**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #45 with severely impaired cognition. On 08/24/23 at 11:44 AM, Licensed Practical Nurse (LPN) #2 was observed placing a clothing protector on Resident #45. Resident #45 asked LPN #2 what the item was, LPN #2 stated that it was to keep clothing clean when eating. Resident #45 proceeded to pull the clothing protector off. LPN #2 replaced the clothing protector which Resident #45 again pulled off. LPN #2 placed another clothing protector on Resident #45 and asked them to keep that one on. Resident #45 was later observed moving the clothing protector to the side of their body. LPN #2 did not request Resident #45's permission before placing a clothing protector on 3 occasions. On 08/29/23 at 11:50 AM, Certified Nursing Assistant (CNA) #2 was observed placing clothing protector on Resident #45 without asking permission prior to doing so. On 08/31/23 at 01:38 PM, an interview was conducted with CNA #2, who stated that they will wash the residents' hands or use wipes and put residents at their assigned tables. They will tell the residents that the clothing protector is being applied and why. CNA #2 also stated that on 8/29/23 they were getting the residents ready for lunch, and it slipped their mind to ask before placing the clothing protector. CNA #2 further stated that they had recently been provided in-service on resident's rights and dignity. On 08/31/23 at 10:52 AM, an interview was conducted with LPN #2 who stated that clothing protectors are placed on residents, and the residents are asked before this is done. LPN #2 also stated that on 8/24/23, Resident #45 removed the clothing protector, balled it up, and threw it across the room repeatedly. LPN #2 further stated that they could not recall when the last in-service was done. On 08/31/23 at 12:42 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that wipes and clothing protectors are provided by the CNAs, and the nurse will give the trays to the residents. Before the meal a clothing protector will be provided, and the CNA must ask before applying. RNS #1 also stated that if a resident refuses the clothing protector the CNAs will not provide them. RNS #1 further stated that the LPNs are responsible for supervising this task. On 08/31/23 at 03:51 PM, an interview was conducted with the Director of Nursing (DON) who stated that CNAs must identify themselves and talk through all procedures with residents. The DON also stated that with all care consent must be given, and if a resident cannot verbalize, the CNAs must still ask. 415.5(a) Based on observation, record review, and interviews conducted during the recertification survey from 8/24/2023 to 8/31/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 3 (Resident #28, #45, and #135) out of 54 total sampled residents. Specifically, 1) Residents #28 and #135 were fed by staff standing over them, and 2) staff placed clothing protectors on Resident #45 without asking permission. The findings are: The facility policy titled Resident's Rights and Dignity, with the last effective date of April 2023, documented that the facility's goal is to deliver quality healthcare services to promote resident's comfort and well-being. All residents should be treated with consideration, courtesy, respect, and sensitivity to their background, culture, religion, and heritage. 1. Resident #28 was admitted with diagnoses that include Traumatic Brain Injury and Dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #28 cognition as severely impaired and never/rarely made decisions. The resident is dependent and requires one-person physical assistance in eating. On 8/24/23 at 1:00 PM, during dining observation, Registered Nurse #3 (RN #3) stood over Resident #28 while feeding the resident. 2. Resident #135 was admitted with diagnoses that include Dementia and Multiple Sclerosis. The quarterly MDS assessment dated [DATE] documented Resident #135's cognition as severely impaired and never/rarely made decisions. The resident is dependent and requires one-person physical assistance in eating. On 8/24/23 at 12:50 PM, RN #3 stood over Resident #28 during dining observation while feeding the resident. During an interview on 8/24/23 at 2:27 PM, RN #3 stated that they usually stand when feeding residents. RN #3 prefers to stand because it is comfortable, making RN #3 move fast. RN #3 is aware that they are required to sit and feed residents. During an interview on 8/31/23 at 8:39 AM, the Staff Educator stated that the staff is supposed to sit when feeding the residents to have eye level with them. During an interview on 8/31/23 at 11:36 AM, the Director of Nursing (DON) stated that the residents are to be fed at eye level. The staff are supposed to sit when they are feeding the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview conducted during the Recertification survey from 8/24/2023 to 8/31/2023 the facility did not ensure that a resident Comprehensive Care Plan was reviewed and revised as needed with interventions to reflect the resident's changing needs. This was evident for 1 (Resident #162) of 4 residents reviewed for Accidents out of a sample of 54 residents. Specifically, Resident #162's Fall CCP was not revised with new interventions after a fall while Resident #162 was trying to use the bathroom. The findings are: The facility's policy and procedure titled Comprehensive Care Plan, last revised on 7/2023, documented that it is the responsibility of each discipline to monitor effectiveness of the stated interventions and to revise the Plan of Care as necessary. Resident #162's diagnoses include: End stage renal disease (ESRD), Dependence on renal dialysis, and Type 2 diabetes mellitus. The Quarterly Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #162 had intact cognition and required supervision and setup for bed mobility and transfers and extensive assistance of one-person for toilet use. A CCP titled Falls effective on 12/12/22 and included a goal that the resident will be free from injury X 3 months with an intervention to instruct resident to call for assistance as needed. Care Plan Activity Report dated 3/02/23 documented that the resident had a fall on 2/28/23. There was no documented evidence that the CCP was reviewed and revised with new interventions after a fall on 2/28/23. On 8/30/23 at 3:30 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated the intervention for Resident 162's fall on 2/28/23 was an x-ray of the foot and ankle. The ADNS further stated this intervention was documented on 3/2/23 under the notes section of the Falls Care Plan. On 8/31/23 at 11:04 AM, the Director of Nursing (DON) was interviewed and stated that the intervention on Resident #162's Fall CCP is a specific intervention for that fall which is documented in the CCP note. Also, the intervention to call for assistance was reinforced with the Resident. The DON further stated if a resident has a fall the supervisor on duty documents an intervention right away in the Fall CCP and then the ADNS reviews the interventions. 415.11(C)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that services provided met professional standards of quality care. Specifically, blood pressure was not taken before a resident was administered blood pressure medication to ensure it was within the parameters to safely administer medication as ordered by the physician. This was observed during the Medication Administration Task. (Resident #145) The findings are: The facility Policy and Procedures titled Medication Administration last revised 8/28/2023 documented that it is the policy of the facility that all medications are administered by licensed nursing personnel as ordered by the physician. On 08/28/23 at 08:58 AM, during Medication Administration observation, Licensed Practical Nurse (LPN) #3 was observed administering medication which included medication for Hypertension (high blood pressure) to Resident #145. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. The Physician Order for Resident #145 with a start date of 4/23/23 documented Metoprolol Succinate ER (Extended Release) 25 mg, once daily. Monitor BP and Pulse. Hold for BP less than 100. Hold for Pulse less than 60. On 08/28/23 at 08:58 AM, during Medication Administration observation it was observed that Licensed Practical Nurse (LPN) #3 did not assess Resident #145's blood pressure prior to administering Metoprolol Succinate ER (a medication to regulate blood pressure). Review of the vital signs monitoring section in the Electronic Medical Record (EMR) revealed that on 08/28/23 at 09:11 AM, LPN #3 documented a blood pressure reading of 128/70 mmHg for Resident #145. On 08/28/23 at 02:18 PM, an interview was conducted with LPN #3 who stated that the blood pressure (BP) was assessed prior to medication being given to all residents. LPN #3 also stated that they assessed and memorized Resident #145's BP prior to giving medication and then entered the BP readings after administering the medication. LPN #3 further stated that they could not recall what the BP reading was for this resident and this was the only resident for whom BP readings were entered after medication was given. On 08/28/23 at 02:27 PM, an interview was conducted with Resident #145 who stated that BP was not assessed today as is usually done, and the LPN probably forgot. On 08/28/23 at 02:43 PM, a follow-up interview was conducted with LPN #3 who stated that Resident #145's blood pressure had not been assessed today prior to medication being given, and the BP reading entered was documented without first assessing the resident's BP. On 08/31/23 at 12:34 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that prior to administering BP medications, the nurse should check the orders, and ensure the resident's vital signs are within the parameters and then document the vital signs. RNS #1 also stated that documentation should be accurate and be placed in Sigma when the BP is assessed before the medication is administered. RNS #1 further stated that rounds are done in the morning by the Unit Coordinator to ensure compliance. On 08/31/23 at 03:55 PM, an interview was conducted with the Director of Nursing (DON) who stated that if BP medications require a parameter, the BP must be assessed prior to administration. If medication is to be held, the MD must be informed. The DON also stated that the assessment of the BP should be documented in sync with the administration, and the system will prompt staff to enter the information. 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey conducted from 8/24/23 through 8/31/23, the facility did not ensure residents who could not carry out Activities of Daily Living (ADL) received the necessary services to maintain good nutrition. This was evident for 1 of 4 residents (Resident #153) out of a sample of 54 residents reviewed. Specifically, Resident #153, who requires assistance with meals, was not assisted with their meals. The findings include: The facility policy and procedure titled A.D.L.'s, with the last revised date of July 5. 2022 documented that the resident will receive A.D.L. care daily to ensure that the needs are met and that residents may function at their optimal level. A.D.L. care provides stimulation interaction and supports the resident's quality of life. The facility policy and procedure titled Mealtime, with the last revised date of April 2023, documented that Mealtime is an important event providing basic nutrition, relaxation, and an enjoyable social experience. All available nursing personnel will assist residents at Mealtime to ensure safety, comfort, enjoyment, individuality, independence, and adequacy of nutrition. Resident #153 was admitted with diagnoses that include Dementia and Depression The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 153 cognition as severely Impaired, never/rarely made decisions, and requires limited assistance from one person in eating. On 8/28/23 at 9:17 AM, Resident # 153 was observed out of the bed in a wheelchair in their room. The resident's breakfast tray was on the table, untouched. During an interview on 8/28/23 at 9:20 AM, Registered Nurse #3 (RN #3), also the unit clinical coordinator, stated that Resident #153's family member was coming in to feed the resident. Breakfast was delivered to the floor at 8:00 AM. The resident family member requested they leave the tray until they came to provide it to the resident. On 8/28/23 at 9:45 AM, Resident #153's family member visited the resident. During an interview on 8/28/23 at 9:50 AM, Resident #153 family member stated that they did not ask them to leave the tray until they came to feed the resident. They are supposed to assist the resident with their meal, but they do not. Yesterday afternoon, their sibling came to visit during lunch. They asked the resident if they had eaten, and the resident said they had not eaten. They asked to see the tray and they brought it to the resident's room untouched. The sibling assisted the resident with the lunch when they returned the tray, and Resident #153 ate. The Resident Nursing Instruction dated 2/2/23 documented that Resident #153 requires limited assistance of one person in eating. On 8/28/23 at 12:45 PM, Resident #153 was out of bed in their wheelchair in their room. The resident lunch tray was on the bedside table. Resident # 153 lunch tray remained on the bedside table untouched at 12:57 PM, 2:22 PM, and 3:15 PM. A review of the progress notes dated 8/1/23 to 8/29/23 has no documented evidence that Resident #153 refused meals from the staff. During an interview on 8/29/23 at 2:33 PM, Certified Nursing Assistant #5 (CNA #5) stated that Resident #153 needs assistance with their meals. They gave the resident their breakfast tray yesterday, 8/28/23, and fed the resident. Resident #153 ate the banana and said they no longer wanted to eat. The tray was left at the bedside because the family would say that they did not feed the resident. If she removes the tray, the son will say they did not feed the resident. The lunch tray was left at the bedside because the family was coming to assist the residents with their meals. During an interview on 8/29/23 at 2:54 PM, Registered Nurse #3 (RN #3), the unit clinical coordinator, stated they left the tray at the bedside. Resident #153's family gets upset when they found out the resident had not been fed, and the tray was not at the bedside. Resident #153's family member is the one who usually assists the resident with their meals. It is not documented that the resident family assisted the resident with their meals. RN #3 is unsure who fed resident #153 lunch yesterday (8/28/23). It is not documented that the resident refuses meals from the staff. During an interview on 8/31/23 at 11:36 AM, the Director of Nursing (DNS) stated that Resident # 153 is more of a behavior. The resident family requested a modified visiting time from 9:00 AM to assist with feeding the resident. The staff are not required to leave the tray at the bedside. The resident likes familiar faces and eats when there is a regular staff. The charge nurse and the clinical coordinator ensure that the resident gets their meals and are fed. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #12 was admitted with diagnoses that included Stroke, Non-Alzheimer's Dementia and weakness on one side of the body. The Minimum Data Set (MDS) dated [DATE] documented that Resident #12 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 and was dependent on staff for assistance with Activities of Daily Living. The Physician's Orders dated 4/15/23 noted Right (R) Elbow splint when out of bed and hygiene, and Right Hand roll splint when OOB except hygiene/ROM (Range of Motion). Care plan with an effective date of 6/17/2020, noted as follows: Right hand roll splint at all times, remove during hygiene, Right elbow splint out of bed, Splints per Physical Therapy (PT) Plan of Care (POC). Last review completed on 7/11/23 On 08/24/23 at 11:00 AM, Resident #12 was observed in the hallway being transported in a wheelchair to the activity room. Resident #12 was observed with a contracture of the upper right extremities. No splint device or hand roll was observed in place on Resident #12's right hand. On 08/24/23 at 12:37 PM, Resident # 12 was observed sitting in the hallway at the nurse station, no splint device or hand roll were in place on the resident's right arm. On 08/25/23 at 12:43 PM, 08/29/23 at 11:39 AM and at 2:25 PM, Resident #12 was observed in the activity room, sitting in their wheelchair with a splint device in place but no hand roll was being worn. ON 08/31/23 at 09:59 AM, an interview was conducted with Certified Nursing Assistant (CNA) #3 who stated that Range of Motion (ROM) exercises, 3 sets lasting between 8-10 minutes, flexing both upper and lower extremities are done with Resident #12. CNA #3 also stated that the Resident #12 gets two devices, one for the elbow and one for the hand. Physical Therapy (PT) comes to get them on sometimes, they apply a heating pad because the elbow brace is too tight, and there is difficulty putting it on almost every other day. CNA #3 further stated that when they cannot get the device on, they let the nurse and therapist know, but they had not seen the Physical Therapist recently to let them know they were having difficulty getting the devices on. CNA #3 stated that is the responsibility of the night shift to apply the devices after breakfast. On 08/31/23 at 12:39 PM, an interview was conducted with Registered Nurse Supervisor (RNS) #1 who stated that the Certified Nursing Assistant (CNA)s and Rehabilitation CNAs are responsible for doing the Range of Motion (ROM) exercises for the residents. RNS #1 also stated that the Rehabilitation CNAs and the regular CNAs are aware that this information can be found in the medical doctor orders. RNS #1 also stated that compliance with devices is monitored by Unit Managers, and if a device is missing it should be reported to the Rehabilitation CNAs. On 08/31/23 at 03:54 PM, an interview was conducted with the Director of Nursing who stated that all splint device concerns must be documented in the Certified Nursing Assistant (CNA) Accountability Notes and communicated to the Licensed Practical Nurse (LPN), who will then refer the information to the Rehabilitation Nurse and Occupational Therapist. 415.12 (e)(2) Based on observation, record review, and interviews conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 2 of 5 residents reviewed for Limited Range of Motion out of 37 sampled residents (Resident #77). Specifically, 1) Resident #77 had bilateral upper extremity contractures and was observed without resting hand splints or elbow splints when out of bed and without hand rolls and soft elbow splints when in bed as per Medical Doctor Order (MDO), and 2) Resident #12 with a right-hand contracture was not provided with a splint device as per Medical Doctor Orders. The findings are: The facility policy and procedure titled Assistive/Adaptive, and Positioning Devices dated 4/2020, last reviewed 4/2023 documented that it is the policy of this facility to ensure that assistive/adaptive and positioning devices are provided as indicated in the plan of care, and monitored for proper fit and use as well as care and follow-up completed according to the resident's plan of care as determined by the interdisciplinary Care Plan Team. The assigned CNA will be responsible for the application of devices according to the Plan of Care and signs the CNA Accountability record every shift daily. 1. Resident #77 was admitted to the facility with diagnoses of Stroke, Brain Dysfunction, and Spinal Cord Injury. The Annual Minimum Data Set 3.0 (MDS) dated [DATE] documented that Resident #77 was severely cognitively impaired, was totally dependent on staff for Activities of Daily Living (ADLS), and had impaired mobility on both sides of their upper and lower extremities. The Physician's Order initiated 2/28/23 and renewed 8/10/23 documented hand rolls when in bed except hygiene, resting hand splints when OOB (out of bed) except hygiene and Range of Motion (ROM). Soft elbow splints when in bed except hygiene and ROM. The Care Plan Activity Report titled ADL Functional/Rehabilitation Potential effective 7/26/2020 documented that the Resident has contractures on both elbows, wrists, and finger joints. Severely impaired mobility and total dependence with all ADLS. Occupational Therapy OT screen/evaluation on 5/26/23 and 8/30/23 prescribe interventions and goals as follows: continue bilateral (B) hand splints, bilateral (B) elbow splints when out of bed (OOB). Bilateral (B) hand rolls & soft elbow splints when in bed. Resident will be free from development of further contractures. On 08/24/23 at 10:27 AM, 08/28/23 at 09:11 AM, and 08/31/23 at 10:07 AM, Resident #77 was observed lying in bed with bilateral elbow, wrist and hand contractures without a splint device or hand roll. On 08/25/23 at 12:50 PM, 8/28/23 at 10:23 AM, 8/29/23 at 12:30 PM, and 8/30/23 at 12:30 PM, Resident #77 was observed out of bed with bilateral elbow, wrist and hand contractures without a splint device or guard in place. On 8/31/23 at 10:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) #4 who stated that they perform care for the resident in the morning and then take Resident #77 out of bed. CNA #4 also stated that splint devices are applied on resident's extremities while the resident is in bed which includes elbow and hand splints placed on both arms while in and out of bed. CNA #4 further stated that when the resident shows on their face that they do not want the splints on, they would leave them off and tell the nurse. CNA #4 stated that there was nowhere to document that devices were removed, and they could only document that they put splints on once every shift. CNA #4 also stated that they remove for 15 minutes every two hours, but there was nowhere in the record where they could document that this had been done. On 08/31/23 at 10:42 AM an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that CNAs are reminded during morning meeting and the Rehabilitation Nurse checks once a shift to ensure that this is being done. LPN #2 also stated that the devices had not been applied for the last two days as the resident started crying as soon as they saw that the CNA was getting ready to place the devices. The CNA was instructed not to apply the device. Rehab was informed and will be evaluating the resident. LPN #2 stated that they were not aware of any reason why the devices had not been in place during observations conducted prior to 08/29/23. LPN #2 also stated that they do review in the electronic medical record to confirm that devices are being applied every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a record review and interviews conducted during a recertification and complaint (NY00312405) survey from 8/24/23 to 8/31/23, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. This was evident for 1 (Resident #90) of 4 residents reviewed for accidents out of 54 sampled residents. Specifically, Resident #90 fell out of bed after the resident was transferred to bed with a Hoyer lift and sustained a laceration on the right facial cheek. The findings are: The facility policy and procedure titled Accidents-Residents, Visitors, Volunteers, last reviewed August 2023, documented that Accidents refer to any unexpected or unintentional occurrence or chain of events which may or may not result in injury or illness to a resident. The policy also documents that fall refers to unintentionally falling to rest on the ground, floor, or other lower level. Resident #90 was admitted to the facility with diagnoses that include Dementia, Traumatic Brain Injury (TBI), and Tracheostomy Status. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 90 is dependent and requires two-person assistance for bed mobility, transfer, and toilet use and one person for personal hygiene. The Comprehensive Care Plan (CCP) related to the fall initiated on 12/24/19 documented Resident #90 has the potential for injury as evidenced by diagnoses of vascular dementia and traumatic brain injury. The interventions include total dependence and two-person physical assistance. A care plan note dated 2/27/23 documented that around 2:30 PM, Resident #90 had a jerking movement post-bed transfer and slid on the left side of the bed in a right-lying position. A Patient Accident/Incident Report dated 2/27/23 documented that Resident #90 was found lying on the left side of the floor in a right-side lying position post-CNA care. The resident had a jerky movement post-transfer. A Nurse's Progress Note dated 2/27/23 at 3:09 PM documented that around 2:30 PM, Resident #90 had a jerking movement post-bed transfer and slid on the left side of the bed in a right lying position. CNA #6 was at the bedside but unable to break the fall. The resident sustained approximately a 2-centimeter laceration on the right facial cheek. The primary physician was informed with orders to transfer the resident to the emergency room (ER). A Nurse's Progress Note dated 2/28/23 at 1:10 AM documented that Resident # 90 returned at 12:30 AM. Brain impression showed no intracranial hemorrhage and no acute facial fracture. During an interview on 8/29/23 at 11:44 AM, Certified Nursing Assistant #6 (CNA #6) stated that Resident # 90 is a two-person assistant for everything apart from mouth care. The resident was transferred to bed from a chair with a Hoyer lift after 2:00 PM, and the fall occurred. CNA #7 assisted with the transfer. The resident was placed in the middle of the bed. CNA #7 moved the Hoyer lift out of the room while CNA #6 turned their back to move the table and the supplies closer to the bed. Resident # 90 had one big cough. CNA #6 turned around, and the resident was on the floor. CNA #6 could not prevent the fall and screamed; CNA #7 returned and informed the nurse. During an interview on 8/29/23 at 11:56 AM, CNA #7 stated that they helped CNA #6 to put Resident # 90 back to bed. CNA #7 was pushing the lifter out and heard CNA #6 screaming. CNA #7 returned to the room, saw the resident on the floor, and went and called the nurse. Resident # 90 was placed in the middle of the bed. The fall happened within seconds. CNA #6 was standing on the left side of the bed facing the resident when CNA #7 was leaving the room. During an interview on 8/29/23 at 12:31 PM, Registered Nurse #3 (RN #3) stated that the CNAs were in the room, they shouted, and RN #3 went to the room. Resident # 90 was on the left side of the bed with blood on their face. The resident sustained a laceration on the right cheek. The doctor saw the resident and ordered to transfer the resident to the hospital. RN #3 initiated the Accident /Incident Report. The CNAs were in-serviced on safe transfer and instructed to ensure everything was at the bedside before transferring a resident back to bed. During an interview on 8/31/23 at 10:57 AM, the Assistant Director of Nursing (ADNS) stated that RN #3 initiated the investigation. They interviewed CNA #6 and found out that the resident had a jerky movement after the transfer and fell. The resident tends to have a strong cough and involuntary jerky movement. Resident # 90 was sent to the hospital for evaluation. The investigation concluded that there was no evidence of abuse, neglect, or mistreatment. It was not a care plan violation. They provided counseling CNA #6 to ensure that everything was safe at the bedside to ensure safety. The accident occurred after CNA #6 turned their back towards Resident #90. During an interview on 8/31/23 at 11:57 AM, the Director of Nursing (DNS) stated that it was an isolated incident and was Resident #90's first fall. The resident has been in the facility for almost five years. The resident was sent to the ER, and the staff was in service that they had to ensure they had all supplies before and during care. They should not turn their back to ensure that the resident is safe. The resident coughed, had a jerky movement, and fell out of bed. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey from 8/24/23 through 8/31/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 out of 2 residents reviewed for respiratory care out of 54 sampled residents (Resident #173). Specifically, Resident #173 was observed using oxygen via trach collar with no label on the tube. The findings are. The facility's policy and procedure, titled Oxygen Tubing Change, with the last revised date of 4/2023, documented that the oxygen tubing is changed by 11-7 Nurse or Respiratory Therapist every Sunday and as needed. Resident #173 was admitted with diagnoses that include Cerebral infarction, Persistent vegetative state, and Pneumonia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #173 is in a persistent vegetative state and received oxygen therapy. On 8/28/23 at 3:29 PM and 8/29/23 at 12:51 PM, Resident #173 was observed in bed with oxygen via trach collar in use. No label was noted on the tube. The Medical Doctor's Orders dated 8/15/23 documented Oxygen at 28% via tracheal collar continuously. A review of the Respiratory Therapy and Treatment Administration Records dated 8/15/23-8/30/23 had no documented evidence of when the oxygen tubing was changed. On 08/30/23 at 3:34 PM, the Respiratory Therapist (RT) was interviewed and stated that Resident #173's oxygen tubing is usually changed every Sunday and as needed, and the Respiratory Therapist is responsible to change the oxygen tubing. The RT further stated we do not date the tubing when it has been changed and there is no where to document that it was changed on the Respiratory Therapy Record either. On 8/30/23 at 3:56 PM, the Director of Respiratory Therapy (DRT) was interviewed and stated that the RT is responsible for changing the oxygen tubing on a regular basis, and they do not date tubing or document in the EMR that the tubing was changed. On 8/31/23 at 11:09 AM the Director of Nursing (DON) was interviewed and stated the Respiratory Therapists are responsible for changing the oxygen tubing and they will review their oxygen policy regarding how to communicate when oxygen tubing is changed. 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #145 was admitted with diagnoses that included Hypertension and Seizure Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. The Physician Order for Resident #145 with a start date of 4/23/23 documented Metoprolol Succinate ER (Extended Release) 25 mg, once daily. Monitor BP and Pulse. Hold for BP less than 100. Hold for Pulse less than 60. On 08/28/23 at 08:58 AM, during the Medication Administration Task it was observed that Licensed Practical Nurse (LPN) #3 did not assess Resident #145's blood pressure prior to administering Metoprolol Succinate ER (a medication to regulate blood pressure). Review of the vital signs monitoring section in the Electronic Medical Record (EMR) revealed that on 08/28/23 at 09:11 AM, LPN #3 documented a blood pressure reading of 128/70 mmHg for Resident #145. On 08/28/23 at 02:18 PM, an interview was conducted with LPN #3 who stated that the blood pressure (BP) was assessed prior to medication being given to all residents. LPN #3 also stated that they assessed and memorized Resident #145's BP prior to giving medication and then entered the BP readings after administering the medication. LPN #3 further stated that they could not recall what the BP reading was for this resident, and this was the only resident for whom BP readings were entered after medication was given. On 08/28/23 at 02:27 PM, an interview was conducted with Resident #145 who stated that BP was not assessed today as is usually done, and the LPN probably forgot. On 08/28/23 at 02:43 PM, a follow-up interview was conducted with LPN #3 who stated that Resident #145's blood pressure had not been assessed today prior to medication being given, and the BP reading entered was documented without first assessing the resident's BP. On 08/31/23 at 12:34 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that prior to administering BP medications, the nurse should check the orders, and ensure the resident's vital signs are within the parameters and then document the vital signs. RNS #1 also stated that documentation should be accurate and be placed in Sigma when the BP is assessed before the medication is administered. RNS #1 further stated that rounds are done in the morning by the Unit Coordinator to ensure compliance. RNS #1 stated that documentation should be done at the time the medication is given and should accurately reflect the readings that were obtained. On 08/31/23 at 03:55 PM, an interview was conducted with the Director of Nursing (DON) who stated that if BP medications require a parameter, the BP must be assessed prior to administration. If medication is to be held, the MD must be informed. The DON also stated that the assessment of the BP should be documented in sync with the administration, and the system will prompt staff to enter the information at the time the medication is being administered. 415.22(a)(1-4) Based on observation, record review, and interviews conducted during the Recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 2 residents (Resident #153 and # 145) Specifically, 1) the Resident CNA Documentation History Detail dated 8/28/23 documented that Resident #153 ate 100% and drank 100% liquids for breakfast and lunch while the tray was observed at the bedside untouched, and 2) the Licensed Practical Nurse (LPN) documented a blood pressure reading for Resident #145 without assessing the resident's blood pressure. The findings are: The facility's policy title, CNA Accountability Documentation, with the last revised date of April 2023, documented that CNA will sign the Accountability record after each ADL function. The charge nurse will review the accountability record to ensure the completion of CNA documentation. The CNA will report any changes in the resident's condition and ADL function to the charge nurse. 1. Resident #153 was admitted with diagnoses that include Dementia and Depression The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #153 cognition as severely impaired, never/rarely made decisions, and required limited assistance from one person for eating. On 8/28/23 at 9:17 AM, Resident #153 was observed out of the bed in a wheelchair in their room. The resident's breakfast tray was on the bedside table, untouched. On 8/28/23 at 12:45 PM, Resident #153 was out of bed in their wheelchair in their room. The resident lunch tray was on the bedside table untouched. Resident #153 lunch tray remained on the bedside table untouched at 12:57 PM, 2:22 PM, and 3:15 PM. The Resident CNA Documentation History Detail dated 8/28/23 at 7:00 AM-10:00 AM and 11::00 AM -2:00 PM documented that Resident #153 ate 100% and drank 100% liquids. During an interview on 8/29/23 at 2:33 PM, Certified Nursing Assistant #5 (CNA #5) stated that Resident #153 ate a banana and refused to eat. CNA #5 said they did not feed Resident #153 or see the resident eating. Resident #153 had only the banana and did not drink liquid. CNA #5 stated they did not know why they documented that Resident #153 ate and drank 100% liquids. CNA #5 said that they did not feed the resident during lunch. They wrote that Resident #153 ate and drank 100% liquids during lunch. CNA #5 did not see how much the resident ate and does not know why they documented 100%. During an interview on 8/29/23 at 2:54 PM, Registered Nurse #3 (RN #3) stated that they asked the CNAs how much the resident consumed. The CNA #5 was required to document in the accountability the amount that the resident consumed. They depend on the CNAs to do accurate documentation. RN #3 is unaware that CNA #5 documented 100% for Resident #153. During an interview on 8/31/23 at 8:46 AM, the Staff Educator stated that CNAs are educated during orientation on how to do documentation. The CNAs must document how much the residents eat and drink after meals. The CNAs must be with the resident to see how much they eat and then document. The charge nurse and the unit coordinator ensure that the CNAs do accurate documentation. During an interview on 8/31/23 at 11:36 AM, the Director of Nursing (DON) stated that the CNAs must document the amount of what the resident eats and drinks. They are trained to do accurate documentation. The unit clinical coordinator is responsible for ensuring that Resident #153 gets their meals and is fed, and the intake is documented accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews conducted during the Recertification survey from 8/24/23-8/31/23, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, while performing wound care for Resident #241 Registered Nurse (RN) #2 was observed not performing hand hygiene before and during wound care, failed to perform hand hygiene multiple times when changing gloves, and failed to set-up a sterile field and prepare supplies according to professional standards. The findings are: The facility policy and procedure titled Wound Management, Pressure Injury Care and Prevention that last revised May 2023 stated that it is the policy that residents with existing pressure injuries be evaluated and managed in accordance with the facility's established clinical practice guidelines. admission MDS dated [DATE] documented resident was severely cognitively impaired, required dependent assistance of two staff, was at risk for pressure ulcer and had unhealed pressure ulcers and had one Stage 4 pressure ulcer. The Nursing Decubitus Report dated 8/15/23 documented resident had a sacral Stage IV 6x8x3cm, 80% pink, 20% slough, w/undermining 12-12+2cm. Changed treatment to Santyl ointment. MD Orders dated 8/11/23 documented irrigate sacral pressure ulcer injury with NSS, then pack w/Santyl +Cal. alginate dressing, cover with combine dressing once daily and PRN. On 08/31/23 at 09:02 AM, a wound care observation was conducted for Resident #241. Registered Nurse (RN) #2 was observed entering the resident's room with treatment supplies including gauze pads, a tube of Santyl, Calcium Alginate and 3 bottles of normal saline solution (NSS) in hand which they placed on the resident's overbed table located on the right side of the resident's bed. No hand hygiene was performed, and no sterile field was set up. Resident #241 was positioned on their right side. NSS bottles were opened and the solution was poured into the irrigation set bottle. Without performing hand hygiene, RN #2 then carried the irrigation set bottle and unopened gauze packets to the back of the resident, and placed them in a dressing tray which was placed directly on the opened incontinence brief. RN #2 tore open three gauze packets and began to irrigate the wound, removing gauze pads as needed from each packet. RN #2 removed gloves and donned clean gloves without performing hand hygiene. RN #2 opened a pack of bordered gauze while holding a tube of Santyl and tongue depressor in hand. RN #2 then knocked over the NSS which pooled under the resident's feet and was not cleaned up. RN #2 opened the tongue depressor and bordered gauze, squeezed Santyl onto the tongue depressor, applied to wound, placed tongue depressor on the bed, applied bordered gauze. RN #2 attempted to place ABD pads however had no tape to secure the pad. Resident #241 then began to pass loose, watery stools. RN #2 removed the dressing tray, removed gloves, and washed hands. RN #2 then left the room. RN #2 returned with a new dressing tray, left the room again and donned and doffed gloves and collected gauze pads and NSS. RN #2 donned clean gloves, removed the dressing which was placed in a bag provided by a Certified Nursing Assistant. Resident #241 continued to ooze loose, watery stool. RN #2 changed gloves twice while assisting the CAN to clean the resident without performing hand hygiene. RN #2 then opened the NSS bottle and placed the irrigation syringe in the bottle. Gauze packets were torn open as needed and wound was irrigated. Dressing tray placed in NSS still laying on bed near resident's feet. ABD packets were torn open, gloves were removed and hands rinsed at sink with no soap applied. A tongue depressor was removed taken from the treatment cart, opened, and placed on tray next to gauze packets. RN #2 returned to the treatment cart retrieved gloves, donned gloves, applied treatment, Alginate, and gauze. Bordered gauze applied. Soap applied to hands, water turned on and hands were washed. On multiple occasions throughout the observation RN #2 was observed entering and exiting the room, retrieving items from the treatment cart and did not perform hand hygiene. On 08/31/23 at 11:54 AM, an interview was conducted with the Rehab RN/Wound Care Nurse (WCN) who stated that they had attended in-services and wound seminars prior to COVID-19, and has no special certification for providing wound care. The WCN also stated that when preparing to do wound care they check the orders, assess the wound, inform the resident that wound care will be performed, take off the dressing. The WCN stated the sequence for handwashing is as follows: wash hands before starting, put on gloves, do treatment, take off gloves, put everything in garbage and then wash hands again. The WCN also stated that handwashing was not necessary after removing gloves and a clean pair can just be put on. The WCN further stated that a sterile field is created by using the dressing tray. On 08/31/23 12:27 PM an interview with conducted with the Infection Control Preventionist (ICP)/In-service Coordinator (RN #1) who stated that handwashing should be done prior to providing care to the resident. The ICP also stated that gloves can be changed during wound care and hand hygiene is advised and can be done when gloves are removed. The ICP further stated that in preparation for wound care supplies and medications are put in the tray, and a plastic bag is placed on the side table. Change gloves after preparation. Place supplies on the table, open supplies before you get started and change gloves. Start cleaning the wound, discard the used items in the plastic bag, change gloves, and apply treatments as ordered. The ICP further stated that they do competencies and observations of nurses performing wound care periodically. On 08/31/23 03:45 PM an interview was conducted with the Director of Nursing (DON) who stated that the Wound Care Nurse will stage and assess, treatment will be reviewed. The wound care doctor comes weekly. The DON also stated that the WCN does the wound care, however all nurses can perform it. The DON further stated that Infection Control Preventionist/In-service Coordinator is responsible to ensure compliance, and the Director of Nursing will oversee. The DON stated that handwashing should be done prior and in-between glove changes and during dressing of the wound. The Aseptic Dressing Technique Observation Tool dated 4/11/12 documented that the WCN was observed by the ICP and completed 20 of 20 steps observed during the in-service which included the set-up of a sterile field and hand hygiene upon removal of gloves. 415.19(a) (1-3)

Based on observations, record review and interview conducted during the recertification survey from 8/24/23 to 8/31/23, the facility did not ensure that the results of the most recent survey report and plan of correction of the facility was posted in a place readily accessible to residents, and family members and legal representatives of residents. Specifically, the survey report was posted at an elevated level, in a locked glass case on the wall opposite the main lobby elevators. This was evident for 12 of 12 attendees of the Resident Council meeting. The findings are: The facility policy titled Accessibility of Survey Results revised April 2022 documented that a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisit reports, etc. along with state approved plans of correction of noted deficiencies, is maintained in an area frequented and accessible to residents, such as in the main lobby. On 08/25/23 at 10:38 AM, during the Resident Council meeting, residents stated that they did not know where the results of the state inspection were located. During multiple observations conducted at various times from 8/24/23 to 8/31/23, the survey report was observed placed in a plastic sleeve, positioned above shoulder height in a locked glass case on the wall opposite the main lobby elevators. On 08/31/23 at 01:26 PM, an interview was conducted with the Facility Administrator (FA) who stated that the survey results are located on the bulletin board across from the elevator. The FA stated that the facility had a number of residents who had a behavior of ripping the survey results off the wall, so the decision was made to place the results in a locked glass cabinet to prevent them being destroyed. The FA further stated they had not considered relocating the results but would place the results outside of the cabinet. On 8/31/23 at 3:00 PM, the survey results were observed placed in a plastic folder, and secured with clear plastic tape to the front glass of the bulletin making the results still inaccessible to residents. 415.3(d)(1)(v)

2. The facility policy and procedure titled Pantry/Food Storage with last effective date 4/2023 noted the following information: Food will be stored in a manner that maintains the integrity of the food and the safety of the resident. A sign posted on the refrigerator door indicated food in the fridge must be dated and can be kept for only one day On 08/24/23 at 10:02 AM, the refrigerator in the Resident Pantry was observed to contain 3 Bologna Sandwiches which, were not labeled or dated, two packages that were labeled for residents but were not dated, and one package of food that was labeled for a staff and was not dated. On 08/24/23 12:48 PM an interview was conducted with Certified Nursing Assistant (CNA) #2 who stated resident drinks, and items from the kitchen are stored in the refrigerator. CNA #2 stated their child had brought food for them today and they placed it in the pantry refrigerator because they did not want it to go bad. CNA #2 also stated that they did not know where staff food should be sure and was not sure whether there was somewhere in the basement where it could be stored. On 08/31/23 at 10:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that food should be labeled with residents name and should be discarded after two days. LPN #2 also stated that the refrigerator should only contain food for staff and staff food should not be stored there. LPN #2 further stated that things were chaotic that morning and they did not know why there were extra sandwiches in the refrigerator that did not have dates. 415.14 (h) Based on observations and interviews conducted during a Recertification survey conducted from 08/24/23 to 8/31/2023, the facility did not ensure that proper sanitation and food handling practices were conducted to prevent potential foodborne illnesses. Specifically, 1) portions of the meat slicer were washed and sanitized but replaced on the machine with ungloved hands and 2) unlabeled, undated food and staff food was observed stored in a pantry refrigerator on a resident unit (Unit 4). The findings are: 1. The facility's slicer Cleaning and Sanitizing Directions state, Remove both the knife cover, cover knob, slice deflector by unscrewing the stainless-steel knob. Wash, rinse and sanitize the knife cover knob, knife deflector and both sides of the knife. On 08/30/2023 at 11:08 AM, the slicer was observed during cleaning. The Acting Director Food and Nutrition Services (ADFN) washed their hands, donned gloves and removed the knife cover, cover knob, slice deflector and blade. They placed them in the soapy water in the sink, then cleaned the rest of the slicer. Once the rest of the slicer was cleaned and sanitized, they removed the parts, rinsed and sanitized them and left them to air dry. They then removed their gloves. When the parts were dry, they replaced them on the machine without donning new gloves. The ADFN was interviewed immediately and stated that there is no written protocol for cleaning the slicer. However, the dietary worker assigned to the task is usually instructed to double glove to replace the removeable parts because replacing the blade is hazardous and can cause injury. The ADFN also stated I removed my gloves too soon, it was a slip-up.

Based on observations and interviews during the recertification survey from 8/24/23 through 8/31/23, the facility did not ensure that garbage was disposed of properly. Specifically, the trash bin was not covered when being transported from the kitchen and the trash was placed in an uncovered and unlocked dumpster. The findings are: The facility's policy and procedure titled, Trash Disposal, last reviewed 04/2023, documents that that all trash is bagged and placed in the trash compactor located in the back parking lot and all cardboard boxes are placed in the cardboard container. On 08/30/2023 at 1:07 PM, trash removal was observed. Dietary Aide #2 washed hands, donned gloves and bagged all the kitchen scraps. However, the Dietary Aide placed the cardboard in the trash bin on top of the sealed trash bags, so that the bin was overfull and could not be covered. The Dietary Aide transported the open bin to the back parking lot, where both trash and cardboard were deposited in an uncovered, unlocked dumpster. On 08/31/2023 at 10:09 AM, the Acting Director Food and Nutrition Services (ADFN) was interviewed and stated that they were aware that food waste and cardboard should not be mixed in the bin and are usually transported separately. They were not aware that the bin needed to be transported covered and said they would educate Dietary Worker #2. The ADFN further stated that Administration was responsible for the trash removal contract and the trash receptacles. On 08/31/2023 at 11:10 AM, the Administrator was interviewed and stated they were aware of the regulations regarding trash containment; the facility usually uses a trash compactor but it is currently being repaired. It broke on 08/23/2023 and was removed for repair by the contracted company, which will return it when it is repaired. The company provided the dumpster in the interim. The Administrator stated that the trash removal company does not have any covered containers and said, We know it's not what the guidelines say but what can we do? 415.14(h)

Based on record review and interviews conducted during the Recertification survey from 8/24/23 through 8/31/23, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during the review of the Infection Control Task. Specifically, the facility's designated IP did not have documented evidence of completing specialized infection prevention and control training. The findings are. The Centers for Medicare and Medicaid Services (CMS) memo titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. Ref: QSO-19-10-NH dated 3/11/19 documented Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting. Effective 11/28/19, the final requirement includes specialized infection prevention and control training for the individual(s) responsible for the facility's IPCP. The course is approximately 19 hours long and comprises 23 modules and submodules. The facility's policy and procedure, titled, Infection Preventionist (IP) with a revised date of 4/10/23, documented that the IP is responsible for coordinating the implementation and updating of established infection and control policies and practices. The facility will designate one or more individuals as the IP who are responsible for the facility's IPCP. The IP will have professional training in nursing, medical technology, microbiology, epidemiology, or other fields. The IP must be qualified by education, training, experience, or certification. The facility's IP's certificate of training dated 6/14/23 documented that the IP has successfully completed Module 1 of the Infection Control Prevention & Control Program from the Nursing Home Infection Preventionist Training Course. During an interview on 8/28/23 at 3:47 PM, the Infection Preventionist (IP) stated they became the facility's IP on 12/2019. The IP started the ICP training in 2019 but did only 1 Module. They did not complete the training in 2019 and had to do it again. They started the training again in June 2023, took module 1, and finished it on 6/14/23. They only took 1 module and completed the rest on 8/27/23. During an interview on 8/31/23 at 12:02 PM, the Director of Nursing (DNS) stated that they were unaware that the IP must have specialized training and certification before they can be the facility's IP. The IP has been working as an IP for five years since 2019. The IP completed 15 modules of the training over the weekend. 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification Survey from 05/18/2022 to 05/26/2022, the facility did not ensure that a resident was cared for in a manner that maintained their dignity. This was evident for 1 (Resident #86) of 2 residents reviewed for Dignity. Specifically, Resident #86's Foley catheter (FC) bag and tubing were left uncovered and exposed to public view. The findings are: The facility's policy titled Catheter: Maintenance of Indwelling dated April 2022 documented a privacy bag will be utilized for all residents with urinary catheters. Resident # 86 had diagnoses urinary retention and cerebrovascular disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 86 was cognitively intact, had an indwelling catheter, and required the assistance of 2 people for bed mobility. The Physician's Order documented Resident #86 was ordered to use a FC from 5/5/2020. The Comprehensive Care Plan (CCP) related to indwelling catheter initiated 05/05/2020 documented Resident # 86 will retain a sense of dignity. On 05/18/22 at 12:27 PM and 05/18/22 03:55 PM, Resident # 86 was observed sitting in their wheelchair in their room with the FC tubing attached to the right wheelchair arm. The FC was uncovered and visible from the hallway with urine draining into the uncovered FC bag. On 05/23/22 at 10:52 AM, Resident # 86 was observed lying in the bed with the FC drainage bag hanging from the right side of the bed, uncovered and visible from the hallway. On 05/23/22 at 12:00 PM, Certified Nursing Assistant (CNA) # 1 was interviewed and stated Resident #86 had a FC privacy bag for their wheelchair and bed to promote privacy by preventing exposure of the FC. CNA #1 observed Resident #48's FC was catheter was not in a privacy bag at bedside and stated they were too busy with other tasks and forgot to place it in a privacy bag. The FC should always be in a privacy. On 05/23/22 at 12:17 PM, the Assistant Director of Nursing (ADN) was interviewed and stated the facility provides privacy bags to residents who use FCs. The CNA or nurse are responsible for placing FCs into privacy bags and the nurse checks to ensure privacy bags are in place during medication or treatment rounds. On 05/23/22 at 02:03 PM, the Director of Nursing (DON) was interviewed and stated uncovered FCs should not hang from a resident's wheelchair or be hung on the side of the bed visible from the hallway. FC privacy bags are used to provide privacy to the resident. 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 5/18/22 to 5/26/22, the facility did not ensure a resident remained free from physical restraints. This was evident for 1 (Resident #48) of 4 residents reviewed for Restraints. Specifically, Resident #48 was observed on several occasions with a wheelchair seatbelt (SB) without a Medical Doctor Order (MDO). The findings are: The facility policy titled Restraints dated May 2022 documented a SB is a restraint and alternatives to restraints must be attempted prior to the use of restraints. Resident # 48 had diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and vascular dementia with behavioral disturbance. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 48 was severely cognitively impaired, was totally dependent on two persons for bed mobility and transfers, and did not use physical restraints. On 05/18/22 at 11:26 AM, 05/19/22 at 11:20 AM, 05/20/22 at 11:00 AM, 05/20/22 at 02:07 PM, and 05/23/22 at 11:49 AM Resident # 48 was observed sitting in wheelchair with an SB strapped across their waist. The Comprehensive Care Plan (CCP) related to falls initiated 03/17/2020 documented floor mats and a low bed were interventions to prevent Resident #48 from falling. Nursing Note dated 3/2/2021 documented Resident # 48 used a SB while in the wheelchair for safety and can release the SB independently. Nursing Note dated 6/3/2021 documented Resident # 48 had a cognitive decline and was unable to release the SB. The SB was used for out-on-pass (OOP) only. The Nursing Accountability Record dated 6/3/2021 documented Certified Nursing Assistants (CNA) monitor that Resident #48 uses SB for OOP only. There was no physician order to use the SB in the medical record while Resident # 48 was in wheelchair. On 05/23/22 at 12:39 PM, CNA # 3 was interviewed and stated they transferred Resident # 48 out of bed to the wheelchair after 11 AM and locked the SB to prevent Resident #48 from falling. CNA #3 could not determine the amount of time Resident #48 spent in the wheelchair with the SB locked. The nurse gives report on resident changes to the CNAs and CNA #3 does not recall if the nurse reported a change to Resident #48's SB use. On 05/24/22 at 12:46 PM, Registered Nurse (RN) # 1 was interviewed and stated they were not aware the CNA locked the SB when Resident # 48 was transferred from bed to wheelchair. There is documentation in the Nursing Notes and Nurse Accountability Record the SB should only be locked when Resident # 48 goes OOP because Resident #48's cognition deteriorated, and they cannot release the SB. CNAs were also given verbal report re: Resident #48's SB use. On 05/24/22 at 01:57 PM, Director of Nursing (DON) was interviewed and stated prior to restraint use, alternative safety interventions are attempted, a 72-hour restraint assessment is completed, the Medical Doctor (MD) writes an MDO, the resident representative gives consent, a CCP is created, the CNA Accountability is updated, and the CNAs are verbal report by the nurse. Resident #48 does not have an MDO for wheelchair SB because Resident #48 is unable to independently release the SB. On 05/24/22 at 02:07 PM, the MD was interviewed and stated Resident #48 did not have a MDO for SB to be used as a restraint. Resident #48 is quiet and does not require a restraint. 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure assessments accurately reflected the resident's status for 2 (Resident #s 104 and 140) of 40 sampled residents. Specifically, the Minimum Data Set 3.0 (MDS) assessments did not document the use of a wander guard device for Resident #104 and Resident #140. The findings are: 1) Resident #104 had diagnoses which include, Cerebrovascular Accident (CVA), Dementia, Hemiplegia, Manic Depression. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition and was independent in performing activities of daily living. The MDS further documented in the Section P0200-Alarm that Wander/Elopement Alarm was not used. On 05/19/22 at 11:00 AM, Resident #104 was observed with a wander-guard (WG) alarm to left ankle. The Elopement Risk assessment dated [DATE] documented that the resident was Potential Risk for elopement. The elopement assessment also documented that the resident required a safety alarm device ( wander guard) A review of physician order was conducted on 05/19/22. There was no physician order for wander guard. The Director of Nursing (DON) stated that, it is the facility policy, no physician order required for resident on wander guard. The Comprehensive Care Plans related to Wandering and Elopement, created on 07/21/2020, last updated on 4/19/22 documented the following: Resident continues to wear wander guard due to persist wandering behavior. A review of the Certified Nursing Assistant (C.N.A) records dated from 05/01/25 to 05/19/22 documented observation of wander guard every shifts. On 05/24/22 at 12:36 PM, an interview conducted with the C.N.A #5 who stated that the resident had been on wander guard device for so long, although the resident had not eloped. The C.N.A also stated that all they do is to monitor the resident and document it. 2) Resident #140 had diagnoses which include Dementia, Anxiety, Depresion. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition and was independent in performing activities of daily living. The MDS further documented in the Section P0200-Alarm that Wander/Elopement Alarm was not used. On 05/19/22 at 12:10 PM, Resident #140 was observed with a wander-guard (WG) alarm to left ankle. The Elopement Risk assessment dated [DATE] documented that the resident was Potential Risk for elopement. The elopement assessment also documented that the resident required a safety alarm device ( wander guard) A review of physician order was conducted on 05/20/22. There was no physician order for wander guard. The Director of Nursing (DON) stated that, it is the facility policy, no physician order required for resident on wander guard. The Comprehensive Care Plans related to Wandering and Elopement, last updated on 4/20/22 documented the following: Resident continues to wear wander guard due to persist wandering behavior. A review of the Certified Nursing Assistant (C.N.A) records dated from 05/01/25 to 05/19/22 documented observation of wander guard every shifts. On 05/24/22 at 12:36 PM, an interview conducted with the C.N.A #4, stated that they work 5 days a week and stated that the resident is confused and never attempt to leave the unit. The C.N.A also stated that all they do is to monitor the observation of resident and document it at the end of the shift. On 05/24/22 at 12:45 PM an interview conducted with the Licensee Practical Nurse (LPN #2) who stated that the resident had been having the wander guard for a very long time, she stated that no need to have a physician order for wander guard, but the CNA must ensure documentation of it 05/24/22 1:03 PM an interview conducted with the MDS coordinator, stated that the facility does not write an order for wander guard, they stated that it is in their policy, it is a nursing implementation. she stated that they have a look back period, we look at the MD order, progress notes, any clinical changes that happen during the look back period, she stated that they also assessment the resident and interview staff if necessary. They stated that they are fully aware that the resident is on wander guard, but we thought if we coded it on the MDS, it will come up as a restraint. That is why we left it out 05/26/22 12:45 PM, an interview conducted with the Director of Nursing (DON), they stated that all residents on wander guard are not coded on the MDS because we were looking at it as a potential restraint. As of today, we have audited all the residents and all their MDS's have been modified. 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Complaint survey from 5/18/2022 to 5/26/2022, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 2 of 2 residents reviewed for Participation in Care Planning out of a sample of 40 residents (Resident # 42 and Resident # 48). The findings are: The facility policy titled Comprehensive Care Plan (CCP) with date of distribution in April 1995/July 2009/January 2022 documented under Procedure section 3. Social Service will invite family members/designated representative to participate in the meeting; 4. Resident will also be included in the meeting if resident is mentally alert and chooses to so participate; 10. Resident (if possible) and Family member/designated representative were members of the CCP Team. 1) Resident # 42 was admitted to the facility with diagnoses including Personal history of traumatic brain injury; Nontraumatic subarachnoid hemorrhage, unspecified; and Other seizures. The Quarterly Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 42 had BIMS score 13, understood others and was usually able to make self understood, and participated in the assessment. Resident # 42 was interviewed on 05/18/22 at 12:10 PM and stated they had only been invited to their care plan meeting with the interdisciplinary team (IDT) like once a year. Resident # 42 also stated they made decision for themselves. The MDS Schedule documented no care plan meeting for Resident # 42 was scheduled after quarterly MDS assessments on 3/24/2021, 6/24/2021, 9/24/2021, and 3/9/2022. There was no documented evidence that Resident # 42 or representative was invited to care plan meeting after quarterly MDS assessments on 3/24/2021, 6/24/2021, 9/24/2021, and 3/9/2022 to be involved in developing their comprehensive care plan and making decisions about their care. On 05/23/22 at 03:27 PM, Certified Nursing Assistant (CNA) # 2 was interviewed. CNA # 2 stated Resident # 42 was alert and oriented x 3, did not reject care, and made decisions for their own care. 2) Resident # 48 was admitted to the facility with diagnoses including Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Vascular dementia with behavioral disturbance, and Other specified depressive episodes. The Annual Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 48 was rarely/never understood and representative participated in the assessment. Resident # 48's representative was interviewed on 05/18/22 at 11:18 AM and stated they were invited by social worker to care plan meeting once a year only. The MDS Schedule documented there was no care plan meeting scheduled after quarterly MDS were done on 6/11/2021, 9/10/2021, and 12/9/2021. There was no documented evidence that Resident # 48's representative was invited to care plan meeting after quarterly MDS assessments on 6/11/2021, 9/10/2021, and 12/9/2021 to be involved in developing the comprehensive care plan and making decisions about care for Resident # 48. On 05/23/22 at 12:39 PM, Certified Nursing Assistant (CNA) # 3 was interviewed. CNA # 3 stated Resident # 48 was not oriented so his or her designated representative made decisions for the resident. On 05/23/22 at 02:31, the Social Worker (SW) was interviewed and stated they were responsible for inviting the resident and/or representative to the initial, annual, significant change and end of program care plan meetings, but they do not invite residents and/or representatives to quarterly care plan meetings. The SW also stated invitations are done by phone call, email, or in-person on the unit. The SW further stated they documented the invitations in Social Work notes and/or under Meeting in the Care Plan. SW stated they did not know the reason residents and/or representative were not invited to quarterly care plan meeting and had to ask Director of Social Services. On 05/23/22 at 02:51 PM, Director of Social Services (DSS) was interviewed and stated the SW was responsible to invite resident and/or representative to initial, annual, significant change, end of program, and as needed care plan meeting but not to quarterly ones. DSS also stated the SW had to document the invitation in the Social Work note or in the Social Work - Annual Evaluation assessment. DSS stated it was the policy of the facility not to invite the resident and/or representative to quarterly care plan meetings. DSS also stated the staff updated the care plan and did not meet for the quarterly care plan meeting if there was no issue to discuss for the resident. 415.11(c)(2)(i-iii) Resident #42 Care Plan Based on record review and interviews conducted during the Recertification/Complaint survey from 5/18/2022 to 5/26/2022, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. 05/18/22 12:10 PM Resident # 42 stated she was not invited any care plan meeting since her admission to the facility on 1/23/2020. Resident # 42 stated she made decision herself. There was no documented evidence that Resident # 42 or representative was invited to any care plan meeting after 2/6/2020 in social worker notes. 05/20/22 11:03 AM Resident # 42 was observed playing game with other residents in the dining room. 05/23/22 10:34 AM Resident # 42 was observed sitting in the wheelchair in the room. 05/24/22 10:16 AM Resident # 42 was observed sitting in the wheelchair in the room packing the clothes. MDS The Quarterly MDS dated [DATE] documented had BIMS score 13, did not reject care, was usually able to make self understood and to understand others. Required limited to extensive assistance with 1 person for ADLs. It also documented Resident # 42 but not representative participated in the assessment. Dx: Personal history of traumatic brain injury; 1/23/2020 Nontraumatic subarachnoid hemorrhage, unspecified; 1/23/2020 Other epilepsy, not intractable, with status epilepticus; 1/23/2020 CCP Care plan related to Language Barrier initiated 01/31/2020 and last updated 3/25/2022 documented the goal was Resident will identify needs through family, staff, interpreter x 3 months with review date 06/23/2022. The interventions included Provide interpreter PRN, Try various methods of communication to establish means of anticipating needs, and Identify staff that speak the language and assign them to the resident. MDS assessment were done on the dates below: Annual - 1/20/2021 Quarterly - 3/24/2021 Quarterly - 6/24/2021 Quarterly - 9/24/2021 Annual - 12/23/2021 Quarterly - 3/9/2022 The MDS Schedule documented Resident # 42 care plan meetings were scheduled on 2/2/2021 and 1/5/2022 after the annual MDS assessments on 1/20/2021 and 12/23/2021 respectively. The MDS scheduled documented no care plan meeting was scheduled after quarterly MDS assessments on 3/24/2021, 6/24/2021, 9/24/2021, and 3/9/2022. The Social Work - Annual Evaluation dated 1/20/2021 documented representative was invited to the care plan meeting. The Social Work - Annual Evaluation dated 12/17/2021 documented representative was invited but declines to attend care plan meeting. The End of Program care plan meeting dated 1/13/2021 documented representative attended the meeting. The Annual care plan meeting dated 1/26/2021 documented representative attended the meeting. The Annual care plan meeting dated 12/27/2021 did not document representative attend the meeting. The Social Work note dated 1/13/2021 documented there was an end of program meeting held today via Zoom with Resident # 42 and representative. All Social Work notes dated after 1/13/2021 to the last SW note dated 3/10/2022 were reviewed. There was no documented evidence Resident # 42 and/or representative was invited to the care plan meetings on 3/24/2021, 6/24/2021, 9/24/2021, and 3/9/2022. 05/23/22 03:27 PM [NAME] CNA CNA stated Resident # 42 was alert and oriented with limited English, able to make needs known, did not reject care. CNA also stated Resident # 42 made decision for themselves. 05/23/22 02:31 PM [NAME] O'Shea Social Worker SW stated the social worker was responsible to invite resident and/or representative to the initial, annual, significant change and unit transfer from Unit 2 (TBI) to other units for care plan meeting but not quarterly care plan meeting. SW stated they called or emailed representative or invited them by face to face on the unit for the care plan meeting. SW stated the invitation was documented in Social Work note and/or under Meeting in the the Care Plan. SW stated they did not invited resident and/or representative to quarterly care plan meeting and they did not know the reason. 05/23/22 02:51 PM [NAME] E. [NAME], Director of Social Services DSW stated the SW invited resident and/or representative to initial, annual, significant change, end of program (like from TBI unit to other ) and as needed but not to quarterly care plan meeting. DSW also stated the Social Worker had to document the invitation in the Social Work note or in the Social Work - Annual Evaluation. DSW stated it was the policy of the facility not to invite the resident and/or representative to quarterly care plan meeting. DSW also stated the staff updated the care plan and did not meet for the quarterly care plan meeting if there was no issue to discuss.

Based on observation, record review, and interview conducted during the Recertification Survey from 5/18/2022 to 5/26/2022, the facility did not ensure all drugs and biologicals are used and labeled in accordance with professional standards. This was evident for 1 (Unit 5) of 12 units observed for Medication Storage. Specifically, five expired medications were observed in the medication room and medication cart. The findings are: The facility policy titled Medication Storage dated 10/2021 documented the following: The facility will store medications in a manner that maintains the integrity of the product, ensure the safety of the residents, and in accordance with Department of Health guidelines. On 05/18/22 at 11:21 AM, the following expired medications were observed on unit 5 medication room: 1) One bottle of Simethicone 80mg with the manufacturer expiration date of 04/2022; 2) one bottle of Melatonin 1mg with the manufacturer expiration date of 03/2022; and 3) three bottles of Oyster calcium 500mg with the manufacturer expiration date of 12/2021. The License Practical Nurse (LPN #1) was present at the time of this observation. On 05/18/22 at 11:30 AM, the LPN #2 was interviewed and stated that the medications should be checked every shift by all nurses who worked on the unit, and expired medication should be discarded. LPN #2 did not check for the expired medication recently because they expected the medication nurses to check. On 05/26/22 at 11:28 AM, the Director of Nursing was interviewed and stated the nurses are responsible for checking for expired medication during their shift. Expired medication should be removed and decarded immediately. The DON could not explain expired medications being found in the medication room on Unit 5. 415.18(e) (1-4)

Based on observation and interview during the recertification survey, the facility did not ensure that expired medications were removed from use. Specifically, the medication storage refrigerator was observed with expired flu vaccine. This was evident for one of three Medication rooms checked for the Medication Storage and Labeling facility task (4th floor). The finding is: On 09/25/19 at approximately 11:59 AM, the medication room was checked with the Licensed Practical Nurse (LPN #1). The medication refrigerator contained 2 doses of Afluria Influenza vaccine with an expiration date of June 30, 2019. LPN#1 was immediately interviewed and stated that she did not check the refrigerator yet. She is trained to check medications in the refrigerator daily to ensure there is nothing expired. She continued to state that she would dispose of any expired medications properly. The outdated medication was disposed of by LPN#1. On 9/29/19 the facility's Policy and Procedure on medication Storage and Handling was requested from RN #4, but it was not provided to this State Agent. 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #187 was admitted to the facility on [DATE] with diagnoses that included Dementia, Alzheimer's Disease and Depression. The Annual Minimum Data Set 3.0 (MDS) dated [DATE] and Quarterly MDS assessment dated [DATE] documented the resident had severely impaired cognition. Both MDS assessments documented use of a trunk restraint used in chair or out of bed. The following observation was made on 09/27/19 at 04:15 PM. The charge nurse removed a lap tray from a resident's room and carried it into the dining room. State staff entered the dining room and observed Resident #187 with the lap tray. On 09/27/19 at 04:25 PM, the Rehabilitation nurse removed the lap tray attached to the wheelchair then asked Resident #187 to release the seat belt and she did. Resident#187 did not attempt to stand. The most recent 72 Hour Restraint Assessment conducted on 8/6/18-8/8/18 in an attempt to discontinue full lap tray. The documented restraint order was full lap tray while OOB (out of bed) to w/c (wheelchair) released a 2 hrs (hours) while in w/c. Special instruction was to pls (please) note if resident will attempt to get out of w/c or slide out of w/c. The documented results were that the resident made no attempts to get out or slide out of the w/c including when the lap tray was removed. The Restraint Information Form dated 9/7/18 documented laptray to be placed from 3-11pm shift due to re. tendency of attempting to get out of her wheelchair unattended. Laptray to minimize risk for fall and increase safety. The Restraints Rehab progress notes dated 09/7/18 documented the resident should use the Full lap tray when OOB to w/c during 3-11 shifts secondary to Hx of fall and a tendency to get out of w/c repeatedly on 3-11 shift with restlessness/agitation during that time (sundown syndrome). The resident was previously using the full tray at all hours. Res remain awake; alert oriented x 1, able to make some needs known. The Restraints Rehab progress notes, written by the Occupational therapist (OT), dated 9/7/18 documented the resident should utilize a Full lap tray when OOB to w/c during 3-11 shifts secondary to Hx of fall and tendency to get out of the w/c, especially 3-11 shifts, with restlessness with agitation during this time. The resident utilized a self-release buckle seat belt secondary to dx Dementia. The resident previously used the full tray at all times. OT will follow-up with the resident. In the resident care notes, the Rehab nurse documented on 3/26/19 the resident is on a 72 hour w/c assessment with no attempts to get out of w/c. The Resident Care Note dated 3/28/19 documented the resident was observed with no sliding noted, good position, and good trunk control The Rehab notes dated 6/1/19 and 9/6/19 documented the Resident continued to use a full lap tray when OOB to w/c during the 3-11 shift secondary to a dx of vascular dementia with a tendency to get out of w/c without assist and Roam around/or wheel self around the unit specially at 3-11 shift. There were no alternative measures and the resident had behavior problems. Staff will monitor and follow-up. The Rehab notes dated 12/3/18, 3/1/19, 6/1/19, and 9/6/19 reflect the previous documentation from 9/7/18. The Physician's Order form signed 9/12/19 documented full lap trap tray when out of bed to wc during 3-11 only due to sundown syndrome and for OF Dementia hx of falls - release every 2 hours x 15 mins. The Comprehensive care plan dated 6/18/19 documented physical restraints secondary to dx of dementia, hx falls, tendency to get out of w/c assist, restlessness/agitation during 3-11 shifts (sundown syndrome). The care plan goals included the resident will achieve proper body position, be restraint-free free and be free from side effects of physical restraint x 3 months. The interventions documented full lap tray restraint when OTB (out of bed) (3-11 shift) and release Q (every) 2H (hours) x 15 min. Monitor resident for tolerance, changes in behavior. Complete 72-Hour assessment in 3 months for restraint reduction if not accomplished sooner. The Certified Nursing Assistant Accountability Record for September 2019 section Restraints: release every 2 hrs x 15 min. Full lap tray in w/c secondary to stand up from w/c without assist h/o falls for safety measures (3-11 only). The record required the Certified Nursing Assistant's (CNA) initial during the shift on the day the lap tray was used. Eight days in September 2019, the record did not contain an initial of a CNA on September 4, 7-8, 13, 18, 21, 24-25, and 30. There was no documented evidence that restraint assessments included monitoring while the lap tray was not in use in the evening to see if the restraint was still necessary. There was no documentation regarding the resident attempting to stand unassisted in the evening. On 09/27/19 at 04:54 PM, an interview was conducted with CNA #1 who has worked with Resident #187 for 1.5 years. CNA #1 stated that she is a aware that the resident is supposed to have the lap tray on during the 3pm-11pm shift and signs the CNA Accountability record when the lap tray is placed on the resident. CNA #1 stated the resident does not attempt to stand up or get out of the chair. CNA #1 stated if the resident attempted to stand or get up, the nurse would be informed. On 09/30/19 at 11:35 AM, an interview was conducted with the Rehab Nurse. The Nurse stated the assessment for physical restraints is conducted every 3 months. The Rehab Nurse stated during Quarterly assessments, the resident is observed, assessed for any changes with behavior, positioning and sitting in the w/c for one day totaling 10-15 minutes. The Rehab Nurse also stated she is on the unit everyday observing the resident's behaviors. The RN stated the 72-Hour Restraint Assessment is completed before a restraint is applied (the initial assessment) and when there are improvements and changes in behavior. The Rehab Nurse stated 6/1/19 and 9/6/19 quarterly assessments were completed by asking the staff if there were any changes in the resident's behavior during the 3-11 shift. The Rehab Nurse stated if there is no change in behavior and the resident is still attempting to stand up while in the wheel chair, the full lap trap tray is continued as ordered. The Rehab Nurse stated behaviors are documented in the nursing notes. The Rehab Nurse stated she does not review the chart to obtain documentation of the resident's attempts to stand up from the wheelchair. The Rehab Nurse also stated the resident cannot remove the lap tray. On 09/30/19 at 03:46 PM, a follow-up interview was conducted with the Rehab Nurse who stated the resident is not assessed with lap tray off. On 09/30/19 at 12:37 PM, an interview was conducted with the Occupational Therapist (OT) who stated nursing observe residents' behaviors such as leaning forward and attempting to stand up repeatedly. The OT stated nursing conducts a 72-hour initial restraint assessment to observe the resident's behaviors and communicates the results to the OT department. The OT stated all communication is verbal and based on the rehab nurse. The OT stated she provides the laptray, but she does not decide if the resident requires the lap tray. On 10/01/19 at 10:48 AM, an interview was conducted with the (Medical Doctor) MD. The MD stated the resident has deteriorating Dementia, decreased mobilization and multiple falls in the past. The MD stated he believes that during the 3-11pm shift, Resident #187 has a tendency to stand up without any warning and can fall and injure herself. MD stated he felt that the lap tray is the best way to prevent the resident from falling. The MD stated all the other causes for falls were ruled out including infection, being placed in a room now closer to the nursing station, providing Physical therapy (PT) and OT. The MD stated the whole team, including OT and nursing, concludes the lap tray is the best method for preventing falls. 415.4(a)(2-7) Based on observations, record review, and interview during the Recertification survey, the facility did not ensure that when the use of restraints is indicated, the faciltiy used the least restrictive alternative for the least amount of time and documented ongoing re-evaluation of the need for restraints. Specifically, (1) a resident's hand mitten was not removed per physician's orders (Resident #81); and (2) residents with handmittens (Residents #81 and #186) and a resident with a lap buddy (Resident #187) did not recieve ongoing re-evaluation of the need for restraints. This was evident for 3 of 7 residents reviewed for Restraints (Residents #81, #186 and #187). The findings are: The facility's, Policy and Procedure: Restraint Assessment Form, dated 10/2018 documented that It is the policy of the facility to assess and re-evaluate residents' restraint need utilizing the, 72-Hour Restraint Assessment Form. The Rehabilitation (Rehab) Nurse will initiate the 72 Hour Restraint Assessment Form upon determination that a resident requires a restraint. The Rehab Nurse will also Initiate the 72-Hour Restraint Assessment when the Comprehensive Care Plan (CCP) team determines that a resident's restraint will be reduced or discontinued. The Rehab Nurse will then review the 72 - Hour Restraint Assessment and make recommendations to CCP team for continuation or reduction. The Rehab Nurse should document findings and recommendations in the Rehab Nursing Notes. 1) Resident #81 was initially admitted on [DATE], with diagnoses which include Cerebral Vascular Accident (CVA), Aphasia, Tracheostomy status and Gastrostomy status (G-Tube). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was re-admitted [DATE]. The resident had severely impaired cognition with short/long term memory problems and fluctuating inattention. No behaviors were identified. The resident required total care from staff for activities of daily living (ADLs). The resident had Range of Motion (ROM) impairment on one side of her upper extremity and both sides of the lower extremities. The MDS further documented the resident had limb restraints used daily in bed and chair. On 09/25/19 at 1:50 PM, the resident was observed with a right hand mitten. The resident was awake, alert, with a trache collar and her left hand was in a splint. The resident swayed her right hand back and forth, repeatedly. On 09/26/19 from 8:33 AM to 12:00 PM, the resident was observed wearing a right (R) hand mitten throughout the morning while in her room, hallway, and dining room. During the observations the resident was quiet, calm, and still. The resident occasionally slowly swayed her right hand back and forth. The resident made no attempts to touch her neck or face area, and her hands remained down by her waistline and at her side. The hand mitten was not removed during the time of the observation. On 09/30/19 from 11:40 AM to 12:08 PM the resident was observed. The resident was in bed, awake, with her eyes wide open. Her assigned Certified Nurse Aide (CNA #2) was completing the morning care for the resident. The resident was dressed, with a mitten on her right hand. The resident was quiet and still. The left hand was free. The CNA removed the hand mitten at the request of the SA prior to the hoyer lift transfer. The right hand was in a closed position. A second CNA entered the room to assist during with the transfer. The mitten remained off during this task. The resident was observed swaying her right hand slowly form side to side. No attempts to raise her hand to touch her face or neck area or hit the side of the bed. A Rehab Nurses Note dated 10/17/17 documented the resident was provided with a R hand mitten to be worn all times with release Q (every) 2 Hrs (hours) for 15 minutes to prevent her from pulling out her trach and G-tube. The note further documented that no circulatory impairment was noted, and a 72-Hour restraint assessment was initiated. The 72 - Hour Restraint assessment dated [DATE] (initial) documented the resident was assessed for a restraint due to attempts to pull out her trache and G- tube. A right hand mitten at all times with release Q (every) 2 Hrs (hours) for 15 minutes was ordered to prevent the resident from pulling out her trach and G-tube. The assessment documented a special instruction for staff to observe the resident for circulatory impairment while wearing the mitten. The resident was assessed from 10/16/17 to 10/18/17 and notes were written each shift during the assessment period. All notes documented by the nurses indicated that the resident had a R hand mitten worn at all timnes secondary to a tendency to pull out her trach and G-tube. all nurses documented there was no circulatory impairment, and they would continue to monitor the resident. The Comprehensive Care Plan (CCP) for Physical Restraint, dated 11/15/18 documented right hand mitten, restraint secondary to CVA, Dementia, Aphasia presenting with decrease cognition, decrease judgement,decrease safety awareness. Interventions included: right hand mitten at all times and release every 2 hours for 15 minutes, complete 72 hour assessment for restraint reduction . The Resident Care Note dated 06/29/19 timed at 3:10 PM documented the resident had a dislodged trache tube and was transferred to the hospital. There is no documented evidence to support that the restraint was off when the trache was observed dislodged. The Physician's Order dated 09/30/19 documented: right hand mitten at all times due to tendency to pull out trache and G-tube - Release every 2 hours and as needed for 15 minutes. The Certified Nursing Assistant Accountability Record for September, 2019 documented, Restraints, release every 2 hours for 15 minutes. This form documented daily shifts and staff initials. The Restraint Rehab. Progress Notes from 10/17/2017 - 07/29/2019 documented the initiation of the hand mitten on 10/17/17. The quarterly restraint assessment notes written by Nursing and Occupational Therapy (OT) documented the resident is still noted with a tendency to pull the trach and G-Tube and they will continue to monitor. There was no documented evidence that the quarterly restraint assessments included trials of releasing the hand mitten and behavior monitoring during those trials to see if the hand mitten was still needed at all times. There was no documented evidence that the resident had her hand mitten released every 2 hours per physician's orders. The Physician Progress Notes from 01/21/19 to 09/30/19 contained no documentation regarding whether the resident's tendency to pull out her trache and G- tube is still being observed. There was no documented evidence that the resident flails her arms or that she hits herself. An attempt to interview the day shift ( 7:00 am - 3:00 PM) CNA assigned to the resident on 09/26/19 was unsuccessful, as she was unavailable. On 9/30/19 at 12:08 PM the Certified Nursing Assistant (CNA #2) was interviewed. The CNA stated that the mitten is usually on when she starts her shift at 7:00 AM. The CNA stated that she performs range of motion during AM care. She stated that she removed the mitten this morning in order to clean the resident's hand. She stated that the resident tries to pull at her G-tube and hits the side of her bed. She further stated that the resident fights when being transferred from bed to chair with the hoyer lift. The CNA stated that she was surprised that the resident made no movements to tug at her G-tube or pull at herself or hit the side of the bed. Both hands remained at the side of her waist. After the transfer was completed, the CNA placed the mitten on the residents' right hand and a splint on the left hand. The CNA stated that she just returned from vacation and was back at work on Saturday 09/28/19. She stated that the mittens should be removed every 2 hours for 15 minutes and then placed back on. When asked how she recalls the times for releasing the mitten, she stated that she just does. The Licensed Practical Nurse (LPN #2) was interviewed on 09/30/19 at 12:45 PM. She stated that the resident is mostly calm with no agitative behaviors. On 10/01/19 at 08:54 AM, the Registered Nurse Unit Manager (RNUM) # 6 was interviewed. The RNUM stated that restraints are devices that prevent freedom of movement. She stated that the resident has a tendency to touch her trache and her G- tube. She stated that she is the person responsible for providing ongoing quarterly restraint assessments. She stated that she initiates the 72 - Hour Restraint Quarterly Assessment form, when a resident is at risk for dislodging a feeding tubing or trache. In order to determine whether to continue the use of a restraint, she gathers information from staff such as the nurses and CNAs. These assessments are done quarterly, and when there is a change in behavior to discontinue the restraint. She stated that the resident has a tendency to touch her trache, and and her G- tube. She further stated in July 2019 the resident pulled out her trache. When asked if the resident was wearing a mitten at the time of the incident, she stated that she did not know. When asked if she assessed the resident herself while the restraint is off, she answered, no. The Occupational Therapist was interviewed on 10/01/19 at 9:10 AM. She stated that she has to conduct quarterly restraint assessments. She stated that she collects her information from the unit nurse and the CNA about the resident's behavior that would support the use of a restraint. She stated that she does not assess the resident herself when the restraints are off. She stated she mostly goes with what the RNUM reports when determining whether to continue the use of the restraint. 2.) Resident #186 was initially admitted on [DATE], with a re-entry admission date of 07/12/2018. The resident had diagnoses which include: Non-Alzheimer's Dementia, Seizure Disorder, status post Gastronomy tube, Restlessness, and agitation. The Annual Minimum Data Set (MDS) assessment dated [DATE] documente the resident had severely impaired cognition and no speech. The resident required total care for Activities of Daily Living (ADLs). The resident displayed continuous inattention and disorganized thinking. The resident had range of motion (ROM) impairment on one side of the upper extremity and both sides of the lower extremities. The MDS further documented restraints were used daily on limbs in or out of bed and in the chair. On 09/30/19 at 10:00 AM, the resident was observed in bed wearing a left hand mitten, which was strapped to her left wrist. Her right hand was free. The resident raised her right hand above her head and lowered it back down below her waistline. The upper sides of the bed had bolster padding on each side. The resident was observed with an abdominal binder in place. The left hand remained at her side. On 09/30/19 at 10:31 AM, the resident was observed in the dining room area without the use of the mitten. She was observed raising her left hand up and down above her head area. The right hand was clenched at her side, and she made repetitive movements up and down onto her lap. On 09/30/19 at 11:24 AM, the resident was observed in the dining room area with the left hand mitten on. The resident moved her right hand to her head area and then rested it on her abdominal area. The left hand resting on the left side of her head. On 09/30/19 at 11:36 AM, the resident was observed in the day room with the left hand mitten in place. The left hand was resting on the side of her head. There were no gross hand movements. On 10/01/19 at 07:53 AM, the resident was observed while in bed, awake and alert. No hand mitten in place at this time. The resident was hugging the left siderail with both hands. She appeared calm, and there were no thrashing movements observed. On 10/01/19 at 08:42 AM, the resident was observed being fed, while in her room, with a left hand mitten in place. The Restraint Information Form, dated 08/28/2014, documented a request for a left hand mitten and family consent due to a tendency to hit herself. The 72-Hour Restraint assessment dated [DATE] documented: Reason for Restraint: due to hitting herself on her face. There was no documented evidence of the resident attempting to pull her G-tube out. The Physician's Order dated 09/06/19 documented, Left hand mitten at all times - release every 2 hours for 15 minutes due to tendency to pull out G-tube. The CCP for Restraints, dated 09/16/19 documented the resident required a physical restraint due to behavioral disturbance and displayed the behaivors of hitting her own face or pulling out the G-tube. The interventions included: Left hand mitten at all times and release every 2 hours; Complete 72-Hour Assessment for restraint reduction. The Behavior notes dated from 09/03/19 to 09/24/19 documented behaviors of hitting, combative during care, and screaming. There was no documented evidence that the resident was pulling at her G-tube. The Rehab Progress Notes dated 02/01/19 to 08/01/19 documented the resident had a tendency to repeatedly pull out her G-tube, decreased cognition, decreased safety awareness and decreased in judgement. There was no documented evidence that the hand mitten was assessed and re-evaluated when the mitten was off during the quarterly restraint assessments. The Resident Progress Notes from 02/09/19 to 07/12/19 were reviewed. A progress note documented on 03/11/19 that the G-tube was dislodged, and the resident was transferred to the hospital. There was no documentation regarding the status of the resident's hand mitten at the time of the incident. There was no documented evidence the resident received ongoing monitoring during times when the hand mitten was removed to determine whether it was still needed. The Physician's Progress Notes dated 05/17/19 to 09/13/19 documented the resident used a left hand mitten at all times. There was no documentation of what behaviors the resident was currently exhibiting that were being treated by the use of the hand mitten. The assigned CNA was interviewed on 09/30/19 at 10:09 AM. The CNA stated that the resident has a tendency to pull out her G-tube. The CNA stated, that the resident can do this even with an abdominal binder in place, and the mitten is removed every 2 hours for 15 minutes. She further stated that she remembers the release time by using her phone. On 09/30/19 at 10:35 AM, the RNUM #2 was interviewed. she stated that the resident has tendencies to hit herself and pull out the G tube. The padding on her bed is used as a protective device to prevent her from hurting herself. There are quarterly assessments and re-assessments completed by the Rehab and Occupational (OT) staff for the ongoing use of the restraints. The RNUM # 2 stated that she monitors her staff and observes the residents to see if they are clean and taken care of. She reminds her staff about removing the restraints as per the physician order. She stated she does not document the resident's behavior when the restraint is off. On 09/30/19 at 10:45 AM, the Rehab Nurse #1 was interviewed. She stated that a restraint is any device that prohibits freedom of movement. The Rehab Department together with the OT writes quarterly assessment notes. They monitor the ongoing need for restraints by consulting with the nursing staff on any changes in behavior and further need for restraints. She documents what the nurses report to her regarding the behavior of the resident. A 72- Hour Restraint Assessment form is implemented before restraints are ordered. The behavior of Resident #186 has not changed, and she continues to have a tendency to pull out her G- tube and hit her face. When the staff notifies her of the need for a restraint for a resident, she begins a 72-Hour Assessment. This form is used to assess, determine and evaluate the need for a restraint. All three nursing shifts must document the behaviors displayed to support the need for a restraint on the 72-Hour Restraint Assessment form. Afterwards, she reviews the form. She stated she notifies the doctor, social worker, OT, and the family of the initial need for a restraint. She stated she documents the Quarterly restriant assessment notes also. When conducting the Quarterly Restraint assessments, she collects information from the nurse and CNA about the resident. She stated she has not made assessments of the resident when the mitten is off. She understands that such observatins are a very important part of the assessment. The Rehab Nurse #1 further stated she relies on the floor staff for information and that is what she documents. On 10/01/19 at 08:23 AM, the OT #1 was interviewed. She stated that the Rehab Nurse informs her of any resident who may be exhibiting a behavior problem that may warrant the use of a restraint. After the 72-Hour Assessment for Restraints is completed by the three nursing shifts, she completes Quarterly assessments to assess for ongoing need of the restraint. In order to complete her quarterly assessments, she visualizes the resident and asks the nursing staff about the ongoing need for the restraint. The OT stated she makes her determination for the ongoing need of the restraint from the Rehab Nurse's quarterly assessment. The OT stated she does not make it a practice to come see the resident when her restraint has been removed in order to make an assessment. The primary physician was interviewed on 10/01/19 at 09:20 AM. The Physician stated that he does not, as a practice, document resident behaviors. He gets a report from the unit nurse about a resident's behavior and their assessment for a need for the restraint. The doctor stated because the residents displayed these behaviors which have been brought to him, he trusts what they say and simply writes the orders. Resident #81 flails her arm, hits herself, and pulled out her trache, and Resident #186 pulled out her G -tube. He stated that he has not seen the residents during his monthly visits without the restraints but does see Resident #186 flailing her arms. The doctor stated that these are the medical symptoms for which he has identified to justify the use restraints. On 10/01/19 at 10:20 AM, the Director of Nursing (DON) was interviewed. The DON stated that a restraint is a device that prevents freedom of movement. The nurse staff make observations of residents. If they see that a resident is making multiple attempts to touch or pull out the trache, a team comes together to determine the need for a restraint. The DON stated she makes daily rounds to see if there are any residents with restraints placed on improperly. She also observes for behaviors and or listens to concerns that might warrant a restraint or behaviors that may warrant an evaluation for discontinuing a restraint. The facility conducts audits on restraints and monitors restraints on a quarterly basis. She stated they use restraints judiciously and only if needed. She stated they have had restraints that have been discontinued.

Based on observations and interviews of staff, the the facility did not ensure that professional standards for food service safety, sanitary conditions and the prevention of foodborne illness were followed. Specifically, a dietary aide did not wash his hands upon return to the kitchen after disposing of trash to the compactors. The was evident in the Kitchen during the Kitchen Observation facility task. The finding is: The facility's policy for Handwashing dated 2017 documented 'staff will wash hands frequently as needed throughout the day following proper hand washing procedures. When to wash hands: After handling soiled equipment or utensils and after engaing in other activites that contaminate hands. On 09/27/19 at 10:11 AM, during an observation of garbage disposal one of the Dietary Aides (DA) did not wear gloves during the transport and disposal of the trash. The DA did not wash his hands immediately upon return to the kitchen after disposing of the garbage. Upon return to the kitchen, the DA held and used the power hose located near the automated dishwasher to add water to the four trash bins. The power hose is also used by staff during the dishwashing process. The DA then walked to the laundry room and touched the door with his hand multiple times to empty the water out each trash bin. While in the laundry room, the DA opened a pipe twice and rubbed his hands together under running water. The DA placed trash bags into each trash bin and returned the bins to the kitchen. The DA walked to handwashing sink and washed his hands with soap. After the observation the DA was interviewed. The DA stated his job duties include stacking inventory and disposing of trash on Saturdays. The DA stated he completes scrapping of food into the trash bin, ties up the garbage, puts it in the dumpster, rinses out garbage with the hose next to the automatic machine then place plastics into the trash bins. The DA stated he ran water on his hands because the plastic bags were sticky. The DA stated he sometimes wears gloves when the garbage bag is busted. The DA stated he washed his hands. During the follow-up interview on 10/01/19 at 12:49 PM, the DA stated he washed hands at the end; after replacing the plastic bags into the garbage and returning the trash bins to dish room and kitchen. On 09/27/19 at 10:51am an interview was conducted the FSD (Food Service Director) who stated the training is done monthly hygiene was done last month and the DA was in attendance. FSD stated while throwing out trash make sure the lid on or covered, after the trash placed in the compactors make sure it is closed properly and press the button. FSD stated gloves are worn while preparing and closing the trash then removed during transport. FSD stated gloves are worn while using the hose to rinse out the trash bins. FSD stated when staff returns to the kitchen they must wash their hands. During the follow-up interview on 10/01/19 12:54 PM, the FSD stated once the staff exits the elevator from throwing out the garbage, the staff should wash their hands.