**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews conducted during the Recertification survey from 03/09/23 to 03/16/23, the facility did not ensure each resident remained free from physical restraints. This was evident for 2 out of 6 residents reviewed for Physical restraints out of a sample of 35 residents. (Resident #54 and #141). Specifically, Resident #141 had a lap tray restraint in use without a medical justification, assessment, evidence of less restrictive alternatives tried, and ongoing evaluation for continued use. Resident #54 had a lap tray restraint in use without a medical justification, assessment, care plan, evidence of less restrictive alternatives tried, and ongoing re-evaluation for continued use. The findings are: The facility policy titled Restraints Reduction/Elimination dated 01/2023 documented a physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the Resident's body that the Resident cannot remove easily and restricts freedom of movement or normal access to the Resident. The clinical team will team will consider various alternatives prior to the use of restraint. The policy also documented that the rehab and the nursing will complete restraint assessment and follow up the physician and the Interdisciplinary team. Then the social worker will complete a restraint consent form and and notify the family member. Upon request, the facility provided a list of residents currently in use of lap trays. The list consists of a total of 16 residents. 1) Resident #141 had diagnoses which include Dementia, Cerebrovascular Accident (CVA), Parkinson's Disease, and Seizure Disorder, Traumatic Brain Injury (TBI) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired . The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS also documented trunk restraints were not used. The Physician's order initiated 11/15/2022, last renewed on 03/01/23, documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. On 03/13/23 at 09:55 AM, Resident #141 was observed in their room, sitting in a wheelchair (w/c) with a lap tray in place. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. Resident #141 was confused, not interview able, and unable to follow simple directions. The resident could not remove the lap tray when asked to do so. The Certified Nurse Aide (CNA) #1 was present during the observation. On 03/15/23 at 11:30 AM, Resident #141 was observed in the day room attending recreational activities with other residents. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. A nursing rehab note dated 11/15/22 (hard copy paper documentation), documented Resident #141 was seen by the Occupational Therapist (OT) on 11/15/22 and was provided with lap tray while OOB to standard wheelchair to facilitate midline positioning. The resident was monitored and able to tolerate the use of the lap tray as a therapeutic device and not as a restraint. The resident's family member consented to the use of the lap tray, and a physician's order was obtained. The health care team agreed to the lap tray use as a positioning device. Resident #141 would benefit from using the lap tray to facilitate midline positioning with release every 2 hours for 15 minutes and as needed (PRN) for Activity of Daily Livings (ADLs) care and skin checks. The restraint consent form dated 11/15/2022 documented that in order to prevent potential injuries, every effort was made to use alternative methods to provide a safe environment for the resident. Since alternatives were unsuccessful, it was determined a physical restraint was necessary. A lap tray was provided to facilitate midline positioning and was not being used as a restraint. The consent form was completed by the social worker and documented a verbal consent was given by a family member. The Comprehensive Care Plan (CCP) for Physical Restraint Secondary to a diagnosis of Traumatic Brain Injury (TBI) initiated 11/15/2022, revised 2/10/23 documented interventions to increase judgement and safety awareness, Rehab screen for restraint reduction if condition improved, and provide resident with change in position Q (every) 2 hours by toileting, ambulation and/or ROM (Range of Motion) exercise. The CNA Accountability Records (CNAARs) from 1/1/23 to 3/13/23 contained no documentation that the lap tray was released every 2 hours for 15 minutes. There was no documented evidence in the medical record that Resident #141 was assessed for use of a physical restraint (lap tray). There was no medical justification documented with the medical symptoms the lap tray was used to treat. There was no documented evidence of less restrictive alternatives tried, monitoring of the tray, and ongoing re-evaluation for the continued use of the lap tray. During an interview on 03/13/23 at 10:23 AM, the Occupational Therapist (OT) stated Resident #141 was currently receiving rehab after having a seizure. The resident has poor awareness, and the lap tray is needed for positioning and because the resident was attempting to get up. The OT stated an assessment was not conducted for the lap tray because Resident #141 continued to receive rehab and an assessment is always conducted for this resident. The OT stated that once they inform the rehab nurse that the resident required a lap tray, they will initiate an order and then the rehab nurse would follow up. They stated that they rehab nurse wrote a note on resident #141 on 3/15/22 and then they signed off on it. During an interview on 03/13/23 at 02:11 PM, CNA #2, the assigned CNA for over 3 months, stated the resident is confused and does not have awareness of their surroundings. CNA #2 stated Resident #141 attempts to get up and sometimes has aggressive behaviors putting them at risk for falls. CNA #2 stated Resident #141 cannot remove the lap tray independently, and they remove the lap tray every 2 hours. CNA #2 could not recall if there were documentation of the lap tray on their task. The C.N.A concluded by saying I don't know. During an interview on 03/16/23 at 01:23 PM, the Rehab Registered Nurse (RN) who stated that the rehab instructed her during the IDT meeting that the resident required a device. The Rehab RN stated that the facility has a lot of residents with TBI who use lap trays. The lap tray is not considered a restraint, even if the resident is confused or unable to remove it, because it is used for positioning. The rehab nurse further stated that the CNAs are responsible for applying the lap tray and releasing it every 2 hours. The release is documented in the CNAAR. The Rehab RN was unable to explain why the lap tray documentation was not being done. They stated that the RN who entered the order and CCP was supposed to make sure the lap tray was reflected on the CNAAR under safety tasks. During an interview on 03/13/23 at 02:40 PM, the Director of Social Work (DSW) stated that if rehab and nursing determines a restraint is necessary, social work will initiate the restraint consent form and notify the family. The DSW also stated that the team meeting concluded the lap tray was a restraint. During an interview on 03/16/23 at 01:05 PM, the MDS Coordinator stated that her staff completed the MDS assessment, and she reviews them. The lap tray is used for positioning because the resident has poor balance. That is why it was not coded as a restraint on the MDS. The facility has a lot of residents that use lap trays. A lap tray is not a restraint if the resident does not have the ability to remove it. If the resident is confused and cannot remove it, the lap tray is not a restraint. During an interview on 03/16/23 01:40 PM, the Director of Nursing (DON) stated that restraints are physical devices that restrict residents' movement. They stated that some residents do not have safety awareness, and the lap tray is used for positioning, not for resident safety. The DON stated that they have tried a series of different alternatives. Even when a resident cannot remove the lap tray, if they need it, it is not a restraint. 2) Resident # 54 admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Parkinson's Disease, Seizure Disorder and Traumatic Brain Injury. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired . The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS documented no restraints or alarms were used for the resident. On 03/13/23 from 11:59 AM to 1:20 PM, Resident #54 was observed seated in a wheelchair (w/c) in front of the Nursing station with a lap tray in place, attached to the w/c. At 12:30 PM, Resident #54 was wheeled to the Dining room, and the lap tray was released to enable the resident to eat. On 03/16/23 from 12:07 PM to 1:00PM , Resident #54 was observed again in front of the nursing station with a wander guard on the left ankle, chair alarm, and lap tray applied to the front of the w/c, restricting the resident's movement. The resident was not able to move or release the lap tray independently. The Physician's order dated 02/06/2023,documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. Wander alert device placement and check every shift. Review of the Comprehensive Care Plan (CCP) revealed there was no CCP developed for the use of the lap tray. There was no documented evidence in the medical record of the medical symptoms the lap tray was used to treat, a lap tray assessment, less restrictive measures tried before the lap tray, ongoing re-evaluation for continued use, or documentation regarding the release of the lap tray. On 03/14/2023 at 12:50 PM, the Occupational Therapist (OT) was interviewed and stated Resident #54 had a history of falls and standing all the time. The lap tray was applied for positioning. The OT stated no other devices were tried prior to the use of the lap tray, and a wander alert device and chair alarm are used for the resident. On 03/16/2023 at 12:16 PM, the MDS Coordinator was interviewed and stated the MDS staff do the initial, significant change, and annual CCPs and assessments. The Nursing staff complete the quarterly and episodic CCPs. The MDSC stated the lap tray is used for positioning and body trunk support, and it is not a restraint. On 03/16/2023 at 12;20PM, the Registered Nurse (RN #1) was interviewed and stated no other devices were used prior to the lap tray. RN #1 stated Resident #54 likes to get up from the chair, and they will also get out of bed and walk down the corridor. Resident #54 had a history of previous falls. Interventions implemented were a mattress on the floor, bed at lowest position, bed alarm, and chair alarm. No other alternatives were tried instead of a lap tray. RN #1 stated the lap tray prevents the resident from standing and falling. Resident #54 will get up from the chair when no one is looking and walk away from the chair. 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that all alleged violations, including injuries of unknown origin, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve serious bodily injury, to the State Survey Agency. This was evident for 1 of 4 resident reviewed for Accident. (Resident #59). Specifically, the facility did not report Resident #59's left distal tibia fracture of unknown origin to New York State Department of Health (NYSDOH) within 2 hours. The finding is: The facility policy titled Accident/Incident Reporting dated 08/2022 states All accidents/incidents/episodic events will be investigated thoroughly, documented and reported to the NYS DOH as appropriate. If the event is an injury of unknown origin, statements must be obtained from all staff going back until a determination can be made as to the time of the injury, using the forms for Certified Nurses Aides and Licensed Nurse. The Risk Manager determines the need to expand scope of the investigation as necessary. Resident #59 was admitted to the facility with diagnoses which include Non-Alzheimer's Dementia, Cerebro-Vascular Accident, and Psychotic Disorder. The Minimum Data Set (MDS ) 3.0 assessment dated [DATE] documented Resident #59 cognition as severely impaired. On activities of Daily Living (ADLS) as completely dependent to staff for dressing and bed mobility, and required the total assist of two persons with a Hoyer lift for transfers. On 03/13/2023 at 11:51 AM, Resident #59 was observed in their room sitting in a Geri chair with a soft cast wrapped with ace bandage on the left lower extremity. Resident is with contractures of upper and lower extremities, non responsive verbally. A Nursing Note dated 1/9/23 at 3:17 PM documented Resident #59 was assessed after being noted with left ankle swelling. The Nursing Supervisor and Physician (MD) were notified, and an order for stat x-ray of the left ankle was given and transfer to the hospital. Resident #59 had facial grimacing and yelled ouch when the ankle was touched during the assessment. A stat Tylenol order was obtained, and the resident was monitored. The x-ray was completed with results pending. A Physician's Note dated 01/09/2023 documented Resident #59 was seen for left ankle swelling. The resident was verbal and had no report of a recent fall or injury. On exam, the left ankle was swollen and warm to touch with restricted Range of Motion. The physician discussed the possibility of left ankle injury with nursing staff. Resident #59 was very rigid during the physical exam with left ankle edema. X-Ray results dated 1/9/23 documented the resident had a non displaced butterfly fracture deformity of the distal fibula. Correlation with dedicated ankle level tibia and fibula radiographs advised. Resident was sent to the hospital on [DATE] and was returned to the facility on [DATE] with a soft cast and wrapped with an ace bandage as documented in the nurses' notes. Accident/Incident investigation was initiated on 01/09/2023 with written statements and interviews taken from the staff on duty and going back 72 hours. The Director of Nursing wrote on the summary of the investigation as follows: This case has been reviewed with the Medical team and the medical Director. The facility believes there is no evidence of abuse, neglect or mistreatment. There was no investigation completion date. Further review of the medical record reveals no documented evidence that the injury of unknown origin was reported to the NYS DOH within 2 hours of the incident. On 03/13/2023 the Director of Nursing (DON) was interviewed and stated the injury of unknown origin was reported to NYSDOH on 1/11/23. The DON stated they know it should have been reported earlier, but there were a lot of things going on at the time. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) A facility policy titled Minimum Data Set (MDS 3.0) documented a purpose to conduct consistent and periodic review of the resident status to ensure continuing accuracy of assessments. The comprehensive resident assessment (MDS 3.0) is completed for entry/discharge reporting. Resident #179 had a diagnosis of ST Elevation Myocrdial Infarction (STEMI), Hypertension, and Chronic Kidney Disease. The admission MDS dated [DATE] indicated that the resident had intact cognition. Resident #179 and their family participated in the assessment and goal setting. The resident's overall expectation was to be discharged to the community. Resident #179 was discharged from the facility on 12/19/22. The discharge MDS assessment dated [DATE] documented the resident had modified independence with decision-making. The type of assessment was discharge (d/c) with return not anticipated, and the resident was discharged to an acute hospital. Active discharge planning was already occurring for the resident's return to the community. A Comprehensive Care Plan (CCP), titled Discharge, with an effective date of 10/10/2022, documented the resident's d/c plan was to return home, and the Resident/ Representative will be actively involved in discharge goals and planning. The interventions included to Discuss Activities of Daily Living (ADL) needs and potential barriers. Elicit resident/representative goals regarding discharge if possible. Explore alternate living arrangements. Explore family/representative, community, and other support systems. Involve resident/representative in any discharge planning efforts. Monitor for discharge readiness. Provide psychological counseling for discharge planning and goal setting. Reassess needs and condition quarterly and as needed. A nursing note dated 12/19/2022 documented Resident #179 was discharged home to the community with their family. During an interview on 3/14/23 at 3:03 PM, the MDS Coordinator (MDSC) stated the MDS staff complete the discharge MDS. The electronic medical record (EMR) will trigger the discharge MDS for discharge with return anticipated or not anticipated. The MDS Coordinator said they check for accuracy before submission. The MDS Coordinator confirmed the record documented Resident #179 was discharged home with return not anticipated. The MDS Coordinator acknowledged that the discharge MDS documented the resident had an unplanned discharge to an acute hospital (A0310 and A2100). The MDSC stated these sections are not checked for accuracy, only whether or not return is anticipated is checked. During an interview on 3/14/23 at 3:13 PM, the Social Worker stated the resident had a planned discharge to the community. The Social Worker does not answer the MDS sections A0310 or A2100 (regarding where the resident was discharged to or type of discharge). During an interview on 3/14/23 at 3:28 PM, the Registered Nurse MDS (RN MDS) stated they read the nursing notes and the IDT section of the EMR to complete the MDS. The RN MDS stated the error was probably just an oversight. If there was a discrepancy between the notes and the IDT information, they would speak to the nursing supervisor and check a book in the nursing office to clarify the resident's status. During an interview on 3/15/23 at 10:19 AM, the Director of Nursing (DON) stated the MDS is done by the MDS Coordinator and a few MDS Assessors. The MDS Coordinator does the auditing to ensure accuracy and timeliness. The DON stated there have been no problems with MDS accuracy identified in the past. 415.11(b) Based on observations, record reviews, and interviews conducted during the Recertification survey from 03/09/23 to 03/16/23, the facility did not ensure that the Minimum Data Set (MDS) assessments accurately reflects the resident's status. This was evident for 2 out of 6 residents reviewed for Physical restraints and 1 out of 3 residents reviewed for close records, out of a sample of 35 residents. Specifically, 1.) the MDS assessments did not accurately document trunk restraints were used for 2 residents with a lap tray (Resident # 54 and Res #141) who were unable to release the lap trays independently due cognitive and disability impairment. 2.) Resident #179 was discharged to the community and the discharge MDS dated [DATE], documented discharge assessment return not anticipated, discharge status to acute hospital. The findings are: 1) Resident #141 had diagnoses which include Dementia, Cerebrovascular Accident (CVA), Parkinson's Disease, and Seizure Disorder, Traumatic Brain Injury (TBI) The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired. The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS also documented trunk restraints were not used. The Physician's order initiated 11/15/2022, last renewed on 03/01/23, documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. On 03/13/23 at 09:55 AM, Resident #141 was observed in their room, sitting in a wheelchair (w/c) with a lap tray in place. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. Resident #141 was confused, not interview able, and unable to follow simple directions. The resident could not remove the lap tray when asked to do so. The Certified Nurse Aide (CNA) #1 was present during the observation. On 03/15/23 at 11:30 AM, Resident #141 was observed in the day room attending recreational activities with other residents. The resident was sitting in the wheelchair with a lap tray in front of the resident and attached to the back of the wheelchair. The restraint consent form dated 11/15/2022 documented that in order to prevent potential injuries, every effort was made to use alternative methods to provide a safe environment for the resident. Since alternatives were unsuccessful, it was determined a physical restraint was necessary. A lap tray was provided to facilitate midline positioning and was not being used as a restraint. The consent form was completed by the social worker and documented a verbal consent was given by a family member. The Comprehensive Care Plan (CCP) for Physical Restraint Secondary to a diagnosis of Traumatic Brain Injury (TBI) initiated 11/15/2022, revised 2/10/23 documented interventions to increase judgement and safety awareness, Rehab screen for restraint reduction if condition improved, and provide resident with change in position Q (every) 2 hours by toileting, ambulation and/or ROM (Range of Motion) exercise. During an interview on 03/13/23 at 02:40 PM, the Director of Social Work (DSW) stated that if rehab and nursing determines a restraint is necessary, social work will initiate the restraint consent form and notify the family. The DSW also stated that the team meeting concluded the lap tray was a restraint. During an interview on 03/16/23 at 01:05 PM, the MDS Coordinator stated that her staff completed the MDS assessment, and she reviews them. The lap tray is used for positioning because the resident has poor balance. That is why it was not coded as a restraint on the MDS. The facility has a lot of residents that use lap trays. A lap tray is not a restraint if the resident does not have the ability to remove it. If the resident is confused and cannot remove it, the lap tray is not a restraint. During an interview on 03/16/23 01:40 PM, the Director of Nursing (DON) stated that restraints are physical devices that restrict residents' movement. They stated that some residents do not have safety awareness, and the lap tray is used for positioning, not for resident safety. The DON stated that they have tried a series of different alternatives. Even when a resident cannot remove the lap tray, if they need it, it is not a restraint. 2) Resident #54 had diagnoses of Non-Alzheimer's Dementia, Parkinson's Disease, Seizure Disorder and Traumatic Brain Injury. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired . The MDS also documented that the resident required extensive assistance of one person for transfers and toilet use. The MDS documented no restraints or alarms were used for the resident. On 03/13/23 at 11:59 AM , Resident #54 was observed seated in a wheelchair (w/c) in front of the Nursing station with a lap tray in place, attached to the w/c. On 03/16/23 at 12:07 PM, Resident #54 was observed again in front of the nursing station with a lap tray attached to the w/c. The resident was not able to move or remove the lap tray independently. A chair alarm was in place, and Resident #54 had a wander alert device on the left ankle. The Physician's order dated 02/06/2023,documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. Wander alert device placement and check every shift. Review of the Comprehensive Care Plan (CCP) revealed there was no CCP for the use of the lap tray. On 03/14/2023 at 12:50 PM, the Occupational Therapist (OT) was interviewed and stated Resident #54 had a history of falls and standing all the time. The lap tray was applied for positioning. The OT stated no other devices were tried prior to the use of the lap tray, and a wander alert device and chair alarm are used for the resident. On 03/16/2023 at 12:16 PM, the MDS Coordinator was interviewed and stated the MDS staff do the initial, significant change, and annual CCPs and assessments. The Nursing staff complete the quarterly and episodic CCPs. On 03/16/2023 at 12;20PM, the Registered Nurse (RN #1) was interviewed and stated no other devices were used prior to the lap tray. RN #1 stated Resident #54 likes to get up from the chair, and they will also get out of bed and walk down the corridor. Resident #54 had previous falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, during the recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to address a resident's medical, physical, mental, and psychosocial needs that are identified in the comprehensive assessment. This was evident for 3 of 35 sampled residents (Resident #s 93, 54, and 128). Specifically, a CCP for Activities was not developed for Resident #93 upon readmission. A restraint CCP was not developed to address Resident #54's lap tray. A CCP was not developed to address the care needs for Resident #128's midline catheter placement and use to administer Intravenous (IV) medication. The findings are: A facility policy and procedure titled Minimum Data Set (MDS 3.0) updated 8/28/2018, documented: The results of the comprehensive assessment (MDS 3.0) are used by the interdisciplinary team to develop, implement, evaluate, and revise the Comprehensive Care Plan (CCP). The MDS Coordinator/designee reviews the CCP to ensure appropriate care planning. The CCP should be updated at the time of the quarterly assessment. The facility Policy and Procedure titled Comprehensive Person-centered Care Plan dated September 01,2018 states It is the policy of this facility that a Comprehensive Person Centered Care Plan for each resident will be developed to include measurable objectives and timetables to meet resident's physical,medical,nursing,mental and psychosocial needs that are identified in the comprehensive assessment . A Baseline care plan will be developed within 48 hours of admission . A Comprehensive care Plan is developed within seven (7) working days after completion of the comprehensive assessment and is reviewed quarterly and as needed/revised as necessary by the appropriate discipline member of the CCP team . 1)Resident #93 was readmitted from the hospital on 2/14/23, with diagnoses Traumatic Brain Injury (TBI), Seizures, and Hydrocephalus. The Activities CCP dated 9/9/21, last reviewed 11/21/22, was deactivated when Resident #93 was discharged to the hospital. discharged upon resident's transfer to the hospital. It was last reviewed 11/21/22. The quarterly MDS dated [DATE] documented the resident had severely impaired cognition. The resident required extensive assistance of 2 for bed mobility and toilet use; total assistance of 2 for transfer. The physician's orders dated 2/14/23, included an order for out of bed to Geri-recliner. As of 3/14/23, there was no active Activities CCP in the medical record. There was no documented evidence that the Activities CCP was developed and implemented upon readmission and at the time of the quarterly assessment. During an interview on 3/14/23 at 10:00 AM, the Licensed Practical Nurse (LPN) #3 stated that the MDS nurse is responsible for initiating the care plans, and Recreation is responsible for updating the Activities CCP. During an interview on 3/14/23 at 10:06 AM, the Registered Nurse Supervisor (RNS) #2 stated that all disciplines, such as recreation, are responsible for developing and updating their care plans. The MDS department is only responsible for the nursing care plans. Upon readmission, the care plans need to be reactivated and revised to reflect any changes. During an interview on 3/14/23 at 10:17 AM, the Activity Director (AD) stated they are responsible for developing the care plans and completing the MDS. The Activity leaders complete the quarterly notes and care plan updates. The AD further stated that for a readmission, they do a readmission assessment and update the care plans. Upon readmission, they go to the history and reactive the previous care plan. During an interview on 3/14/23 at 10:48 AM, the MDS Coordinator (MDSC) stated an audit, which includes making sure the care plan is updated, is done prior to the care plan meeting. The MDSC stated recreation staff did not attend Resident #93's care plan meeting held in February 2023. The MDSC stated the Activities CCP should have been reactivated by the time the meeting was held. 415.11 2) Resident # 54 admitted to the facility with diagnoses which include Non-Alzheimer's Dementia, Parkinson's Disease, Seizure Disorder and Traumatic Brain Injury. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition was severely impaired. The MDS also documented the resident required extensive assistance of one person for transfers and toilet use. The MDS documented no restraints were used for the resident. On 03/13/23 at 11:59 AM , resident observed several times seated in his wheelchair in front of the Nursing station , outside his room with a lap tray, unable to move, unable to release the laptray independently and a wanderguard to the left ankle and a chair alarm attached to the wheelchair. The Physician's order dated 02/06/2023 documented the following: Out of Bed (OOB) to wheelchair with lap tray to facilitate midline positioning. Release every 2 hours for 15 minutes and PRN (as needed) for ADL (Activities of Daily Living) care and skin checks. Wander guard placement and check every shift. Review of the Comprehensive Care Plan (CCP) revealed there was no CCP for the use of the Lap tray. On 03/16/2023 at 12:16 PM, the MDS Coordinator was interviewed and stated the MDS staff create the significant change and annual CCPs. The Nursing staff complete the quarterly and episodic CCPs. On 03/16/2023 at 12;20PM, the Registered Nurse (RN #1) was interviewed and stated there was no care plan created for the lap tray, and no other device was used prior to the lap tray. 3) Resident #128 was admitted to the facility with diagnoses of Cerebro-Vascular Accident, Hypertension, and Urinary Tract Infection (UTI). The Minimum Data Set 3.0 (MDS) dated [DATE] assessment documented the resident had moderately impaired cognition with a Brief Interview of Mental Status score of 8 out of 15. The resident required supervision for Activities of Daily Living (ADLS). On 03/14/2023 at 2:34 PM, Resident #128 was observed in their room seated in a w/c. Resident #128 had a midline on the left antecubital for Intravenous (IV) antibiotics. The Physician's order dated 03/10/2023 documented orders for Ceftriaxone 1 gram (gm) IV daily (OD) for 7 days and Midline IV care every 3 days and as needed with flush of 10 cubic centimeter (CC) of saline OD. The Nurse Practitioner (NP) notes on 03/10/2023 documented Resident #128 was evaluated for follow up for recurrent UTI with positive retroperitoneal ultrasound (US) for left sided mild hydro nephrosis and increased echogenicity. Resident #128 endorsed some urinary discomfort and back pain, and the last urine culture showed E Coli sensitive to Ceftriaxone. The resident was diagnosed with Recurrent UTI/Pyelonephritis with hydro nephrosis and the recommended treatment was IV Ceftriaxone 1 gm for 7 days. Review of the nurses' notes dated 03/11/2023 documented the resident was started on Ceftriaxone 1 gram intravenous solution with IV Midline, intact and patent, no signs of leakage/bleeding/infection noted. Review of the Comprehensive Care Plan (CCP) revealed no CCP documentation on the Urinary Tract Infection and the insertion of the midline catheter for Intravenous access for antibiotic medication. On 03/15/2023 at 2;40 PM, the Licensed Practical Nurse (LPN # 1) was interviewed and stated there was no CCP addressing the midline catheter and IV antibiotics. LPN #1 stated the care plans are created by the MDS staff. On 03/15/2023 at 2:43 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated MDS staff are responsible for the care plans, and they have per diems who also come to assist. The staff are making the care plan now. On 03/26/2023 at 12:00PM, the MDS staff was interviewed and stated MDS staff does the initial, significant and the annual care plans. The Unit RN is responsible for the episodic and quarterly care plans. 415.11 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 2 (Resident #45 and Resident #66) of 7 residents reviewed for Limited Range of Motion from a sample of 35 residents. Specifically, Residents #45, a resident with left hand contractures, was observed without a left palm guard in place, as ordered, and Resident #66, a resident with left hand contractures, was observed without a left resting hand roll in place, as ordered. The findings are: 1) Resident #45 was admitted to the facility with diagnoses which include Hemiplegia and Hemiparesis following cerebrovascular disease affecting the left non dominant side, Seizure Disorder and Primary Hypertension. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident required extensive assist of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene. Furthermore, the Resident had functional limitation in Range of Motion on the left upper and left lower extremities. The Physician's Order, renewed on 02/08/2023, documented an order for the resident to wear a left palm guard when out of bed. On 3/13/2023 at 11:16 PM, Resident #45 was observed in the hallway with no left palm guard on. On 3/14/2023 at 9:27 AM, Resident #45 was observed in their room sitting in the wheelchair with no left palm guard on. On 3/15/2023 at 11:19 AM, Resident #45 was observed sitting in the hallway talking to another resident with no left palm guard on. The Occupational Therapy quarterly assessment created on 1/14/3023 and completed on 1/20/2023 documented a rehab nursing recommendation for left palm guard when out of bed for skin protection. The quarterly review for the ADL's care plan updated on 1/26/23 documented Resident #45 has no significant change in ADL functioning. Goals were met and the plan of care was continued. On 3/15/2023 at 12:16 PM, the Certified Nursing Assistant (CNA #3) was interviewed and stated that somebody saw the resident throwing the hand splint in the garbage two to three weeks ago. CNA #3 stated that is why the resident is not wearing the left palm guard. On 3/15/ 2023 at 11:51 AM, the Occupational Therapist (OT) was interviewed and stated that the resident was on rehab from 1/11/2023 to 1/31/2023. The recommendation was for the resident to have a left palm guard to keep the fingers off the palm to prevent any loss of motion. The OT further stated, when out of bed, resident is supposed to have the palm guard in his left hand. The palm guard was missing. As per OT, no one reported to him that the palm guard was missing. That's why the resident was not wearing the palm guard. On 3/15/2023 at 12:02 PM, the Registered Nurse (RN #3) was interviewed and stated that the device was provided to the resident by Occupational Therapy. Resident #45 is non-compliant with the device and put it in the garbage. The medication nurse told her 3 weeks ago, and she did not report it to rehab or document it. 2) Resident #66 was admitted to the facility with diagnoses which include Essential Primary Hypertension, Cerebral Infarction, Diffuse Traumatic Brain Injury, and DiabetesMellitus. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The resident required extensive assist of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene. Furthermore, the Resident had functional limitation in Range of Motion on the left upper and left lower extremities. The Physician's Order, renewed on 02/06/2023, documented an order for the resident to wear a left resting hand roll when out of bed as tolerated. On 3/13/23 at 11:43 AM, Resident #66 was observed in their room sitting in the wheelchair with no left resting hand roll on. On 3/14/23 at 11:39 AM, Resident #66 was observed in the hallway sitting in the wheelchair with no left resting hand roll on. On 3/15/23 at 12:38 PM, Resident #66 was observed in the dining room getting hand fed by the CNA with no left resting hand roll on. The Occupational Therapy quarterly assessment created on 1/14/3023 and completed on 1/19/2023 for resident #66 has a rehab nursing recommendation for left resting hand roll when out of bed as tolerated. The quarterly review for the ADL's care plan updated on 1/26/23 documented that Resident #66 tolerated physical and occupational therapy. Goals were met, and the plan of care was continued. On 03/15/23 at 01:09 PM, CNA #4 was interviewed and stated that Resident #66 was fighting with them, so they needed someone to assist with putting the hand roll on. Then, CNA #4 forgot to put the hand roll on. On 03/15/23 at 01:04 PM, RN #3 was interviewed and stated that Resident #66 wears the hand roll as ordered, and it was just put on the resident. On 03/15/23 at 3:02 PM, the Occupational Therapist (OT}was interviewed and stated that Resident #66 was on rehab from 1/10/23 to 1/27/23. A hand roll was recommended to keep the left hand open. If a device is missing, they replace it right away. The OT further stated this afternoon, nursing staff called them to report Resident #66's hand roll was missing. The hand roll was replaced this afternoon. 415.12(e)(2)

Based on observation, record review, and interviews conducted during the Recertification survey from 3/9//23 to 3/16/23, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (3 North Unit). Specifically, two bottles of expired Bisacodyl tablets were stored in 3 North Unit medication room. The findings are: The facility policy titled Removal of Expired Medications last revised 01/2023 documented, Medication carts, cabinets and refrigerators will be routinely checked by nursing personnel. All expired medications will be removed and discarded. Nursing staff will remove and bring expired or unused medications to the Nursing office for proper disposal or return to pharmacy. On 3/15/2023 at 9:37 AM to 10:09 AM, the 3 North Unit medication room was observed with the Licensed Practical Nurse (LPN #2) and the following was observed in the top drawer of the counter: two unopened bottles of Bisacodyl tablets each with 100 counts (lot # B00STLY13K) with expiration date of 02/2023. On 3/15/2023 at 10:10 AM, LPN #2 was interviewed and stated they check the medication room regularly for expired medications and nothing in the medication room should be expired. LPN #2 stated they did not notice the two expired bottles of Bisacodyl tablets in the medication room cabinet. On 3/16/2023 at 2:13 PM, the Registered Nurse Supervisor (RNS #2) was interviewed and stated the nurse in charge of the unit must check all medications in the medication room for expiration. If expired, the medications must be brought to the nursing office for destruction and they will call the vendor (Tristate) for replacement. The expired Bisacodyl tablets were overlooked and should have been removed from the medication cabinet. On 3/16/2023 at 2:25 PM, the Licensed Consultant Pharmacist was interviewed and stated they inspect medication rooms and medication carts once a month. If medications are expired, they will remove the medications from the unit and bring them to the Director of Nursing. On 3/16/2023 at 2:31PM, the Director of Nursing (DON) was interviewed and stated the nurse in charge of the unit must check the medication room and cart for nearing expiration or expired medications. Corrective Action was taken for the expired Bisacodyl tablets found in 3 North unit medication room. 415.18(e) (1-4)

Based on observation, record review and interview, during the recertification survey of 3/9/23 to 3/16/23, the facility failed to ensure food was storeed, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, multiple items were observed in the dairy and meat walk-in refrigerators without proper labeling and dating. Two expired food items were observed in the emergency storage area. An employee was observed without a hair restraint or beard restraint, with hair exposed. The findings are: A facility policy and procedure titled Food Storage review/updated 2/3/23, documented that old stock is always used first. Food should be dated as it is placed on the shelves if required by state regulation. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. All refrigerated and frozen foods should be covered, labeled, and dated. A facility policy and procedure titled 3-day Emergency/Disaster food supply, dated 12/25/17, review/updated 2/3/23, documented the facility will ensure that there is a 3-day emergency/disaster food supply for both staff and residents. The facility will ensure the emergency food supply is adequately stocked and rotated by completing an inventory on a routine basis. A facility policy titled Accepting Food Deliveries reviewed/revised 2/3/23, documented perishable foods will be properly covered, labeled, and dated and stored in the refrigerator or freezer as appropriate. A facility policy titled Dietary Uniforms, updated 6/11/2022, documented employees are required to have hair restraints that cover all hair on the head. [NAME] nets are required when facial hair is visible. On 3/09/23 09:21 AM an initial tour of the kitchen was conducted with the 2nd Cook, and the following was observed: Dairy walk-in refrigerator: In pans: 3-bean not dated; vanilla pudding not labeled/dated. 2 milk crates were on the floor; 4 trays portioned fruit dessert not dated. In the meat/produce walk-in refrigerator, there was a Styrofoam flip container labeled meatloaf for residents no date; a second Styrofoam flip container was without a label and date. In the dry storage day room, a package of onion soup mix, farina, and 3 bags of cream of rice cereal were not dated. A bag of diet cookies were not labeled and dated (product was out of the original box). In the walk-in freezer, there were several boxes stored on the floor, an unlabeled and undated open bag of a breaded food product was not closed so that the item was exposed. There was also an undated open bag of chicken. A second tour of the kitchen was conducted on 3/14/23 at 11:28 AM with the Food Service Director (FSD) and the following was observed: Dietary Aide (DA) #1 was observed in the kitchen on 3/14/23 at 11:48 AM wearing a surgical mask with their sideburns visible and a baseball cap with dreadlocks extending down their back without a hair covering. In the dietary storage room, a bulk sized case of thickened orange juice, expiration date 12/21/2022, and 4 oz. portion control cups, expiration date 2/26/2023 were observed in the emergency food supply. An interview was conducted with Dietary Aide (DA) #2 on 3/16/23 at 9:37 AM, who stated that today they were assigned to the storeroom as relief. When the delivery comes in, everything is dated. They rotate items, the new on the bottom, old on top or front to back. They check the expiration dates on delivery. In the refrigerator or freezer, whichever cook used the product was responsible for putting it away properly (closing the package, labeling, and dating). An interview was conducted with the DA#1 on 3/14/23 at 11:48 AM. DA #1 was asked about their beard and hair not being covered. They stated that the hair coverings do not fit easily to cover their hair, but when they are on the tray line, they put on the bouffant hair covering and then their hat over it. They tuck their dreadlocks into the hair covering. DA #1 stated that they were trained about keeping their hair covered when they first started working at the facility. With regard to their beard, they stated that they use the surgical mask to cover it. There are no beard nets or mesh hair nets to use that will cover the sideburns that are not covered by the face mask. On 3/14/23 at 11:53 AM, an interview was conducted with the FSD who stated the policy is that everyone has to wear a head covering, either a hair net or a bouffant. The FSD further stated that DA#1 is supposed to wear the hair covering, not a baseball cap. Their dread locks are supposed to be covered. The FSD said the beard is covered only through the mask. When they were asked about the sideburns, they stated they had nothing to cover it up with. On 3/16/23 at 10:47 AM, an interview was conducted with the FSD who stated the cooks put their left-over foods into the refrigerator, and they are responsible for labeling and dating. They further stated that when a product comes out of its original packaging the storeroom, then the storeroom person is responsible for dating the item. The FSD further stated that all staff have been in-serviced on hair restraints and will be re-in-serviced on beard restraints. As for the expired food items, the FSD said that they check the emergency food supply inventory/dates along with the storeroom person. On 3/16/23 at 10:10 AM, an interview was conducted with the 1st [NAME] who stated that a product is supposed to be wrapped, labeled, and dated with what the product is. The 1st [NAME] stated that the storeroom person is responsible to ensure things are wrapped and dated, as well as the person cooking who then puts something away. Everyone should be wrapping/dating whatever they are using and putting back. 415.14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey it was determined that the facility did not ensure that two quarterly MDS (Minimum Data Set) resident assessments were transmitted to CMS (Centers for Medicare/Medicaid Services) within 14 days of completing the residents' final assessment. This was evident for 2 out 5 residents reviewed for accuracy and timely submission of assessments out of a sample of 33 residents. ( Resident #1, and #2) The findings are: The policy and procedure on Minimum Data Set (MDS 3.0) reviewed on 9/2017 documents IDC (Interdisciplinary) team members completes discipline specific assessments. Completes appropriate section of MDS 3.0. Signs completed MDS 3.0 attesting to its completion. Submission and Filing of MDS: MDS coordinator review completed MDS assessments after performing logic checks and corrections. The administrator submits MDS to the state. The MDS assessment for Resident # 1 was completed on [DATE], but was not submitted until [DATE]. The MDS assessment for Resident #2 was completed on [DATE], but was not submitted until [DATE]. An interview was conducted on [DATE] at 9:21 AM with the RN ( Registered Nurse) MDS assessor. The surveyor interviewed the MDS assessor about residents assessment for resident #1 and #2. The RN MDS assessor stated that they submitted both quarterly assessments late. The ARD (Assessment reference date ) was [DATE] end [DATE] and the quarterlies were submitted on [DATE]. The state agency surveyor (SA) asked the RN MDS what the process once there are ready for submission she determines when to submit the MDS complete books. Both assessments were information in Section O (psychotherapy total number of therapy days). Both resident was not receiving psychotherapy. The RN who suppose to complete the section was unaware that the section was completed by the RN MDS assessor. An interview with the Administrator was conducted on [DATE] at 3:15 PM. The MDS process is they have a MDS coordinator and different professional go into the books and complete there sections and once the books are ready for submission the MDS coordinator, and MDS assessor and RN MDS person who covers the coordinator can give the administrator a list of books that are completed to be submitted. Once they provide the list of completed MDS the administrator submits the books right away. The SA asked the administrator what happen to resident # 1 and #2? The administrator responded that the coordinator never gave the assessments to the administrator to submit. The administrator states that his role is to submit the books that are completed, he submits all assessments the day he gets the completed one, whether it is a resident who expired, transferred, or left to the community. If the book is rejected he notifies the MDS personnel right away and they would fix it. Another interview was conducted on [DATE] at 9:45 AM with the MDS assessor. She stated it would be the MDS coordinator responsibility to ensure the MDS is complete and submitted. An interview was conducted with the MDS coordinator on [DATE] at 12:07 PM. The MDS coordinator stated the following is my responsibility: coordinating and completion of the MDS books, care planning schedule for care plans, schedule MDS books along with care plan meeting. The MDS coordinator is responsible Monthly for medicare MDS assessment to be completed reviewed and submitted. She is responsible for all residents MDS assessments. The surveyor asked if she reviews that all books are completed and submitted in a timely manner and what occurred with resident #1 and resident #2 assessments. The MDS coordinator missed looking at Section O to ensure it was completed (the psychotherapy). The new MDS assessor did not want to put in the wrong information and it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and staff interviews conducted during the recertification survey, it was determined that the facility did not ensure that assessment accurately reflected the residents' status. Specifically, The (MDS) Minimum Data Set assessments for Residents #11 and #134 did not accurately reflect the active diagnoses for which residents were being treated. This was evident for 2 out 33 of sampled residents reviewed. The findings are: 1) Resident # 11 was observed in a private room on 8/20/18 at 10:33 AM. The room is directly across from the nursing station. During subsequent observations of the resident on 8/23/18 12:008 PM the CNA (Certified Nurses Assistant) was setting up the resident's lunch plate and then fed the resident. The resident refused most of the meal. The resident was also observed in bed fully clothed on most days during the recertification survey. The MDS dated [DATE] documented the following diagnoses: HTN, GERD, BPH, non alzheimers dementia, Schizophrenia, cataracts, blindness both eyes, AMS, syncope & collapse, unspecified dementia with behavioral disturbance. The MDS dated [DATE] only documented the diagnoses of hypertension and muscle weakness. The resident's most recent medical record documented that the resident was still being treated for the following diagnoses: schizoaffective disorder, dementia, and blindness as evidenced by diagnoses of end stage retinitis. On 2/27/18 the consultant Opthalmologist documented a diagnosis of Retinitis Pigmenttosa. Further documented was the resident has retinal detachment in left eye, vision has no light perception, eye pressure soft to the touch. Further documented diagnoses of end stage retinitis. The physician's order dated 7/26/18 documented orders for Haldol 5mg (milligram) po (by mouth) bid twice a day) for schizophrenia. The CCP (Comprehensive Care Plan) dated 7/30/18 Documented the following identified problems and interventions: 1) Dementia, Mood state indicated by easily annoyed, restless, sad affect, little energy, may urinate on floor 2) cognitive deficit 3) Blindness OU dense cataract OD s/p retinal detachment OS glaucoma no tx. 4) decreased communication, 5) self care deficit 6) activities 7) psychosocial well being 8) Behavioral problem 9) at risk for falls and injury related to cognitive deficit, sensory deficit, communication deficit, incontinence, handheld assist, psychotropic drug use, aggressive behavior, likes to go back to bed after meals, dx schizophrenia, rhobdomyelitis and syncope with interventions to orient to surrounding & environment PRN, call bell within reach, keep bed low & locked, instruct res to request for assistance from staff, PT/OT screen assist with transfers & ADL's as necessary, continual assessment of mobility & need for assist, psych f/u & meds as ordered with eval doc 5/10/18 res has non injurious fall in room - neurocheck done x 24hrs CCP continue no injury. 8/20/18 res was obs on floor lying on left side no injury no s/s of distress, intervention= neurocheck, body check. 2) Resident #134 was observed on 08/23/18 at 2:18 PM seated in high back wheel chair, clean, well groomed, lap tray on wheel chair with lunch tray on top. The resident independently feeding self with use of right hand and left hand splint in place. both feet supported on stirrups. The MDS dated [DATE] documented the resident with diagnoses of Anemia, diabetes. The MDS dated [DATE] only documented that resident with the following diagnoses: Anemia and generalized muscle weakness. The resident's medical record documented that the resident was receiving treatment for seizures, schizoaffective disorder, hypolipedemia, diabetes, hypocalcemia, thrombosis, depression, and hypertension. On 08/28/18 at 1:17 PM the MDS coordinator who was responsible for all assessments was interviewed. The MDS coordinator stated that she missed the review of that section of the MDS that documents diagnoses. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review staff interview the facility conducted during the recertification survey it was determined that the facility did not ensure that residents comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment. Specifically, The CCP (Comprehensive Care Plan) for Resident #11 identified the resident as at risk for falls and had interventions in place in an attempt to prevent falls. However, the resident had multiple falls and the facility did not review the effectiveness of the interventions. This was evident for 1 out of 33 sampled residents. The findings are: On 08/20/18 at 10:33 AM Resident #11 was observed in private bedroom room located across from the nurse's station. The resident was observed lying in supine on side in bed fully clothe with headboard of bed facing door to hallway and foot of bed facing window. The resident's quarterly MDS assessment dated [DATE] documented the following: unclear speech, sometimes understand/understood, severely impaired vision, no corrective lens, short/long memory problems, severely impaired decision making, mood of trouble sleeping, feeling tired occurs 12 - 14 days, trouble concentrating, moving slowly occurs 7 - 11 days, required limited assistance of 1 person with bed mobility. Required extensive assistance of 1 person with transfers, and locomotion on/off unit, Total dependence of 1 person assistance with toilet use, personal hygiene, and bathing, It also documented 1 fall since prior assessment with no injury. The resident's CCP dated 7/30/18 documented the following: 1) Dementia, Mood state indicated by easily annoyed, restless, sad affect, little energy, may urinate on floor 2) cognitive deficit 3) Blindness OU dense cataract OD s/p retinal detachment OS glaucoma no tx. 4) decreased communication, 5) self care deficit 6) activities 7) psychosocial well being 8) Behavioral problem 9) at risk for falls and injury related to cognitive deficit, sensory deficit, communication deficit, incontinence, handheld assist, psychotropic drug use, aggressive behavior, likes to go back to bed after meals, dx schizophrenia, rhobdomyelitis and syncope with interventions to orient to surrounding & environment PRN, call bell within reach, keep bed low & locked, instruct res to request for assistance from staff, PT/OT screen assist with transfers & ADL's as necessary, continual assessment of mobility & need for assist, psych f/u & meds as ordered with eval doc 5/10/18 res has non injurious fall in room - neurocheck done x 24hrs CCP continue no injury. 8/20/18 res was observed on floor lying on side with no injury no signs or symptoms of distress. The intervention in place was neurocheck, body check. documented that the interventions were ongoing. No documented evidence that the IDT reviewed the interventions in place to prevent falls on 7/30/18. The CCP documented that the interventions were ongoing, however it does not document that the IDT reviewed the current interventions to determine if they were effective to prevent further incidents of falls. The CCP documented neuro checks and body check as intervention. Neuro checks are a standard of practice after a fall it is not considered an intervention to prevent a fall or mitigate an injury of a fall. There was no documented evidence that the facility implemented new interventions after each fall. On 08/27/18 at 12:58 PM the ADNS (Assistant Director of Nursing) was interviewed. The ADNS the it was her responsibility to revise the CCP after 8/20/18 fall as the current charge nurse is new to the facility. However, it was the responsibility of the former RN who was the charge nurse to have updated the CCP after the fall in May, 2018. The RN who was the charge nurse should have revised the care plan and the nurse no longer works here. She further stated that the MDS coordinator is in charge of care planning. When a resident has an accident or incident the CCP is reviewed for a new intervention if required. If assessed then discussed would the resident benefit from something more then there would be a change to the CCP. She further stated that the resident has a behavior of laying himself on the floor If the incident is unwitnessed they still make out an incident report. In the evening monitoring is done every 30 minutes, but not same during day. His room is right across from nursing station and easily seen by the nurse 08/27/18 01:16 PM RN#1 was interviewed. RN # stated that when the resident has an accident or incident it is her responsibility to initiate the neurocheck for 24hrs, to make sure no neurological changes. Assess for injuries an any distress. After an accident or incident the CCP should show a different intervention than what was there. The protocol is to assess and do neuro and body checks. RN #1 acknowledged that this would be done for anyone found on the floor and was not specific to this resident. On 08/28/18 at 11:55 AM ADNS was interviewed again to verify the process. The ADNS stated that the CCP identified that the resident was at risk for falls. However, although the resident was found twice on floor a new CCP for actual fall would not be done. What would be updated would be the identified problem of at risk for falls to reflect actual fall. She further stated that a CCP would be generated for actual falls if there was an injury. No new interventions were added after the 2 falls of 5/10/18 and 8/20/18 and a new intervention should have been added. 415.11(c)(2)(i-iii)

2) On 8/24/2018 10:00 AM on the 2nd floor LPN #1 was randomly observed giving resident #165 his medication at the medication cart. The LPN then proceeded to position resident #35 in his wheelchair, he was sitting in front of his room. No hand hygiene was observed between giving resident #165 medication and providing direct assistance to Resident #35. 3) After assisting resident #35, the LPN returned to the medication cart and proceeded to retrieve medication from the cart and then proceeded to pop out medication from the blister pack. LPN #1 did not perform hand hygiene after assisting resident #35; or prior to retrieving medication from the medication cart and opening the blister pack and popping out the medication. On 08/28/18 at 11:29 AM a second interview was conducted with LPN #1. She stated hand washing is performed when giving and after medication, between residents, when touching resident equipment, when residents are on contact precautions and residents' bodily fluids. She stated antimicrobial agent is used when given medication between residents. Soap and water is used after medicating three patients, or being in contact with blood or bodily fluid. Hand washing is performed for a duration of 3-4 minutes. She stated that the last time she received in-services were two months ago. On 08/27/18 at 10:27 AM the Infection preventionist was again interviewed. She stated that the protocol on hand washing for example are performed after using the bathroom, visibly soiled and contaminated, before feeding after taking care of residents, nursing care and procedures. She stated that the staff get in-services at least twice per week and when need arises. The staff gets demonstration and then the facility does return demonstration. The staff can also use an online learning service that staff for education. There is also a competency that is performed to ensure compliance. On 08/28/18 at 08:28 AM the ADON (Assistant Director of Nursing) was interviewed. She stated that staff should be washing their hands before care, after care, between residents and during medication administration. Before using the rest room and after using the rest room and if hands become soiled staff are supposed to wash their hands right away. She stated that there is alcohol based hand rub that is available for hand hygiene on each unit, on medication carts and communal areas within the facility. If a resident has C-DIFF the staff must use soap and water and performed proper hand hygiene. She stated that in-services are given by the infection control nurse. 415.19 (b) (4) Based on observation the facility failed to ensure that its staff demonstrates proper hand hygiene between residents to prevent the spread of infections. Specifically the Licensed Practical nurse (LPN#1) was observed on 2 occasions administering medications and not practicing hand hygiene. 2) LPN#1 was also observed not practicing hand hygiene after assisting a resident with care and then opening medication to give to another resident. This deficient practice was observed by one nurse on multiple occasions. The findings are: The facility Policy and Procedure on Standards Precaution dated January 2018 documented wash hands immediately after gloves are removed, between patient contacts, and otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures. Use plain, non-antimicrobial soap for routine hand washing. Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances such as outbreaks. The facility general guidelines on infection control stipulates that standard precautions shall be used when caring for residents at all times regardless of their infection status , it must be used in the care of all residents , in all situations, before preparing or handling medications. 1) On 8/22/18 at 9:00 am during medication observation LPN #1 on 2 south was preparing to administer medication when she noticed a resident was having difficulty propelling his chair. She had stopped, held onto the wheelchair handles and assisted the resident moving. The LPN had not washed her hands but proceeded opening the medication cart and was reaching out for medication packages . She was stopped by the surveyor. The LPN stated: I should have washed my hand prior going into the medication cart. On 8/22/18 at 9:15 AM LPN #1 was interviewed on infection control and prevention, she replied: I did wrong, I should have washed my hands before touching the medication on the cart or used the hand sanitizer, I have it right here on the cart. I did touch the handles of the chairs, a lot of people touch these handles. She was asked about her education regarding infection control as it relates to medication administration. She replied that she was educated in hand hygiene procedure and policies. LPN #1 was interviewed about details regarding the in-service and education. She stated: I was instructed that we must wash our hands before starting medication administration and afterwards, between residents we must maintain universal precautions when caring for residents at all times. The in-service coordinator was interviewed on 8/22/18. She stated that LPN#1 was enrolled in a in-service class on hand washing on 1/17/18, the in-service attendance record indicated the same. 415.19(b)(4)