Every finding on record at West Village Rehabilitation and Nursing Center

Based on observation, record review, and interview, the facility failed to ensure that infection control practices were maintained during medication administration. This was evident in three (Residents #52, #28, #31) of seven residents observed during medication administration. Specifically, Licensed Practical Nurse #1 failed to disinfect the blood pressure cuff before, after, and between resident use.The findings include:The facility's policy titled Standard Precautions for Infection Control, effective 01/2026, documented that standard precautions shall be followed during all resident care activities. The policy further stated that reuseable equipment shall not be used for another resident until appropriately cleaned and reprocessed. Blood pressure cuffs are required to be cleaned with an approved healthcare disinfectant product between residents' use.On 05/29/2026 at 8:57 AM, a medication administration observation was conducted with Licensed Practical Nurse #1 on Unit 5. The nurse obtained a rolling cart containing a digital blood pressure machine from the hallway. The cart did not contain disinfectant wipes.In room [ROOM NUMBER]-A, Licensed Practical Nurse #1 performed a blood pressure reading for Resident #52 and administered medications. The blood pressure cuff was not disinfected before or after use. The machine was left in the resident's room.In room [ROOM NUMBER]-B, Licensed Practical Nurse #1 performed a blood pressure reading for Resident #28 and administered medications. The blood pressure cuff was not disinfected before or after use. The machine was again left in the resident's room.Licensed Practical Nurse #1 then retrieved the same blood pressure machine and proceeded to room [ROOM NUMBER]-A, where a blood pressure reading was obtained for Resident #31. The blood pressure cuff was not disinfected before, after, or between resident use.During an interview on 05/29/2026 at 9:50 AM, Licensed Practical Nurse #1 stated that blood pressure cuffs should be cleaned with antimicrobial wipes between resident use to prevent the transmission of germs from resident to resident. Licensed Practical Nurse #1 acknowledged that the cuff was not disinfected before, after, or between resident use, and stated that they forgot.During an interview on 05/29/2026 at 9:54 AM, Registered Nurse #2, the nursing supervisor and Infection Preventionist stated that blood pressure cuffs should be disinfected between each resident use to prevent cross contamination and the spread of infection.During an interview on 06/01/2026 at 11:58 AM, the Director of Nursing Services stated that nursing staff are expected to disinfect blood pressure cuffs between resident use10 New York Codes, Rules and Regulations 415.19

Based on observation, record review, and interviews, the facility failed to ensure that a resident who required assistance with activities of daily living received necessary grooming and personal hygiene services. This was evident in one (Resident #123) of three residents reviewed for activities of daily living out of 19 total sampled residents. Specifically, Resident #123 reported not receiving assistance with shaving or nail care and was observed with full ungroomed beard and long, jagged, dirty fingernails.The findings include:The facility's policy titled Activities of Daily Living, effective 11/2018, stated that residents are to receive necessary support with activities of daily living, including grooming, based on assessed needs and services. The policy further stated that refusals of care are to be documented in the progress notes and care plan.The facility's policy titled Grooming and Hygiene, effective 05/2025, stated that residents will receive individualized grooming and hygiene care to maintain dignity, comfort and wellbeing. The policy identified nail care and shaving as routine grooming services and requires refusals to be reported to the licensed nurse and documented. Resident #123 was admitted to the facility with diagnoses including Sepsis (a potentially life-threatening condition that arises when the body's dysregulated response to infection) and Parkinson's Disease (a brain disorder that slowly affects movement, balance, and coordination).The Comprehensive Minimum Data Set (a resident assessment tool) dated 05/04/2026 documented that Resident #69 had intact cognition; required partial/moderate assistance with personal hygiene which includes washing and drying face and hands and shaving; and no rejection of care behaviors.A care plan for activities of daily living was initiated on 06/01/2026, it documented that Resident #123 required supervision or touching assistance to maintain personal hygiene which includes shaving, washing, and drying face and hands.On 05/27/2026 at 9:57 AM, Resident #123 requested to speak with the State Surveyor and stated they had asked Certified Nursing Assistant #3 since admission for help in shaving and nail care, and that despite repeated requests, staff had not provided assistance.On 05/27/2026 at 10:00 AM, Resident #123 was observed in bed, wearing a hospital gown, with a full ungroomed beard and long, jagged, dirty fingernails. These observations were confirmed during joint observation with Registered Nurse #4 on 05/28/2026 at 9:59 AM and again on 05/28/2026 at 3:35 PM in the presence of the Director of Nursing Services. Registered Nurse #4 acknowledged that Resident #123's beard were full and ungroomed and that the resident had long, dirty fingernails.A review of the Certified Nursing Assistant Documentation Survey Report for May 2026 revealed no documented evidence that shaving had been provided or refused from 05/06/2026 through 05/31/2026. There was also no documented evidence that nail care had been provided or refused from 05/04/2026 through 05/16/2026 and from 05/25/2026 through 05/31/2026.During an interview on 05/28/2026 at 10:16 AM, Certified Nursing Assistant #3, the aide regularly assigned to Resident #123, stated that they do not cut residents' fingernails or shave residents. The aide stated that Resident #123's nails had last been filed on 05/17/2026 and acknowledged that Resident #123's beard had not been shaved.During an interview on 05/28/2026 at 10:41 AM, Registered Nurse #4, the charge nurse on the unit, stated that they had observed Resident #123 with full, ungroomed beard and long, dirty fingernails and had instructed the Certified Nursing Assistant on 05/26/2026 to provide nail care which obviously was not done. Registered Nurse #4 stated that review of documentation showed shaving had not been performed since the resident has been admitted to the facility.During an interview on 06/01/2026 at 11:37 AM, the Director of Nursing Services stated that grooming and hygiene are a high priority and that staff are expected to provide, document, and escalate concerns regarding residents' personal care needs, including refusals. The Director of Nursing Services acknowledged that there was no documentation indicating concerns regarding Resident #123's grooming needs and stated that had these concerns been communicated, action would have been taken to ensure the resident's grooming needs were met.10 New York Codes, rules and Regulations 415.12 (a)

Based on observation and interviews made during a recertification survey from 7/31/24 to 8/7/24, the facility did not ensure that garbage and trash were disposed of properly. Specifically, garbage was not properly contained outside of the facility. The garbage dumpsters were not covered with lids. The findings are: The facility's policy and procedure titled, Proper Disposal of Garbage and Refuse, last reviewed 09/2021, documents that, the garbage storage area will be kept in a sanitary condition to prevent the harboring and feeding of pests. On 08/06/2024 at 12:55 PM, the kitchen trash disposal procedure was observed. Dietary Aide #1 donned gloves, sealed the trash bags, placed them in a covered bin and brought the bin to the loading dock where a row of dumpsters were lined up to receive cardboard, other recyclables and food waste. The dumpsters were clean and in good repair and each had an attached lid, but the lids were in an open position. When questioned about this, the Dietary Aide deferred to the Director Food Services, who was interviewed at 1:01 PM and stated that they would call the Director Facilities Management. On 08/06/2024 at 1:05 PM, the Director Facilities Management was interviewed and stated that since the dumpster lids were attached and space was tight, the dumpsters were kept open 24 hours a day. The Director Facilities Management stated that even though the dumpsters had wheels and could be brought forward in order to access the lids, this was not practical given their constant use. When educated that open dumpsters invited pests, the Director stated, We don't have mice here. 483.60(i)(4)

Based on record reviews and interviews conducted during the recertification survey from 07/31/2024 to 08/07/2024, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented to meet a resident's needs. This was evident for 1 (Resident # 21) of 5 sampled residents reviewed for unnecessary medications. Specifically, a care plan for the use of Ambien (Zolpidem Tartrate) was not developed for Resident # 21. The findings are: The facility policy titled Care Planning Process with effective date 7/2022 documented a comprehensive care plan shall be developed for each resident within 7 days after the completion of the comprehensive assessment which includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psycho-social needs. It also documented the care plans are developed by the interdisciplinary team. It further documented the care plan shall address issues/problems pertinent to the individual resident. Resident # 21 was admitted to the facility on [DATE] and had diagnoses that included Insomnia, low back pain, and spinal stenosis. The Admission Minimum Data Set 3.0 dated 5/24/2024 documented Resident # 21 was cognitively intact. The Minimum Data Set also documented Resident # 21 had diagnoses of insomnia, spinal stenosis, and other low back pain. It further documented Resident # 21 was taking medications including Hypnotic. The Minimum Data Set documented only Resident # 21 participated in the assessment. On 08/05/24 at 12:11 PM, Resident # 21 was interviewed and stated they had to take the sleeping pill Ambien to fall asleep every night due to pain at low back. The Physician ordered Ambien (Zolpidem Tartrate) *Controlled Drug* 5 mg tablet at bedtime for difficulty sleeping from 5/24/2024 to 6/5/2024. The Physician ordered Ambien *Controlled Drug* 10 mg tablet at bedtime for difficulty sleeping starting on 6/7/2024. Consult Form - Psychiatry V3.2 dated 7/3/2024 documented Resident # 21 to continue taking Ambien 10mg at bedtime and Resident # 21 may refuse so. Consult Form - Psychiatry V3.2 dated 7/26/2024 documented the non-psychiatric medication was to continue Ambien 10mg at bedtime and Resident # 21 may refuse. Medication Administration Record for July 2024 documented Ambien ( Zolpidem Tartrate) 10 mg tablet was administered to Resident # 21 every day at bedtime in July 2024. Review of Resident # 21's medical record revealed there was no comprehensive care plan related to sleeping pill use of Ambien was developed and implemented for Resident # 21 since their admission to the facility. On 08/05/2024 at 10:13 AM, Client Care Associate # 3 was interviewed and stated Resident # 21 typically woke up between 10:00 AM and 10:30 AM. Client Care Associate # 3 also stated Resident # 21 told them that they had a problem falling asleep due to low back pain and concern for the spouse's health. Client Care Associate # 3 further stated Resident # 21 told them that they had to take a sleeping pill every night in order to fall asleep. On 08/05/2024 at 09:59 AM, Registered Nurse # 2 (the nurse supervisor on the 6th floor) was interviewed and stated, Resident # 21 is taking the sleeping pill Ambien every night due to insomnia. Registered Nurse # 2 also stated the sleeping pill was classified as a Controlled Substance. Registered Nurse # 2 further stated there should be a care plan for a resident taking the sleeping pill. Registered Nurse # 2 stated the nurse supervisor was responsible for initiating the comprehensive care plans based on a resident's need. Registered Nurse # 2 reviewed Resident # 21's medical record and was unable to locate a comprehensive care plan related to sleeping pill use. Registered Nurse # 2 stated there should be a comprehensive care plan to address Resident # 21's use of sleeping pill. On 08/05/2024 at 10:49 AM, Director of Nursing was interviewed and stated, the sleeping pill Ambien is a controlled substance and there should be a care plan to address its use. They reviewed Resident # 21's medical record and was not able to locate a comprehensive care plan related to sleeping pill use or insomnia. Director of Nursing was not able to explain why the care plan for Ambien use or sleeping problem was not initiated since Resident # 21 admission to the facility more than 2 months ago. 10 NYCRR 415.3(h)(1)

Based on interview and record review conducted during a recertification and abbreviated (NY 995) survey, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #151) of 20 total sampled residents. Specifically, the Nurse Practitioner (NP) did not correctly transcribe an and order intravenous (IV) antibiotic therapy (ABT) for Resident #151. The findings are: Resident # 151 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #151 was cognitively intact and had a wound infection. On 11/05/21, the complainant reported to the Aspen Complaint Tracking System (ACTS) Resident #151 was being underdosed for their IV ABT. On 8/22/22 at 11:02 AM, the complainant was interviewed via telephone and stated the facility Medical Doctor (MD)/NP did not follow the order of Resident #151's Infectious Disease Doctor (IDD) causing Resident #151 to receive IV ABT every 6 hours a day instead of every 4 hours a day. This caused Resident #151 to stay in the nursing home longer. MD Order (MDO) dated 10/04/21 documented Resident #151 was ordered to receive IV ABT - [MEDICATION(S)] 2gm solution every 4 hours a day. The MDO was discontinued on 10/14/21 and changed to [MEDICATION(S)] 2gm solution 4 times a day (every 6 hours). The MDO was for [MEDICATION(S)] 2gm solution was again discontinued and changed on 11/4/21 to every 4 hours a day. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing was interviewed on 8/22/22 at 3:18 PM and stated the nursing staff are responsible for conducting MDO reconciliation. On 8/22/22 at 12:05 PM, the Medical Director was interviewed and stated the NP that changed Resident #151's IV ABT order on 10/14/21 from every 4 hours a day to every 6 hours a day is no longer working at the facility. The IDD called the facility and gave a telephone order for Resident #151 to continue with IV ABT every 4 hours a day until November 2021. Instead of writing the MDO every 4 hours, the NP wrote down the MDO as 4 times a day, every 6 hours. Once the error was discovered, the IDD changed the MDO for IV ABT back to every 4 hours a day. 415.15(b)(2)(iii)

Based on interviews and record review conducted during the recertification and abbreviated complaint (NY 068) survey, the facility did not ensure that a copy of the Notice of Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman within a timely manner. Specifically, a Notice of Transfer for Resident #146 was sent to the Ombudsman's Office after the documented date of discharge had passed, and a Notice of Transfer for Resident #147 was not sent to the Ombudsman's Office. This was true for 2 of 5 residents reviewed for Discharge. out of a sample size of 38 residents. The findings are: The facility policy and procedure related to Discharge/Transfers Rights and Regulations dated 5/18 documented that before a facility transfer or discharges a resident, the facility must . send a copy of the notice to a representative of the Office of the State Long-term Care Ombudsman. 1. Resident #146 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact, the resident and family or significant other participated in the assessment, the resident expects to be discharged to the community, and there was an active discharge plan already occurring. A Notice of Discharge/Transfer dated 7/16/19 was signed by the resident on 7/16/19 and documented that the resident will be discharged on [DATE] because the resident completed therapy. A subsequent Notice of Discharge/Transfer dated 7/18/19 was signed by the resident on 7/18/19 and documented that the resident will be discharged to the community on 7/27/19. Social Work Note (SWN) dated 7/26/19 documented that the resident was provided with a new last covered date from insurance of 7/3/19. A SWN dated 8/2/19 documented that the Social Worker (SW) was contacted by the New York State Department of Health (NYSDOH) Appeals Office informing the SW that the resident had requested an appeal of his discharge. A Notice of Discharge/Transfer dated 8/7/19 documented that the resident was to be discharged from the facility on 8/4/19. A SWN dated 8/7/19 documented that the NYSDOH contacted the SW to inform her that the resident's notice was completed late and a new notice and discharge date must be provided to the resident and resident's wife. A subsequent Notice of Discharge/Transfer dated 8/7/19 documented that the resident was to be discharged to the community on 8/11/19. A SWN dated 8/9/19 documented that a new request for discharge appeal was made to the NYSDOH Appeals Unit (Case# NY 053). A SWN dated 8/28/19 documented that a judiciary hearing was held with the resident and resident's wife. An agreement was reached, and the resident and resident's wife agreed to be discharged home on[DATE]. A Notice of Discharge/Transfer dated 8/28/19 documented that the resident was to be discharged from the facility on 9/6/19. A facility email communication with the Cidny Ombudsman dated 8/15/19 documented that a Notice of Discharge/Transfer was attached for Resident #146. There was no documented evidence that communications had been updated with the Ombudsman office reflecting the appeals hearing and new date for discharge. 2. Resident #147 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] documented that the resident had minimal cognitive impairment, the resident and resident's family or significant other participated in the assessment, the resident expected to be discharged to the community, and there was an active discharge plan occurring. A SWN dated 7/31/19 documented that the resident and family were informed that the resident's last covered day in the facility would 8/7/19. The family disagreed and decided to appeal to the insurance company. A SWN dated 8/1/19 documented that the insurance appeal was denied. The daughter of the resident informed the SW that an appeal was filed with the NYSDOH. A SWN dated 8/2/19 documented that the SW was contacted by the NYSDOH Appeals Office and was informed that the resident had filed a discharge appeal. A SWN dated 8/7/19 documented that the facility was informed that the discharge appeal hearing was scheduled for 8/13/19. A subsequent SWN dated 8/7/19 documented that the family decided to withdraw their appeal of the resident's discharge from the community and would like to schedule the discharge for 8/8/19. A Notice of Discharge/Transfer dated 8/8/19 documented that the resident was to be discharged home on[DATE]. There was no documented evidence that the facility sent a Notice of Discharge/Transfer for Resident #147 to the Ombudsman's Office. On 10/24/19 at 03:34 PM and on 10/25/19 at 09:58 AM, an interview was conducted with a supervisor within the Office of the State Long-Term Care Ombudsman. The supervisor is responsible for overseeing the department within the Ombudsman's Office that receives and processes Notices of Transfer/Discharge from facilities. The supervisor stated that although she had contacted the facility in mid-summer regarding the fact that they have not been sending Notices of Discharge/Transfer to the Ombudsman's Office, the supervisor only started receiving some notices in (MONTH) 2019. There were no notices received in relation to Resident #147. The notice the Ombudsman's office received for Resident #146 was sent on 8/15/19. The Notice of Discharge/Transfer was dated 8/7/19 and documented that the resident was to be discharged on [DATE]. This notice was sent to the office 4 days after the proposed discharge date of the resident. This was the only notice received for Resident #146. No other updated notices or further communication was received by the facility regarding Resident #146. That same day that the notice was received for this resident, 8/15/19, a representative from the Ombudsman's Office called the facility and educated the facility on the process for communicating Notices of Discharge/Transfer to the Ombudsman's Office. We have explained that in addition to a list of residents who have been discharged to the hospital and to home, the facility must provide the Notices of Discharge/Transfer as soon as possible for residents who are not in agreement with being discharged to the community. It does not seem that facility understands the process. On 10/25/19 at 11:06 AM, 10/28/19 at 12:04 PM, and 10/28/19 at 12:08 PM interviews were conducted with the Vice President of Clinical Services (VPCS). The VPCS stated that based on her recollection, Resident #146 was the only resident that did not agree with his discharge plan and a hearing was conducted in the facility as a result of the resident requesting an appeal with the NYSDOH. The VPCS stated that she is not familiar with Resident #147 and the resident's request for an appeal of her planned discharge. Once the Social Work Department becomes aware of a request for an appeal, we do not move forward with any discharge plan. There is always some communication with the Ombudsman's Office because they are an advocate for the resident, and it is good to have them, and their perspective involved. The person responsible for communicating the Notices of Discharge/Transfer with the Ombudsman's Office is on leave right now and not available in the facility. However, the VPCS stated that she would contact her in an attempt to access the records that she has regarding the communication with the Ombudsman's Office. The VPCS stated that she believes the notices should be sent to the Ombudsman's Office within a few days of the resident's scheduled discharge date . An interview was conducted with SW #3 on 10/28/19 at 10:53 AM and with SW #2 on 10/28/19 at 11:17 AM. Both SW #3 and SW #2 stated that they had no involvement with alerting the Ombudsman's Office when a resident appeals a discharge. Any appeal that rises to the level of the NYSDOH is taken care of by the Director of Social Work. There is currently no Director of Social Work employed by the facility. 415.3(h)(1)(iv)(a-e)

Based on record review and interviews conducted during the recertification and abbreviated complaint (NY 048) survey, the facility did not ensure that a resident's discharge plan included consideration of information received by appropriate community entities. Specifically, a resident who required continued wound care was discharged to a shelter that does not have the capacity to coordinate wound care services. This was evident for 1 of 5 residents reviewed for discharge out of a sample size of 21 residents (Resident #144) The findings are: A facility policy and procedure related to Discharge/Transfers Rights and regulations dated 5/18 documented that the social worker, together, with the other clinicians shall provide sufficient preparation to ensure safe and orderly transfer or discharge. Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was cognitively intact, had an infection of the foot, applications of dressing to the feet, and that the resident expected to be discharged to the community. Discharge MDS dated [DATE] documented that the resident was cognitively intact and that he had an active discharge plan for resident to return to the community. A Comprehensive Care Plan (CCP) related to Discharge Planning was initiated on 8/23/19. The CCP documented that the resident has a discharge plan set by the interdisciplinary team to include home health services. Documented interventions included that a referral to a home care agency would be made by Social Services. physician's orders [REDACTED]. The left lower extremity was to be cleansed with normal saline, patted dry, Xeroform dressing applied, covered with an abdominal pad, and secured with [MEDICATION NAME]. physician's orders [REDACTED]. Social Work Notes (SWN) dated 8/28/19 documented that the discharge plan was for the resident to return to the community. On 8/29/19, SWN documented that the Director of Social Services (DSS) from the resident's former shelter contacted the Social Worker (SW) and informed him that the resident cannot return to the shelter to live once he is discharged from the facility. The note documented that other options were to be explored. A subsequent SWN from 8/29/19 documented that the resident did not get assistance from the Mayor's office in finding an apartment in the community. The resident told the SW that he will return to his former shelter. Nursing Note dated 9/3/19 and time-stamped 1:02 PM documented that the resident was discharged to the community and left the facility by himself with his rolling walker. The note did not document whether the resident received any wound care demonstration or was trained on how to dress his wound. A SWN also dated 9/3/19 and timestamped 2:28 PM documented that the SW called the resident's former shelter to follow up with the home care contact information and to fax them discharge instructions for the resident. A subsequent SWN dated 9/3/19 and timestamped at 5:25 PM documented that the SW received a phone call from the home care agency. The SW was informed that the shelter would not be able to accommodate home care services, including wound care, for the resident. There is no documented evidence that any further contact was made to the home care agency, the shelter, or the resident. Discharge Planning Instructions dated 9/3/19 documented that the resident was to receive a skilled nursing assessment after discharge, home health aide services as per agency determination, and a physical therapy evaluation. The resident's skin has left lower extremity erosion and continues with daily dressing. Special treatments are documented as wound care to the left lower extremity: cleanse with normal saline, pat dry, apply Santyl, cover with an abdominal pad, and secure with [MEDICATION NAME]. On 10/24/19 at 03:03 PM, an interview was conducted with the complainant, the DSS from the resident's former shelter. The DSS stated that they were only informed that the resident was going to be discharged back to them after receiving communication from the resident himself. The resident's care manager was emailed late on a Friday evening (8/30/19) from the resident informing them that the facility is discharging him on Tuesday (9/3/19) and the resident does not know what to do. The email was not received by the case manager until Tuesday, 9/3/19, because Monday, 9/2/19, was a holiday and the staff was not at work to receive email communication. The DSS stated that usually, facilities will contact the DSS or case management office at the shelter to coordinate and ensure a safe discharge back to the shelter. The DSS contacted the SW from the facility and informed them that the shelter had not been made aware of the resident's discharge plan to return and would like time to review the plan. The facility still discharged the resident that day despite the reservations of the shelter. The DSS was faxed the discharge instructions for the resident later that day after he had already returned to the shelter. The DSS stated that the shelter was told by the facility SW that the resident would be receiving homecare services for wound care treatment. After speaking with the home care agency, the DSS was informed that the resident's home care referral had been denied. The shelter cannot accommodate skilled nursing care that requires private rooms for wound care treatment. The shelter is a congregate living situation where 10 or more men dorm in one single room. The DSS stated that this information was communicated to the facility SW prior to the resident's discharge. The home care agency representative stated that they were under the impression that the resident would be discharged to a private apartment in the community, not a shelter. The DSS stated that she informed the facility SW a week prior to the resident's discharge on 9/3/19 that the shelter requires at least a 24-hour notice from the facility prior to a resident's discharge back to the shelter. This is to ensure that an appropriate discharge plan has been devised and agreed upon by all parties. The resident did follow up with his medical doctor in the community but left the shelter soon after his discharge back there on 9/3/19. The resident is now at another shelter. An interview was conducted with the facility SW on 10/25/19 at 11:14 AM. The SW has been working in the facility since 7/2019 and there is currently no Director of Social Service in the facility. The SW stated that he does recall this resident and that, initially, the resident had informed the facility that he would be discharged to an apartment in the community. The resident stated that his goal would be to return to the address that he has on file if he cannot get an apartment by the time his discharge is ready to occur. The team decided upon a discharge date for the resident and the resident agreed. The resident was unable to secure an apartment and ended up returning to the address that he had on file. The SW stated that the resident informed him that his previous address was a shelter but indicated that he had his own space. The SW stated that there was communication at some point with the shelter prior to discharge. The SW stated that he informed the shelter that the resident wished to return there and that he was informed by the shelter that the resident would not be able to return. The resident is the person that told him he would be able to return to the shelter. The SW stated that is not familiar with how the shelter system works and has never coordinated a discharge to this type of agency before. The SW did not take the shelter's communication with him into account and only went based off of the resident's indication that he could return. The SW stated that he called the shelter on 9/3/19 to inform them that the resident would be discharged there on that day. The shelter requested that a medication list and discharge instructions be faxed over to them. The resident did require home care services, but the SW was unsure as to whether the resident had a skilled nursing need upon discharge. Initially, the SW did not recall any issue with the home care referral; however, after reviewing his SWN, the SW stated that he does remember that the home care agency was unable to service the resident at the shelter. The SW stated that the home care agency could not be accommodated at the shelter, but he cannot recall the reason. The SW cannot recall if he contacted the shelter after this to follow up on resident's well-being. The SW also stated that he cannot recall what steps, if any, he took after finding out that home care would not be able to service the resident in the community. He believes he may have called the home care agency but does not know what happened after they denied his case. The SW stated that he called the resident and left a voicemail to follow up with him post discharge but did not receive a call back. 415.11(d)(3)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident's ostomy urine drainage bag was observed touching the floor in the resident's room. This was evident for 1 of 2 resident's reviewed for Catheter Care out of a total sample of 40 residents (Resident #149). The finding is: The facility policy titled, Daily Catheter Care- Conduit Care dated 1/19 did not document any information related to maintaining the drainage bag. The facility policy titled, Care of Stoma [MEDICAL CONDITION] dated 11/10 did not document any information related to maintaining the drainage bag. The policy titled, [MEDICAL CONDITION] Care -Irrigation' dated 11/10 did not document any information related to maintaining the drainage bag. The policy titled, Ostomy Care- Irrigation dated 11/10 did not document any information related to maintaining the drainage bag. Resident #149 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS)dated 10/25/19 documented resident with severely impaired cognition, occasionally incontinent of bowel and has a urinary ostomy. Physician order [REDACTED]. On 10/22/19 at 10:09 AM, the resident was observed lying in bed. The resident had an [MEDICAL CONDITION] tube that was attached to a drainage bag. The drainage bag was observed attached to the right-side rail of the bed and touching the floor. On 10/22/19 at 10:39 AM, the [MEDICAL CONDITION] drainage bag was observed attached to the right-side rail of the bed and touching the floor. On 10/22/19 at 10:40 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated I started my shift at 7 AM. I gave the resident medications at 9 AM. I checked the drainage bag then and it was not touching the floor as the bed was higher. The CNA must have lowered the bed. The drainage bag is not supposed to be touching the floor. This is an infection control issue. On 10/22/19 at 10:43 AM, Client Care Associate (CCA) #1 was interviewed and stated, I started my shift today at 7 AM. I came into this room at that time. I see now that the Foley drainage bag is touching the floor. The bed is low that's why it is touching. I lowered the bed to prevent falls. To tell you the truth I did not see the drainage bag on the floor. The drainage bag is not supposed to be on the floor. It could be an infection control issue. On 10/22/19 at 10:50 AM, the Registered Nurse (RN) #1 Unit Manager was interviewed and stated, I see the ostomy drainage bag on the right side is resting on the floor. It is not supposed to be resting on the floor. It is on the floor because the bed is on the lowest position for his safety. The bag should be hanging off the siderail about 6 inches off the floor. This is an infection control problem. I will change the bag and elevate the bed, so the new drainage bag does not touch the floor. On 10/28/19 at 12:36 PM, the Vice President of Clinical Services was interviewed and stated, As far as infection control precautions we do not allow the stoma drainage bag to touch the floor. I was told the Client Care Associate (CCA) lowered the bed to keep the resident safe and the bag touched the floor at that time. The CCA should have unhooked the drainage bag from the side of the bed, lowered the bed and repositioned the drainage bag on the siderail area of the bed and make sure it does not touch the floor. We did education over the weekend to the nursing staff on infection control procedures and expectations. We emphasized that any kind of drainage bags, such as Foley catheter bags, [MEDICAL CONDITION] drainage bags or stoma drainage bags should not be touching the floor. As far as the policy's I presented to you they have general infection control procedures. I do not have a policy in place that specifically addresses the different types of draining bags and that they should be placed so as not to touch the floor. 415.19(a)(1-3)

Based on staff interviews and record review during an abbreviated survey (NY 663), the facility did not ensure that a resident receive appropriate discharge. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 was admitted to the facility on [DATE] and was discharged to the community on 3/12/2018. Resident #1 did not receive a notice of discharge/transfer with appeal rights. The Facility Policy and Procedure titled, Discharge/Transfers Rights and Regulations, dated 03/2017 states that the Resident/Patients have the right to appeal discharges to the State agency designated by the State for such appeals. Discharge/Transfer will be given to the resident as soon as practicable before discharge. The written notice must include: the reason for transfer or discharge, the effective date of transfer or discharge, a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request and the name, address and telephone number of the Office of the State Long- Term Care Ombudsman. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIM- used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Notice of Medicare Non-Coverage document dated 3/9/2018, (signed by Resident #1), documented that Resident #1 was informed that coverage at the facility will end on 3/11/2018 and discharge date is 3/12/2018. A Social Worker's (SW) Progress Note dated 3/12/2018 documented that Resident #1 is prepared for discharge home today. The Director of Social Service (DSS) was interviewed on 5/4/2018 at 10:55 AM and stated that she missed giving Resident #1 the notice of Discharge/Transfer with appeal rights. 415.3(h)(1)(ii)(a)(b)

Based on staff interviews and record review during an abbreviated survey (NY 663), the facility did not ensure that Office of the State Long Term Care Ombudsman was notified of the transfer/discharge of each discharged resident. This was evident in 1 out of 3 sampled residents, (Resident #1). Specifically, the facility initiated discharge for Resident #1 but did not send a copy of the discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. The Facility Policy and Procedure titled, Discharge/Transfers Rights and Regulations, dated 03/2017 states that the Resident/Patients have the right to appeal discharges to the State Agency designated by the State for such appeals. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIM- used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Notice of Medicare Non-Coverage document dated 3/9/2018, (signed by Resident #1), documented that Resident #1 was informed that coverage at the facility will end on 3/11/2018 and discharge date is 3/12/2018. A Social Worker's (SW) Progress Note dated 3/12/2018 documented that Resident #1 is prepared for discharge home today. The Director of Social Service (DSS) was interviewed on 5/4/2018 at 10:55 AM. She responded to a question regarding Discharge/Transfer notification to the Office of the State Long-Term Care Ombudsman. She stated that she did not send a notice of Discharge/Transfer notice to Ombudsman because Resident #1 appealed the discharge after he was discharged home. 415.3(h)(1)(ii)(a-c)

Based on observation, record review and interview the facility did not ensure that a resident with a documented stage 2 pressure ulcer on admission received the necessary treatment to promote healing in a timely manner. This was evident for one of 3 residents reviewed for Pressure Ulcer. (Resident #540). The finding is: Resident #540 is an [AGE] year old with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented: intact cognition, extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS further documented the presence of a pressure ulcer at Stage I or higher, one Stage 2 pressure ulcer present on admission. The most severe tissue type for any pressure ulcer was [MEDICATION NAME] tissue. The Nursing Skin assessment dated [DATE] documented: Pressure site: sacrum. Length: 4 (centimeters) Width: 2 (centimeters) Depth: 0. No exudate, [MEDICATION NAME] tissue, stage 2, appearance: dry, color: red, drainage amount-none (dry). The Braden Scale dated 10/6/16 documented a risk assessment score of 15 indicating mild risk. The Registered Nurse (RN) Nursing Admission note dated 10/7/16 documented a Stage 2 sacral pressure ulcer. The Nurse Practitioner (NP) Medical notes dated 10/7/2016, 10/11/16, 10/15/16 and 10/17/16 documented: Physical Exam: Skin: WDI (Warm, Dry, Intact). The Medical note completed on 10/11/16 by the unit Physician was reviewed. The box to be checked indicating the presence of a pressure ulcer was not checked, skin examination section documented intact skin and the comment section was blank. The Assessment and Plan documented that the resident was seen by the Physician with the NP. The weekly skin assessment documented: 10/21/16: sacrum: 1 x 1 x 0 cm. Tissue type: [MEDICATION NAME]. The original Physician Interim Order dated 10/21/16 documented: Wound care: Stage 2 PU to sacrum- apply Z-guard and cover with [MEDICATION NAME] daily. Schedule: every day at 9:00 AM. There was no documented evidence that wound care orders were obtained when the pressure ulcer was identified on 10/6/16. The Treatment Record (TAR) dated 10/22/16 to 11/3/2016 documented: Wound care: Stage 2 PU to sacrum apply Z-guard and cover with [MEDICATION NAME] Daily. The TAR documented initials by the unity nurses for the provision of treatment. The Certified Care Associate (CCA) was interviewed on 11/4/16 at approximately 12 Noon. The CCA stated that she cared for the resident for the first time on 10/8/16 and informed the nurse that the resident had skin breakdown to the sacrum. The Nurse Practitioner (NP) was interviewed on 11/4/16, at 12:25 PM. The NP stated that she documented the residents skin was warm, dry and intact based on information provided by the unit RN and also conducted a head to toe assessment. The NP further stated that she may have missed identification of the sacral pressure ulcer. The unit Licensed Practical Nurse (LPN) was interviewed on 11/4/16 at 12:55 PM and stated that on admission a skin check is done. If redness is observed, they can use Z-guard (skin protectant) [MEDICATION NAME] with [MEDICATION NAME] for protection every day. If redness does not go away, they report that finding to NP and the NP will order Z-guard and [MEDICATION NAME]. If the nurses document the skin breakdown as a stage 2 pressure ulcer, the medical doctor is contacted right away. On 11/4/16, at approximately 1:16 PM the Registered Nurse manager (RNM) was interviewed and stated that there might have been a break in communication between nursing and the medical staff. The nurse who noted the pressure ulcer should have reported her findings of a stage 2 pressure ulcer to the NP and unit Physician. 415.12(c)(2)

Based on record review and interview the facility did not ensure that the Physician reviewed the resident's total plan of care. Specifically, a resident was not accurately evaluated and treatment orders obtained for a resident admitted with a stage 2 pressure ulcer in a timely manner This is evident for 1 of 3 residents reviewed for Pressure Ulcers. (Resident #540) The finding is: Resident #540 is an [AGE] year old with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented: intact cognition, extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. The MDS further documented the presence of a pressure ulcer at stage I or higher, one stage 2 pressure ulcer present on admission. The most severe tissue type for any pressure ulcer was [MEDICATION NAME] tissue. The Nursing Skin assessment dated [DATE] documented: Pressure site: sacrum. Length: 4 (centimeters) Width: 2 (centimeters) Depth: 0. No exudate, [MEDICATION NAME] tissue, stage 2, appearance: dry, color: red, drainage amount-none (dry). The Braden Scale dated 10/6/16 documented a risk assessment score of 15 indicating mild risk. The Registered Nurse (RN) Nursing Admission note dated 10/7/16 documented a stage 2 sacral pressure ulcer. The Nurse Practitioner (NP) Medical notes dated 10/7/2016, 10/11/16, 10/15/16 and 10/17/16 documented: Physical Exam: Skin: WDI (Warm, Dry, Intact). The Medical note completed on 10/11/16 by the unit Physician was reviewed. The box to be checked indicating the presence of a pressure ulcer was not checked, skin examination section documented intact skin and the comment section was blank. The Assessment and Plan documented that the resident was seen by the Physician with the NP. The weekly skin assessment documented: 10/21/16: sacrum: 1 x 1 x 0 cm. Tissue type: [MEDICATION NAME]. The original Physician Interim Order dated 10/21/16 documented: Wound care: Stage 2 PU to sacrum- apply Z-guard and cover with [MEDICATION NAME] daily. Schedule: every day at 9:00 AM. There was no documented evidence that wound care orders were obtained when the pressure ulcer was identified on 10/6/16. The Nurse Practitioner (NP) was interviewed on 11/4/16, at 12:25 PM. The NP stated that she documented the residents skin was warm, dry and intact based on information provided by the unit RN and also conducted a head to toe assessment. The NP further stated that she may have missed identification of the sacral pressure ulcer. On 11/4/16, at approximately 3:25 PM, the unit Physician was interviewed via the telephone. The Physician stated that he examined the resident on 10/11/2016 and did not document the pressure ulcer in his notes, because he did not see it. If there are any skin breakdowns, the nurses write the concern in the communication book. The NP checks the book daily and makes wound rounds weekly. There is written and verbal communication between the nurses and medical staff during visits to the floor and that he didn't know how the pressure ulcer identification and treatment were missed. The Physician further stated that formal rounds with the Nurse Practitioners entail discussing residents plan of care, reviews their documentation,medications, treatments and laboratory findings. 415.15(b)(2)(iii)

Based on observation and interview the facility did not ensure that infection control procedures were maintained.Specifically, a Registered Nurse (RN) did not wash her hands after removing a soiled dressing and before cleansing site and applying new dressing. This was evident for 1 resident out of sample of 21 residents. Resident #450 This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #450 is an [AGE] year old admitted on [DATE],with a [DIAGNOSES REDACTED]. The Resident was on contact precautions for loose stools. The MDS (Minimum Data Set 3.0) dated 8/25/14 documented that the resident's cognition is intact. The MDS further documented that the resident requires extensive assistance with most Activities of Daily Living. The primary care physician's orders [REDACTED]. On 9/11/14 there was an order for [REDACTED]. On 9/12/14 at 10:45am the surveyor observed the RN (Registered Nurse) perform wound care to the resident's Sacral area. The RN donned gloves, then removed the soiled dressing. She then discarded the soiled dressing. The RN did not wash her hands. She then returned to the glove rack in the resident's room, donned a new pair of gloves and proceeded to clean and dress the wound. On 9/12/14 at 12 noon,the RN was interviewed regarding facility policy/procedure for infection control and standards of practice for wound care and handwashing. The RN stated ,I had inservice and an audit done by nurse manager.RN further stated, I do not recall the exact policy and procedure on handwashing and changing gloves.When surveyor questioned RN regarding use of a clean barrier for the treatment site and supplies.RN stated,a clean barrier is only required for sterile dressing change and kits are available for use. On 9/12/14 at 12:40pm the ADON was interviewed regarding nurses inservice on wound care and dressing changes.specifically RN observed.States, nurses receive inservice by Nurse Practitioner(NP).ADON provided inservice sheets for New Employee Orientation Checklist dated 6/12/13, for RN on Dressing Change Competency.Clean Dressing Technique Audit Tool,dated 6/12/14 for RN,Skill #11wash hands after removing gloves(skill met). On 9/12/14 at 1pm .DON provided a copy of the Policy/Procedure dated 11/10: Title:Clean Dressing Change:Perform hand hygiene before and after removing old gloves and donning new gloves. 415.19(b)(4)

Based on observation, resident and staff interviews and record reviews, the facility did not ensure that the resident's schedule is accommodated as evidenced by not being provided morning care prior to receiving physical and occupational therapies. This was evident for 1 of 40 sampled residents reviewed for significant care concerns. (Residents #106) This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident #106 is a [AGE] year white female admitted on [DATE], with the [DIAGNOSES REDACTED]. On 11/1/11 at 10:47 AM, the resident was observed in bed in a night gown, waiting for morning care. The nurse was observed finishing administering medication to the resident. The therapist was waiting to take the resident to therapy. On 11/1/11 at 10:55 AM, the resident was interviewed and stated that she wakes up at 6:30 AM but does not get washed and dressed until 11:00 AM. The resident stated that she does not know what time her therapy is scheduled but she goes around 11:00 AM to 11:30 AM for Physical (PT) and Occupational (OT) therapy. Whenever the Certified Nursing Assistant comes and gets her ready, that is the time she goes for therapy. The aide has told her that she needs to wait until she is ready to wash her. The resident further stated that it is not her fault that she is not ready when the therapist comes to take her to therapy. On 11/2/11 at 10:25 AM, the resident was observed in bed in her night gown. She stated that she was assigned a new aide today and she is waiting to get ready. She further stated that yesterday she went for therapy at 11:30 AM. The Minimum Data Set (MDS) 3.0 initial assessment dated [DATE] documented that the resident's cognition is intact, no behavior, requires extensive assist of one person for bed mobility, transfer, locomotion on/off unit, dressing, toileting, personal hygiene and bathing, and receives OT 5 times per week and PT 6 times per week. The Comprehensive Care Plan (CCP) dated 9/7/11 for activities of daily living (ADL) documented that the resident requires extensive assist of one person for ADL. The physician's orders [REDACTED]." On 11/2/11 at 10:30 AM, the newly assigned floater CNA (Certified Nurse Assistant) was interviewed and stated that this resident was assigned to her this morning. The CNA was asked what time does the resident go to to therapy, the CNA stated she did. The CNA further stated that she was going to see the resident now. On 11/2/11 at 10:33 AM, the unit nurse (Registered Nurse) was interviewed and stated that she is not sure the exact time the resident goes to therapy, but the resident goes in the morning. She then called rehab department to find out resident ' s therapy time and stated that her group therapy is at 10 AM, on this floor, conducted by OT. Asked why the resident is not ready at 10:30 am and still in bed in night gown, she said she will look into that and went to the resident ' s room. On 11/2/11 at 3:01 AM the unit nurse (RN) in a second interview stated that resident is depressed, and forgets. My responsibility includes to know the rehab schedule and to make sure resident is dressed and ready to go; No written schedule, only therapist knows and tell us. On 11/2/11 at 10:35 AM, the floor OT Therapist was interviewed and stated that he runs a group exercise therapy program from 9:30 am to 10:30 am, and resident # 106 is not in his group. On 11/2/11 at 11:16 AM the PT assistant stated that the resident ' s scheduled time for therapy is 10:00 am. The PT assistant further stated that 2 weeks ago, the resident was moved from group session to one on one session. When he come if resident is not ready, he comes back again. He further stated that Yesterday he came by 9:15 AM to speak with resident and she was not ready; If she was ready, he would have taken her for therapy, and so came back again at 10:30 AM and she was not ready and 11:15 AM the transporter picked her up. Today don't know if the transporter picked her up so far. He had not seen the resident. He is aware resident is up early, Resident says, she is not ready because she is not washed up. On 11/3/11 at 11:35 AM, the day shift CNA who was assigned to resident on 11/1/11, was interviewed over phone and stated that the resident sometimes refuses to go for therapy, and she has to encourage her to go to go for therapy at 10:30 AM or 11:00 AM. The CNA stated that the resident wakes up at 7:00AM, and sometimes after breakfast, she goes to sleep. She further stated that she does not know the scheduled therapy time. 415.5(e)

Based on staff interviews and record reviews, the facility did not provide residents with notification prior to a roommate change. This was evident for 2 out of 4 residents reviewed for notification of changes out of a sample of 40 residents reviewed for significant care concerns. (Residents # 4 and # 408) This resulted in no actual harm with the potential for more than minimal harm. The findings are: 1) Resident # 4 is a 63 years old white male admitted on 12/8/09 with [DIAGNOSES REDACTED]. On 10/31/11 at 1:23 PM, the resident was interviewed and stated that he had 3 to 4 roommates changes in the past 9 months and no notice was given of their arrival before there was a change in the roommate. There is no documented evidence that the resident was provided notice prior to receiving a new roommate. The Minimum data Set (MDS) initial assessment dated [DATE] documented that the resident has a Brief interview for Mental Status (BIMS) score of 15 which indicates that the resident is cognitively intact. The Social Services progress notes from 4/6/11 through 10/18/1 were reviewed, there was no documented evidence that the resident was informed of any roommate change. On 11/3/11 at 12:55 PM the Registered Nurse Supervisor was interviewed and stated that the new resident moved in on 9/30/11 and left the facility on 11/1/11 and currently the resident #4 has no roommate. The social worker used to inform the resident of room and roommate changes but the social worker is no longer here. On 11/3/11 at 1:52 PM, the current social worker for the floor, was interviewed and stated that during morning meeting, with all disciplines present, there is a discussion concerning the medical history of [REDACTED]. Then the resident is notified and after the resident has agreed to the move, the new roommate will be moved. She further stated that she was not the Social worker at that time following resident #4 care. She also stated that she documents the room change but not the roommate change. The social worker stated that our policy is to notify the resident prior to the new roommate's move and document this in the chart. 2) Resident # 408 is a [AGE] years old female admitted on [DATE] with the [DIAGNOSES REDACTED]. On 11/1/11 at 10:24 PM, the resident was interviewed and stated that the new roommate moved into her room at night, and no prior notice was given to her. There is no documented evidence that the resident was provided notice prior to receiving a new roommate either in the care plans or in progress notes. The MDS 3.0 initial assessment dated [DATE] documents resident with a BIMS score of 15, with no cognitive impairment. On 11/3/11 at 2:15 PM the Social worker was interviewed and stated that the new roommate was admitted on [DATE] in the evening around 5:30 PM. She had not yet seen the current resident and was not aware of a new roommate coming into her room. She further stated that the facility staff decide in morning ( AM) meeting who will be an appropriate roommate. Then the Social Worker will speak with the existing resident to inform them of the arrival of the new roommate and document in progress notes of the new roommate. She also stated that the policy is to inform the current resident of the roommate coming in. On 11/3/11 at 10:17 AM the Director of Nursing was interviewed and stated that during morning report all discipline staff including social services, admissions, medicine, nursing and rehab are present, and discuss the patient needs and decide which resident will fit the best with the existing resident. Once it is determined, the Social worker will go and notify the existing resident about the new roommate. If Social worker is not present, nursing will communicate the change. 415.5 (e)(2)

Based on record review and staff interview, the facility did not revise a care plan to appropriately address a resident's needs after a fall. This was evident for 1 of 3 residents reviewed for accidents in a total of 32 residents reviewed for significant care concerns( #136). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident # 136 was admitted [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) 3.0 annual assessment dated 2/20/2011 documented that the resident had moderate cognitive impairment. The MDS also documented that the resident had no behavior issues and no history of falls. The MDS also documented the resident had impaired range of motion (ROM) to the upper and lower extremity on one side. During a staff interview conducted on 10/31/2011 at 12:50 PM the nurse stated that the resident sustained [REDACTED]. She also stated that the resident fell from her wheelchair on 10/6/11 but did not sustain any injury. The Progress notes dated 10/6/11 documented that the resident fell and sustained bruises to the right hand, right knee, left knee, right hip, and right abdomen. A comprehensive care plan (CCP) for Falls potential due to impaired vision, impaired balance, lack of voluntary movement to right side, and use of antidepressant dated 10/22/11 documented interventions including "encourage use of glasses, ensure glasses are clean and in good repair. The CCP also documented on 10/22/11 "no fall reported in last 6 months There was no documented evidence of a CCP for actual falls. An interview was conducted with the registered nurse supervisor (RNS) on 11/3/11 at 12:40 PM who stated that care plans are updated for any changes to the resident's condition. She further stated that the CCP update did not acknowledge the fall but should have been revised to document the actual fall and required interventions. 415.11(c)(2)(i-iii)

Based on record review, resident and staff interviews, the facility did not ensure that the resident received services according to his plan of care. Specifically, the standing program was not initiated for the resident according to discharge recommendation of physical therapy. This was evident for 1 of 24 residents reviewed for significant care concerns. (Resident # 378) This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident # 378 is a [AGE] year old with [DIAGNOSES REDACTED]. On 11/3/2011 at 11:35 AM, the resident was interviewed and stated that he does not participate in any stand up exercises with staff on his unit. The resident stated "What's that all about?" The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident has intact cognition. The Comprehensive care plan for ADL (activities of daily living) Function/Rehab Potential documents on 10/21/2011 " Provide as ordered (specify) standing program ." The Physical therapy discharge summary dated 10/21/2011 documents " He (resident) is being referred to Nursing rehab. On his unit to do sit stand exers. (exercises) 2-3xs (times) a day doing 5 reps. (repetitions) x (times) 3 each time. " The Interdepartmental communication form dated 10/21/2011 documents a request from physical therapy " Please begin standing activity for (name of the resident) ... " The receipt section of the form was signed on 10/21/2011. The C.N.A. (Certified Nursing Assistant) care card from 10/21/2011 did not document any instructions to CNAs to perform standing exercise program with the resident. The Certified Nursing Assistant was interviewed on 11/3/2011 at 11:23AM and stated she is a floater and assists the resident approximately every other week. The CNA stated she obtains resident specific care instructions from an electronic care card. The CNA stated she does not do standing program exercise with the resident as the care card does not include such instruction. The Physical Therapy Assistant was interviewed on 11/3/2011 at 11;13 AM and stated upon discharge from rehabilitation the standing program was recommended so that the resident would not lose his ability to stand. The Registered Nurse (RN) was interviewed on 11/3/2011 at 11:53AM and stated that routinely, when the communication form is forwarded from rehabilitation, the nurse should sign it to confirm receipt and should transcribe instructions to the resident's care card. In this case, this was not done. The RN stated she started on the floor a week ago. She was not able to identify the nurse, who signed the communication form from rehab. The Registered Nurse Supervisor was interviewed on 11/3/2011 at 11:53 AM and stated that the nurse who signed the communication form should have entered instructions for standing program in the Special instructions section of care card and initiate the task in electronic record. "This was not done." 415.11 c (3) ii

Based on record review and staff interviews, the facility did not ensure that the clincial record is accurately documented as evidenced by not documenting that the resident had a weight loss and not documenting that the resident was receiving antipyschotic medication. This was evident for one (1) resident out of a sample of 40 residents who were reviewed for weight (wt) loss and [MEDICAL CONDITION] medications. (Resident #106) This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident # 106 is a [AGE] year white female admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 initial assessment dated [DATE] documented that the resident's cognition is intact, and no behavior symptoms. This MDS further documented that the resident was not receiving [MEDICAL CONDITION] medication. The physician's orders [REDACTED]. The CCP (comprehensive care plan) for [MEDICAL CONDITION] medication dated 9/7/11 documented that the resident is receiving [MEDICATION NAME]. The CCP (comprehensive care plan) dated 9/8/11 for "Nutrition" documented that the resident is on regular, no salt added diet. On 9/13/11 the CCP was updated to reflect the resident's weight (wt) as 122 lbs (pounds) and good oral intake. On 10/12/11, the CCP was updated by Dietitian and documented the resident's weekly wt as 112 lbs "...weight increased by 11 pounds ..." and that "... most probably an error..." and requested that the resident should be reweighed. On 11/2/11 at 12:22 PM, the registered Dietitian (RD) was interviewed and stated that on 10/11/11 the resident's wt was 112 lbs and she had made an error and documented it as wt increase of 11 lbs instead of a wt loss, The dietitian further stated that she felt the weight was an error and asked the resident to be reweighed. She had meant it to be a wt loss, not a wt gain. On 11/3/11 at 9:54 AM, the Director of Assessment and Clinical Reimbursement was interviewed and stated that on 11/2/11 at 2 PM, he made a modification in the MDS because the admission assessment did not indicate that the resident was receiving antipyschotic medication. He stated that he went ahead and checked the correct boxes, modified and resubmitted the MDS. 415.22(a)(1-4)