Department. The finding is: The facility's policy titled Nursing Ambulation Plan (NAP)/ Standing Program dated 1/2021 documents the NAP/ Standing program will be provided by the Certified Nursing Assistant (CNA)s and any signs of decline would be reported to the nurse. Residents will be evaluated by PT [department] for determination of the NAP/ Standing program. The PT [department] will determine the distance of ambulation and necessary devices based on their evaluation. Each resident on the program will have a care plan. Resident #100 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no behaviors and required extensive assistance of one person for walking. A MDS documented that the resident's balance during transitions and walking was not steady and the resident was only able to stabilize themselves with staff assistance. The resident had impairment to the lower extremities on one side for functional limitation in Range of Motion (ROM). Resident #100 was observed sitting in a wheelchair in their room on 7/16/2021 at 12:14 PM and stated they (Resident #100) were not receiving rehabilitation services and were not being walked. The PT Discharge plan dated 6/1/2021 documented that the resident was discharged from PT services with recommendations for the NAP to ambulate the resident 40 feet two times a day with limited assistance of one person and a rolling walker with a wheelchair to follow. The Comprehensive Care Plan (CCP) updated on 7/20/2021 documented the resident required assistance with Activities of Daily Living (ADL) related to Left foot drop, Osteo-Arthritis, Impaired mobility, [CONDITION(S)], and incontinence. The goal documented the resident will maintain current ADL status. The interventions included ambulating with a rolling walker up to 40 feet two times a day with the use of a leg lifter on the left side, one person assist with contact guarding, and a wheelchair to follow. The Certified Nursing Assistant (CNA) task (directions for the CNAs to provide care to the resident) documented to ambulate the resident with limited assistance of one staff with a rolling walker up to 40 feet twice a day with a wheelchair to follow and use the leg lifter on the left side. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation survey report (completed by CNAs) for June 2021 documented the resident was ambulated 5 times from June 1st through June 30th, 2021. In July 2021 the resident ambulated three times from July 1st through July 20th, 2021. CNA # 9 was interviewed on 7/21/2021 at 3:03 PM and stated that they (CNA #9) were assigned to Resident #100 for the past 2 weeks. CNA #9 stated that they (CNA #9) had walked the resident once on 7/16/2021 in the past week. Previously, the resident refused to be ambulated and this was brought to the nurses' attention. Anonymous CNA # 10 was interviewed on 7/19/2021 at 3:45 PM and stated that the resident was not ambulated during the evening shift because the staff did not have enough time to provide floor ambulation. PT #1 was interviewed on 7/21/2021 at 12:20 PM and stated that the nursing staff had identified a functional decline in Resident #100's ADL status on 7/20/2021 and a referral for a re-evaluation was made. On 7/20/2021 the resident was identified with a decline in ambulation and was only able to ambulate 15 ft with maximum assistance from staff. The PT stated before the decline the resident was able to ambulate 40 feet. The Registered Nurse (RN) Supervisor #3 was interviewed on 7/21/2021 at 1:03 PM and stated they (RN #3) were never informed that Resident #100 was refusing floor ambulation until 7/20/2021. Once RN #3 became aware of the resident's refusal to ambulate, they (RN#3) requested a PT evaluation. RN #3 stated, The CNAs should have brought this to my attention. RN # 3 further stated that there was no CCP developed to address the resident's noncompliance. The Director of Nursing Services (DNS) was interviewed on 7/22/2021 at 9:30 AM and stated that many times Resident #100 refused to participate in the NAP. The CNAs did not document or notify the nurses that the resident was refusing to ambulate. The DNS further stated that the resident did have a decline in their ambulation status. 415.12(a)(2)

Based on observations, record review, and interviews during the Recertification Survey completed on 7/22/2021, the facility did not provide respiratory treatments and care consistent with professional standards of practice for one (Resident #175) of 4 residents reviewed for respiratory care. Specifically, Resident #175 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was observed receiving oxygen at a liter flow rate greater than the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The finding is: The facility's policy for Oxygen Administration dated 11/2020 documented to verify the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #175 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS further documented the resident was receiving oxygen therapy. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #175 was observed on 7/16/2021 at 10 AM sitting in their room in a wheelchair. Resident #175 was using a nasal cannula that was attached to an oxygen concentrator. The display window on the oxygen concentrator indicated the resident was receiving 4 liters of oxygen per minute. During a subsequent observation on 7/21/2021 at 9:30 AM, the resident was observed in their room receiving oxygen via nasal cannula that was attached to the oxygen concentrator at 3.5 liters/min. The Comprehensive Care Plan (CCP) dated 8/3/2020 for Altered Cardiovascular status related to Hypertension documented interventions including to provide oxygen as ordered by the Physician. Registered Nurse Supervisor (RNS) #2 was interviewed on 7/22/21 at 11:45 AM and stated the resident should be on 2 liters of oxygen via nasal cannula. The RNS further stated the resident had requested a higher setting of Oxygen and the RNS increased the oxygen flow rate to 4.5 liters per minute. The Physician was not made aware of the resident's request to increase the oxygen flow rate. RNS #2 was unable to state why they (RNS #2) did not notify the Physician of the resident's request to receive a higher oxygen flow rate. The RNS further stated that an order should have been obtained if the resident was using a higher oxygen flow rate. The resident was interviewed on 7/22/2021 at 1:00 PM and stated that they (Resident #175) are uncomfortable when the oxygen setting is low and preferred higher oxygen flow rate. Resident #175 stated they asked the nurses to increase the oxygen settings on the Concentrator machine when the settings are low. Physician #6 was interviewed on 7/22/2021 at 1:33 PM and stated that they (Physician #6) were not aware that Resident #175 was receiving oxygen at 3.5. to 4 liters via nasal canula and stated that the staff should have followed the order and administered oxygen at 2 liters per minute. The Physician further stated the resident never complained to them that they wanted their oxygen flow rate increased and no staff member ever notified Physician #6 about the resident's request to increase the oxygen flow rate. The Director of Nursing Services (DNS) was interviewed on 7/22/2021 at 3:30 PM and stated that the resident should receive oxygen as ordered by the Physician. They (the DNS) further stated that they (the DNS) believed the resident had changed their oxygen flow rate because the resident was not comfortable on 2 Liters of oxygen and that the nursing staff was not aware the resident was changing the oxygen settings. The physician was not made aware of the resident's request to increase the flow rate. 415.12(k)(6)

Based on record review and interviews during the Recertification Survey completed on 7/22/2021, the facility did not ensure that services provided or arranged by the facility meet current professional standards of quality for one (Resident #175) of six residents reviewed for medication administration. Specifically, the nursing staff did not rotate the insulin injection administration sites. The finding is: The facility's Insulin Policy dated 8/2020 documented the injection site should be rotated. Resident # 175 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS further documented the resident received insulin 7 of 7 days in the assessment look back period. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/9/2021 LPN #7 administered the insulin at 6:30 AM and 9:00 PM to the right arm consecutively without rotating the site. The License Practical Nurse (LPN) # 7 was interviewed on 7/22/2021 at 4:30 PM and stated that Resident # 175 had ecchymosis (black and blue discoloration) on their arms. LPN #7 administered the insulin on the right arm repeatedly as it was less bruised. LPN #7 stated that they knew that the insulin injection sites were supposed to be rotated, however, the resident requested to administer the injection to the right arm. LPN #7 stated that he did not notify the physician of the resident's request to administer the insulin to the same site consecutively. The Assistant Director of Nursing Services (ADNS) was interviewed on 07/22/21 at 11:30 AM and stated that the nurses are supposed to rotate the insulin injection sites each time the insulin is given. The ADNS stated that the resident insists on using the same site. The ADNS further stated that the nurses should have developed a care plan related to the resident's request to be administered to the same site. The Director of Nursing Services (DNS) was interviewed on 7/22/21 at 11:45 AM and stated they became aware of the resident's request to have the insulin administered to the same site today (7/22/2021). The DNS stated that a care plan was not developed to indicate the resident's choices regarding insulin administration. The DNS stated that she expected the staff to follow the resident's request. Physician #8 was interviewed on 7/22/2021 at 1:33 PM and stated that they (Physician #8) were not aware that the resident was requesting for the insulin to be administered at the same site every day. Physician #8stated that they (Physician #8) expected that the insulin site should be rotated with each insulin administration especially because Resident #175 is on a blood thinner medication. 415.11(c)(3)(i)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for 1 (Resident #219) of 2 residents reviewed for Pain. Specifically, Resident #219 was administered [MEDICATION NAME] as needed (PRN). There was no consistent documented evidence that the resident's post pain medication administration was assessed for effectiveness. The finding is: The facility's policy and procedure dated 2/2000 titled Pain Management documented . Re-assessment of pain shall be performed after each method of pain relief is tried to assess effectiveness of the method using the numeric pain intensity scale form . Resident #219 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented that resident was not under hospice care and received PRN pain medications. The Comprehensive Care Plan (CCP) developed for at risk for Pain related to Pancreatic [MEDICAL CONDITION] and Malignant Pleural Effusion dated 2/1/19 documented to administer [MEDICATION NAME] as ordered and to monitor/record/report any signs and symptoms of non-verbal pain. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] - 2/2/19 at 6:12 PM -2/5/19 at 5:54 AM -2/5/19 at 9:52 AM -2/5/19 at 10:17 PM -2/6/19 at 9:10 AM -2/7/19 at 12:07 AM -2/7/19 at 1:08 PM -2/8/19 at 12:38 AM -2/8/19 at 9:18 AM -2/8/19 at 9:05 PM -2/9/19 at 9:03 AM There was no post pain medication administration assessment documented in the MAR indicated [REDACTED]. The Pain monitor did not have corresponding post pain assessment level on the dates mentioned above. The resident was interviewed on 3/18/19 at 9:00 AM. The resident stated that she is generally comfortable. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 3/20/19 at 11:00 AM. The RN stated that the nurses should have documented the post pain [MEDICATION NAME] administration to determine if the resident was relieved. An interview with the Director of Nursing Services (DNS) was conducted on 3/20/19 at 11:45 AM. The DNS stated that the pain re-assessment after administering [MEDICATION NAME] should have been done and documented. 415.12

Based on observation, record review and staff interviews during the recertification survey the facility did not ensure that an injury of unknown origin was thoroughly investigated to rule out abuse, neglect or mistreatment. This was evident for one of three residents reviewed for accidents. Specifically, Resident #102 was observed with an injury to the right forehead that was not thoroughly investigated. The findings are: 1) Resident#102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3. An Accident Incident (A/I) Report dated 2/22/19 at 9:50 AM documented the resident was observed with a discoloration to the right side of the forehead that measured 3 centimeters (cm) by 5 cm and was blue/purplish in color. The A/I documented the resident was not able to make a statement due to poor cognition. The Certified Nursing Assistant (CNA) statement dated 2/22/19 from the 7:00 AM to 3:00 PM shift documented Resident#102 was observed to have a bruise to the right forehead. The CNA statement documented the CNA reported the observation to the LPN. The Licensed Practical Nurse (LPN) statement documented on 2/22/19 at 10:00 AM Resident #102 returned from the beauty parlor and a bruise was observed on the right forehead. The A/I statement also documented the resident stated to the LPN she fell in the morning and a lady picked her up. A Nursing progress note dated 2/22/19 documented the resident was noted with ecchymosis to the right side of her forehead at 9:50 AM. The ecchymosis area measured 3 cm by 5 cm and was blue and purple in color. The Nursing progress note documented the resident could not recall what happened and that a new Comprehensive Care Plan (CCP) intervention was initiated to add padding to the corner of the resident's nightstand to prevent injury to the resident. A Nurse Practitioner (NP) note dated 2/22/19 documented the resident was examined and neurology checks were in progress. The NP note documented the resident had no pain when the right forehead area was palpated and the right side of the resident's head had an ecchymosis area. A Nurse progress note dated 2/22/19 documented on the morning of 2/22/19 at 5:30 AM the LPN gave the resident medication and the resident was up in the hallway with the nurse. The Nurse progress note documented the LPN did not observe ecchymosis to the right forehead of the resident. A CCP dated 2/22/19 documented the resident had ecchymosis to the right side of her forehead that measured 3 cm by 5 cm. The CCP interventions documented to monitor location and place padding to the corner of the night stand to protect the resident's skin. The A/I investigation final report dated 3/1/19 documented Resident #102 reported to a CNA that she fell in the morning and did not sustain an injury. The A/I final report documented the CNA told the LPN the resident was on the floor mat and the LPN told the CNA to get the resident up off the floor mat and put her in the wheelchair. There was no documented evidence in the A/I report the CNA and LPN statements reflect that the resident was found on the mat in her room on the morning of 2/22/19. The A/I report had no documented evidence of a statement from the beautician since the CNA reported a bruise to the resident's right forehead after the beauty parlor visit on the morning of 2/22/19. An observation of the resident was made on 3/19/19 at 12:15 PM. The observation revealed a right forehead bruise, purple and yellow in color, The resident stated she felt fine and had no pain. An interview was held on 3/19/19 at 12:30 PM with the Registered Nurse (RN) Assistant Director of Nursing Services (ADNS). The ADNS reviewed the A/I and stated that there was no documented evidence the A/I report was thoroughly investigated and that the A/I had conflicting staff statements. The ADNS stated the A/I report documented staff statements which did not reflect the final investigation documentation. An interview was held with the LPN (who worked on 2/22/19) on 3/20/19 at 9:45 AM. The LPN stated she was passing the elevator and observed Resident #102 getting off the elevator from the beauty parlor and noticed a bruise on the right side of the resident's forehead. The LPN stated she reported the bruise to the LPN charge nurse. An interview was held on 3/20/19 at 10:15 AM with the LPN who worked on 2/22/19 on the 11:00 PM to 7:00 AM shift. The LPN stated he had no recollection of a report that Resident #102 was found on a floor mat in her room. Resident #102 was observed sitting in her wheelchair by the nurse's station at 5:30 AM and there was no observed bruise to the resident's forehead. 415.4(b)(1)(ii)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that the Minimum Data Set (MDS) assessment represented an accurate picture of the resident's status during the observation period. This was evident for 1 (Resident #219) of 3 residents reviewed for respiratory care. Specifically, Resident #219 had a [DIAGNOSES REDACTED]. This was not reflected in the active [DIAGNOSES REDACTED]. The finding is: Resident #219 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The MDS did not include [MEDICAL CONDITION] as an active diagnosis. The Physician's Assistant (PA) Note dated 1/23/19 documented [MEDICAL CONDITION] as one of the resident's diagnoses. An interview with Director of Nursing Services (DNS) was conducted on 3/18/19 at 10:52 AM. The DNS stated that the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. An interview with MDS Coordinator was conducted on 3/18/19 at 12:43 PM. The MDS Coordinator stated that it was an oversight and that she will correct the MDS to reflect the [MEDICAL CONDITION] diagnosis. 415.11(b)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure that a comprehensive care plan (CCP) for each resident was developed and implemented that was person-centered consistent with the resident's measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for 1 (Resident #2) of 1 resident reviewed for advance directives; 1 (Resident #219) of 1 resident reviewed for catheter; and 1 (Resident #126) of 2 residents reviewed for Pain. Specifically, 1) Resident #2 had a DNR order. There was no CCP developed for Advance Directives. 2) Resident #219 had a Right Port-a-catheter in place. The CCP developed for Right Port-a-Catheter included an intervention to monitor the site for signs and symptoms of infection, swelling or drainage. There was no documentation of monitoring of the site by the Licensed staff. Resident #219 also had an Oxygen order via nasal cannula (N/C) at 3 liters per min (L/min). The resident was observed with O2 at 2 L/m and 3.5 L/min on separate occasions. 3) Resident #126 had an order of [MEDICATION NAME] release 15 milligram (mg) every (q) 12 hours (h) for Chronic Right Shoulder Pain. The Medication Licensed Practical Nurse (LPN) #2 administered the [MEDICATION NAME] to the resident 5 hours late. The findings are: 1) Resident #2 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired in cognition with Brief Interview for Mental Status (BIMS) score of 3. The Do Not Resuscitate (DNR) Form 2 was completed on 9/21/17. The Medical Order for Life Sustaining Treatment (MOLST) physician's orders [REDACTED]. There was no CCP developed for Advance Directives in the medical record. The Interdisciplinary CCP dated 2/28/19 did not include Advance Directives. An interview with the Director of Social Services was conducted on 3/20/19 at 10:08 AM. The Director of Social Services stated that the CCP for Advance Directives should have been developed. 2a) Resident #219 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The Quarterly MDS assessment dated [DATE] documented O2 therapy was provided in the facility within the last 14 days. The Resident #219 had a Right Port-a-catheter in place. The CCP developed for at risk for skin breakdown related to Right Port-a-Catheter in-situ, to be accessed by Oncology only, dated 2/1/19 documented to monitor, document and report to the Physician any signs and symptoms of infection, swelling, or drainage. Review of the medical record revealed that there was no monitoring on the Right Port-a-Catheter completed and documented by the licensed staff. An interview with the Director of Nursing Services (DNS) was conducted on 3/20/19 at 12:10 PM. The DNS stated that the Certified Nursing Assistants (CNAs) check the skin integrity but the licensed staff do not monitor and document the Right Port-a-Catheter site for any signs and symptoms of infection, swelling, or drainage. 2b) The physician's orders [REDACTED]. On 3/12/19 at 9:00 AM and 3/15/19 at 9:45 AM, the resident's O2 via nasal cannula was observed at 3.5 L/min and 2L/min levels, respectively. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 3/15/19 at 9:45 AM. The RN stated that the O2 level should be at 3 L/min as ordered. 3) Resident #126 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] documented the resident had a BIMS score of 15 which indicated intact cognition. The MDS documented a scheduled pain medication regimen, pain was present in the last 5 days, with pain intensity of 3 on a scale from zero to ten. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The 3/4/19 documentation on the Narcotic Sheet for [MEDICATION NAME] that the medication was administered to the resident at 2:00 PM. An interview with the Licensed Practical Nurse #2 was conducted on 3/20/19 at 12:00 PM. LPN #2 stated that she was late in administering the resident's MS ContinER on [DATE]. An interview with the Director of Nursing Services (DNS) was conducted on 3/20/19 at 9:01 AM. The DNS stated that the nurse should have signed after popping the blister pack for [MEDICATION NAME] was late in administration of [MEDICATION NAME] 2 PM. 415.11(c)(1)

Based on observation, interview and record review during the recertification survey, the facility did not ensure all residents with a decline in vision were evaluated by an Optometrist. This was identified for 1 of 1 resident reviewed for vision. Specifically, Resident #9 had a decline in vision and there is no documented evidence a vision exam was completed. The finding is: Resident # 9 was admitted on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The MDS also documented the resident's vision was adequate and the resident had corrective lenses when completing vision assessment. On 3/14/19 at 3:50 PM, the resident was interviewed and stated she was upset because she had never seen a vision doctor. The resident stated she cannot see the television (TV) and that she has magnifying glasses, but still has a problem seeing. The resident further stated that she has to squint to see the TV. A Comprehensive Care Plan (CCP) updated 3/9/19 documented the resident was at risk for visual decline related to visual impairment. Goals included that the resident will show no decline in visual function through the review date. The interventions included to arrange consultation with eye care practitioner as ordered by MD. A review of the medical record revealed there were no optometry assessments of the resident since the resident's admission on 1/19/2011. The Unit Registered Nurse (RN) Manager was interviewed on 3/14/19 at 3:55 PM and stated she was unaware of the resident's complaint and could not find an optometry evaluation in the medical record. A Licensed Practical Nurse (LPN) was interviewed on 03/19/19 at 12:49 PM and stated that she completed the assessment of the resident's vision on the MDS. The resident's vision was adequate and she was able to see print using her glasses. She stated she was not aware the resident had complaints of vision when viewing the TV. The Director of Nursing Services (DNS) was interviewed on 3/19/19 at 1:30 PM and stated an Optometry consult was not found for the resident and stated the resident prefers to see her own doctors. The DNS was unaware why no optometry evaluations were done. The DNS stated if the resident is complaining of vision, an optometry consult should have been completed. 415.12(3)(b)

Based on record review and staff interviews during a recertification survey the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. This was noted for one (Resident #32) of 3 residents reviewed for accidents. Specifically, Resident #32 was not transferred to the emergency room (ER) in a timely manner after a fall with a fracture. The finding is: Resident # 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had impaired short and long term memory and that a Brief Interview for Mental Status (BIMS) interview could not be completed. The MDS also documented the resident required limited assist of one person for walking in the room and corridor. The MDS documented that the resident required extensive assistance of two persons for toilet use. A Comprehensive Care Plan (CCP) for high risk for falls, initiated on 9/27/18, documented the resident had falls on 9/20/18, 9/27/18 and 9/29/18. A Fall Risk review dated 9/29/18 documented the resident was at high risk for falls. The summary of investigation report dated 11/24/18 documented that the resident was observed to suddenly stand up and loose her balance in the dining room and staff was unable to prevent the fall, but was able to get to her to prevent her head from hitting the floor. The summary also documented that the Supervisor immediately assessed the resident who showed signs and symptoms of pain with gentle palpation of the left hip. The summary documented that the resident's left lower extremity (LLE) was immobilized and the resident was returned to bed. The summary also documented that the covering Physician's Assistant (PA) was called and an X-ray of left hip was ordered. The X-ray showed an acute displaced and angulated left femoral neck fracture, pain medications were administered, and the resident sent to the hospital. A progress note written by Registered Nurse (RN #1) dated 11/24/18 at 9:45 PM documented that RN #1 responded to supervisor STAT (immediate) call at 5:30 PM. The resident was observed lying on her left side on the floor in the small dining room on Unit 400. Per the CNA present, the resident attempted to stand from her wheelchair, lost her balance and fell before staff could intervene. The CNA present stated the resident did not hit her head. Upon assessment the resident was moaning and guarding the LLE. The resident complained of (c/o) left hip pain when gently palpated. The resident was log-rolled and was assisted into bed with assist of 4 staff members, the LLE remained immobilized with no weight bearing (NWB). The PA who was covering the physician was made aware and ordered an X-Ray of left hip/femur. The results showed an acute displaced and angulated left femoral neck fracture (Fx). The PA ordered to send the resident to the emergency room (ER). The resident received Tylenol for pain management prior to transfer to the ER. The LLE remained immobilized until transfer to the ER. A progress note by RN #2 dated 11/24/18 at 11:58 PM documented the resident was found on the floor at 5:30 PM. The nursing supervisor was notified. No visible signs of injury, left leg appeared externally rotated, physician (MD) notified, order received to obtain X-ray. Results of x-ray revealed left neck femur fracture. The MD was made aware, the resident will be transferred to the hospital via Ambulance for further evaluation. A progress note by Licensed Practical Nurse (LPN #2) dated 11/25/18 at 2:20 AM documented that at 2:15 AM the resident left via ambulette to the hospital. The Director of Nursing Services (DNS) was interviewed on 03/18/19 at 9:10 AM regarding the incident dated 11/24/18. The DNS stated she would review the incident and get back to the surveyor. The 3:00 PM-11:00 PM RN #1 who wrote the note on 11/24/18 at 9:45 PM was interviewed on 3/19/19 at 10:00 AM. RN #1 stated he told the LPN to call the doctor to inform the doctor that the resident had fallen and was showing hip pain and to request X rays. RN #1 further stated that the Per-diem RN #2 came in at 7:00 PM and took over and that she did not recall if the X-ray results were called in or faxed into the facility. RN #1 also stated she thought she and RN #2 were both in the office and both were aware of the X-ray results but she was not sure. RN #1 also stated she was unaware of when and who called the PA with the X-ray results and who had received orders to send the resident out to the hospital. She stated she had already given her report to RN #2 and RN #2 had taken over. The Physician Assistant (PA) who was on call on 11/24/18 was interviewed on 3/19/19 at 11:00 AM and stated she got a call at 6:01 PM that the resident had fallen earlier and was now complaining of hip pain with no other signs of injury. The PA stated she ordered an X-ray and received a call back at 9:15 PM that there was a fracture and ordered a STAT transfer to the ER for follow up of the Fx. She stated she was covering the weekend and would have given the report to the PA on Monday. She stated she would not have written any notes because she was only covering the weekend for calls and did not have access to the resident's medical record in this facility. She stated that STAT transfers are usually within 30 minutes of the order. The 11/24/18 11:00 PM-7:00 AM shift LPN #3 was interviewed on 03/19/19 at 11:27 AM. She stated she recalled getting a report that the Ambulance company was called and paperwork was ready for sending the resident to the hospital. She stated that after 12:00 PM she was concerned that the Ambulance still had not arrived and reported her concern to RN #2. LPN #3 stated that RN #2 told her she would call the Ambulance company again. LPN #3 stated she wrote a note at 2:15 AM. LPN #2 who worked on the 3 PM-11 PM shift on 11/24/18 was interviewed on 3/20/19 at 10:30 AM and stated he had started working on (MONTH) 28th, (YEAR) and was still being trained and assisted by RN #1 and LPN #1 that night. LPN #2 stated he called the PA to report the fracture and obtained an order to send the resident to the hospital but does not recall if it was a STAT order. He stated he did not put the order in because he still had to finish giving out medication. The Per-diem 3:00 PM to 11:00 PM RN#2 who documented the note dated 11/24/18 at 11:58 PM was interviewed on 3/20/19 at 11:00 AM. RN #2 stated she received a report from RN #1 that they were waiting for the X-ray result. RN #2 stated she did not recall the time or how the X-ray results were relayed to her. RN #2 also stated she thought that a LPN called the PA with the X-ray results and obtained an order to transfer the resident out to the hospital but did not know what time the call was made. RN#2 also stated she did not recall staying over on the 11:00 PM-7:00 AM shift and did not recall who took over for her for the oncoming 11:00 PM-7:00 AM shift. The 3:00 PM to 11:00 PM LPN #1 working on 11/24/18 was interviewed on 3/20/18 at 11:30 AM. LPN #1 stated that she was not assigned to the resident but was just helping because the other nurse was busy. LPN #1 stated she had made a call to the Ambulance company to pick up the resident and then RN #2 told her to cancel it because X-rays results were not obtained. LPN #1 stated she did not recall the time she made these two calls and she did not document because the resident was not assigned to her. The DNS was interviewed on 3/20/19 at 1:00 PM and stated that she had reviewed the incident report upon completion and was concerned regarding the time lapse in the resident's transfer to the hospital. She stated that she did not know there was a STAT order for transfer. She reviewed the incident, then documented her report on 3/20/19. The report documented the following: RN #1 was called to assess the resident at 5:30 PM. PA was called at 6:00 PM. An X-ray was done at approximately 7:46 PM. The results were faxed to the facility at approximately 9:06 PM, however, they also called the results into the facility at 10:30 PM. RN #1 reported the results of the X-ray to the PA who then ordered that the resident to be transferred to the hospital (time line not provided). RN #2 who covered the shifts from 7 PM on 11/24/18 to 8:26 AM on 11/25/18 denied that the transfer order was STAT; however, she failed to enter the MD order for transfer. At approximately 11:55 PM the Ambulance company was contacted to transport the resident by LPN #1 and the Ambulance company gave the facility an ETA (expected time of arrival) of 1 hour; however, the Ambulance arrived at 2:36 AM and then arrived at the hospital at 2:55 AM. The Ambulance company was not called back when they did not arrive as expected as the patient was resting comfortably. The Physician in charge of the Medical group was interviewed on 3/20/19 at 1:35 PM and stated that the resident did not need to be transferred STAT because it was not an emergency. The DNS was interviewed on 3/20/19 at 1:40 PM and stated she started in this facility a couple of months ago and is discovering systemic issues and is trying to address them. 415.12

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a baseline care plan for each resident must be developed and implemented that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission. This was evident for 1 (Resident #28) of 1 resident reviewed for Unnecessary medication. Specifically, Resident #28 had an [MEDICAL CONDITION] diagnosis. There was no baseline care plan developed within 48 hours of admission for [MEDICAL CONDITION]/[MEDICAL CONDITION] Disorder. The finding is: Resident #28 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a score of 14 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The resident had an active [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The order was discontinued on 10/26/18. The physician's orders [REDACTED]. The order was discontinued on 10/26/18. The physician's orders [REDACTED]. The order was discontinued on 2/22/19. The physician's orders [REDACTED]. The order was discontinued on 2/22/19. The physician's orders [REDACTED]. Review of the medical record revealed that there was no baseline CCP developed for [MEDICAL CONDITION] within 48 hours of admission on 10/11/18. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 3/20/19 at 10:00 AM. The RN stated that she could not locate the baseline CCP for [MEDICAL CONDITION] Disorder. The RN stated that the CCP for [MEDICAL CONDITION] Disorder should be developed. 415.11