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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the recertification survey, the facility did not ensure that each resident's right to privacy and confidentiality of personal health information was maintained. Specifically, positioning profiles (photographs of residents wearing assistive / positioning devices) were observed on closet doors in resident rooms. This was evident for 3 of 3 residents (Resident #5, #31 and #109) reviewed for privacy. The findings are: According to the facility's policy on resident rights dated October 2017, residents have rights to privacy and confidentiality of personal and clinical records. Observations conducted during the initial screening process on 01/03/20 revealed positioning profiles displayed on the outside of closet doors for Resident #5, Resident #109 and Resident #31, all residing on the [NAME] Unit. These photographs were visible to anyone entering these rooms. In an interview with a certified nursing assistant (CNA) #1 on 01/09/2020 at 11:12 AM it was revealed that photographs similar to the ones posted on resident #109's and resident #31's closet doors were commonly displayed to guide them on the application of the devices and how to position the residents under their care. An interview conducted with the Registered Nurse- Unit Manager on 01/09/2020 at 10:43 AM revealed that the photographs were supposed to be inside the closet doors and not displayed outside where they were visible to all who enter the room. An interview was conducted with the Rehabilitation Director on 01/09/20 at 10:55 AM who stated that the positioning profiles should have been placed inside the closet doors and not on the outside. 415.3 (d)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the most recent recertification survey and an abbreviated survey (# NY00247956), the facility did not: A. Implement a person centered care plan for 1 of 7 residents (#49) reviewed for accidents, 1 of 4 residents (#86) reviewed for positioning and 1 of 5 residents reviewed for nutrition (#199). Specifically, 1.) hip protectors were not applied as per the care plan for Resident #49; 2.) wheelchair leg rests were not applied as per the care plan for Resident #86; and 3) weekly weights were not done for the first 4 weeks after admission for Resident #199. B. Develop a care plan for 2 of 2 residents (#49 and #48) reviewed for incontinence. Specifically, a care plan with measureable goals and timetable was not developed to address increased bladder incontinence for Resident #49; and a care plan to address bowel incontinence was not developed to address bowel incontinence for Resident #48. The findings include, but are not limited to the following: 1. Complaint # NY00247956: Resident # 49 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Hypertension, and Failure to Thrive. The 7/18/19 admission MDS (Minimum Data Set: an assessment tool) revealed Resident #49 had severe cognitive impairment, received extensive assist with transfers, and had no falls. The 10/12/19 Quarterly MDS revealed Resident #49 received supervision with transfers and had a fall without injury. The 7/12/19 ADL (activities of daily living) needs care plan revealed an intervention for the use of hip protectors at all times. The 11/10/19 Incident and Accident (A/I) report revealed that the resident was observed at 8:05AM lying on the floor on her right side. The resident was sent to a local hospital and was admitted with a right hip fracture. The investigative report of this incident revealed the resident was not wearing a hip protector at the time of the incident. The unit Licensed Practical Nurse (LPN #1) was interviewed on 1/9/20 at 11:20 AM and stated the resident was supposed to wear hip protectors at all times. The Certified Nursing Assistant (CNA #1) was interviewed on 1/9/20 at 11:30AM and stated that on the morning of the fall she had gotten the resident out of bed at 6:30AM. She further stated she knew the resident was supposed to use hip protectors but did not apply them because they were not available. 2 .Resident # 86 had diagnoses that include Peripheral Vascular Disease, Spinal Stenosis and Depression. The 10/26/19 Annual MDS revealed that Resident #86 was cogntively intact, received extensive assist for completion of ADL's and had bilateral lower extremity impairment. The 4/27/19 care plan for developing limitation in ROM (range of motion) related to decreased mobility of both legs and the 4/28/19 ADL self performance deficit care plans included an intervention for the use of leg rests when in the wheelchair. Observations on 1/3/20 at 12:00 PM and 1/7/20 at 10:00 AM revealed that leg rests were not being used. On 1/7/20 at 1:17 PM Resident #86 was being wheeled from the main dining room to the unit and no leg rests were present. The resident was wheeled with his feet elevated approximately one inch above the floor. CNA#2 who was observed pushing the resident's wheelchair was interviewed on 1/7/20 at 1:24PM. She stated she had asked the resident to keep his feet up and off the floor before she began pushing the wheelchair. She stated if the resident dropped his feet when being pushed in the wheelchair he could fall. The Unit Manager (RN #2) was interviewed on 1/9/20 at 5:15 PM. She stated the resident was very tall and needed to be pushed in the wheelchair. She further stated the resident did not self propel the wheelchair. 3. Regarding bladder incontinence for Resident # 49, the 7/12/19 Bladder Assessment revealed that the resident was always continent. The 7/18/19 admission MDS revealed Resident #49 received extensive assist with transfers and toilet needs, and was occasionally incontinent of bladder. The 10/12/19 Quarterly MDS revealed Resident # 49 received supervision with transfers and extensive assist with toileting and was frequently incontinent of bladder. The 7/12/19 activities of daily living (ADL) care plan was updated on 12/31/19 to indicate occasional incontinence, with the following interventions: on 11/14/19 check and change every 2 hours, and on 11/15/19 toilet every 3 hours. Review of the Bladder Record revealed the resident had the following incontinence episodes: July 2019 - 8 episodes, October 2019 - 44 episodes, and December 2019 - 71 episodes. After reviewing the resident's care plan it was determined the resident had no care plan that included measureable goals and interventions to address the type of bladder incontinence and attempts to decrease the frequency of bladder incontinence. The unit Nurse Manager (RN #2) was interviewed on 1/7/19 at 1:45 PM. She stated she was responsible for the development of care plans. After reviewing the medical record she stated a care plan had not been developed to address the resident's incontinence status. The resident had occasional incontinence, occurring mostly during the night shift. 4. Resident #48 is a 97- year-old male with the diagnoses of Heart Failure, Arthritis and Benign Prostatic Hypertrophy (BPH). The annual MDS dated [DATE] showed that the resident had no significant cognitive impairment, had hearing impairment with no hearing aid, had unclear speech, was occasionally incontinent of bowel (that is, during the past 7 days there was only one episode of bowel incontinence) and required supervision for toileting. The 10/12/19 quarterly MDS showed that the resident had no cognitive impairment and was frequently incontinent of bowel (2 or more episodes of incontinence and at least one episode of continence). The care plan revealed no mention of the cause of the bowel incontinence and no measureable goals and interventions to address bowel incontinence. The acting Unit Manager (AUM) Licensed Practical Nurse, was interviewed on 1/9/20 at 11:35 AM. This interview revealed that the resident was still frequently incontinent of bowel, which was probably related to the loose consistency of his stools secondary to the use of a medication (Allopurinal) used to treat gout. (This was initially documented by the Nurse Practitioner on 9/17/19). The AUM further stated that the Registered Nurse (who was not available) was responsible for the development of the care plan. On 1/9/20 the nurse aide (CNA #3) assigned to the resident on the day shift was interviewed at 12:07 PM. She stated that the resident was sometimes incontinent and it was mostly of bowel. 415.11(c)(1)

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

2. Resident # 49 was admitted with diagnoses including Non-Alzheimer Dementia, Hypertension and Failure to Thrive. The 7/18/19 admission MDS revealed Resident #49 had severe cognitive impairment, received extensive assist with transfers, and toilet needs, and was occasionally incontinent of bladder. The 10/12/19 Quarterly MDS revealed Resident # 49 received supervision with transfers, and extensive assist with toileting, and was frequently incontinent of bladder. The 7/12/19 Bladder Assessment revealed Resident #49 was always continent. The 7/12/19 Dependence on staff meeting ADL (activities of daily living) needs care plan noted that the resident was to be toileted every 3 hours. This plan was updated; 11/14/19 to check and change every 2 hours; 11/15/19 to toilet every 3 hours and on 12/31/19 to indicate occasional incontinence. Review of the Bladder Record revealed the resident had the following incontinence episodes: July 2019 - 8 episodes, October 2019 - 44 episodes, and December 2019 - 71 episodes. The was no documented evidence in the resident's record as to why the resident was incontinent of urine or what type of incontinence the resident experienced. After reviewing the resident's care plan it was determined the resident had no interventions in place that addressed the type of bladder incontinence, voiding patterns and attempts to restore normal bladder function to the extent possible. The unit Nurse Manager was interviewed on 1/7/19 at 1:45PM she stated the resident had occasional incontinence, occurring mostly during the night shift. She stated a discussion with the CNA revealed the resident had episodes of incontinence (damp undergarments) at times. The unit CNA (CNA #5) was interviewed on 1/7/19 at 1:59 PM, she stated the resident was toileted every 3 hours and was normally continent. 415.12(d)(1) 415.12(d)(2) Based on interviews and record review conducted during the most recent recertification survey, the facility did not ensure that 2 of 2 residents reviewed for bowel and/or bladder incontinence were provided the necessary treatment or services to restore continence to the extent possible. Specifically: 1.) For Resident #48, no person-centered goals and interventions were put in place to address bowel incontinence and no measures addressing voiding patterns, use of diuretic and supplies to promote urinary continence were identified in the resident's plan of care to ensure implementation across all shifts. 2.) For Resident #49, specific measures were not put in place to attempt to decrease the frequency of urinary incontinence. The findings are: 1. Resident #48 is a 97- year-old male with diagnoses of Heart Failure, Arthritis and Benign Prostatic Hypertrophy (BPH). The annual Minimum Data Set (MDS, an assessment instrument) dated 5/3/19 showed that the resident had no significant cognitive impairment, had hearing impairment with no hearing aid, had unclear speech, was occasionally incontinent of bowel and bladder (that is, during the past 7 days there was only one episode of bowel incontinence and less than 7 episodes of urinary incontinence), and required supervision for toileting. The 10/12/19 quarterly MDS showed that the resident had no cognitive impairment, was frequently incontinent of bowel (2 or more episodes of incontinence and at least one episode of continence) and continent of bladder. The resident's current medication regimen included a diuretic, Furosemide 20 mg daily, for edema (given at 8:30 AM), which put the resident at risk for urinary incontinence. The current comprehensive care plan (CCP) revealed that the resident had urge incontinence related to BPH. The goal was for the resident's risk for septicemia (infection of the blood) to be minimized/prevented via prompt recognition and treatment of symptoms of a urinary tract infection (UTI). The interventions to achieve this goal included clean peri area with each incontinent episode, encourage fluids during days to promote voiding responses; ensure unobstructed pathway to bathroom; and monitor for signs and symptoms of UTI. The CCP revealed no mention of the cause of the bowel incontinence, no specific input from the resident in the formulation of the goals and interventions, no reference to monitoring voiding patterns (such as frequency, volume, nighttime or daytime,), use of incontinence supplies (such as urinals and type of underwear) and the type of prompting needed to encourage urination and defecation and the time for offering of fluids in light of the use of a diuretic. According to documentation by the Certified Nurse Aides (CNAs) assigned to the care of the resident, the number of urinary incontinent episodes were recorded for the past three months as follows: November 2019 - 13 December 2019 - 06 January 2020- 05 (to date) Thirteen of all these urinary incontinent episodes (total of 24) occurred between 9:00 PM and 3:00 AM. There was no monitoring of the bowel movements. The computerized electronic medical record was not programmed to prompt the CNA to record the number of incontinent and continent episodes for bowel. The information given to the CNAs on the incontinence record was not updated to reflect the change in the resident's level of bowel incontinence. The information noted that the resident was occasionally incontinent of bladder and always continent of bowel. The acting Unit Manager (AUM), Licensed Practical Nurse, was interviewed on 1/9/20 at 11:35 AM. This interview revealed that the resident was still frequently incontinent of bowel, which was probably related to the loose consistency of his stools secondary to use of a medication (Allopurinal) used to treat gout. (This was initially documented by the Nurse Practitioner on 9/17/19). The AUM further stated that she updates the care plans after they are developed by the Registered Nurse. On 1/9/20 the nurse aide (CNA #3) assigned to the resident on the day shift was interviewed at 12:07 PM. She stated that the resident was sometimes incontinent and it was mostly of bowel. On 1/9/20 at 2:50 PM the surveyor made an attempt to interview the resident with the assistance of the AUM. The surveyor terminated the interview due to difficulty in communicating with the resident and his denial that he was incontinent of urine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification survey, it was determined that for 3 of 7 residents (Residents #166, #199 and #216) reviewed for Nutrition and Hydration the facility did not ensure that each resident was provided the necessary care to either maintain, to the extent possible, acceptable body weight or proper hydration. Specifically, for Resident #199 there was a lack of weekly weight monitoring for the first 4 weeks following admission as indicated in the facility's weight policy and the plan of care; and for Residents #166 and #216, there was a lack of adequate monitoring of daily fluid intake to assess the adequacy of daily fluid consumption. The findings are: 1. Resident #199 was admitted to the facility on [DATE] with diagnoses that included Coronary Artery Disease, Hypertension, Fracture of unspecified Lumbar Vertebra, Fracture of Second Cervical Vertebra, and Depression. The admission Minimum Data Set (MDS- an assessment tool) completed on 12/27/2019 showed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15, which indicated impaired cognitive status and weighed 178 lbs. A review of Physician orders dated 12/16/19 showed that the resident was prescribed a Regular diet. The Nutrition Care Plan initiated on 12/3/2019 indicated inadequate protein intake and increased nutrient needs. The goal was to improve oral intake to greater or equal to 75% of meals. The interventions to achieve this goal included: to provide diet as ordered, monitor weight weekly for 4 weeks, then once per month and Carnation shake daily. The resident's weight chart showed the following weights: 11/27/2019- 177.9 Lbs, 12/11/19 -178.0 Lbs, and 12/25/19 -150.4 Lbs. These weights represented a loss of 15.46% in approximately 4 weeks. There was no documented evidence of weights for the weeks of 12/1/19 to 12/7/19 and 12/15/19 to 12/20/19. On 1/7/2020 at 4:00 PM Unit Manager (RN #3) was interviewed and she stated that routinely residents are weighed weekly for 4 weeks on admission, then monthly as per facility policy. Also, the facility's electronic medical record has a system in place for when there is a weight loss of 3 Ibs. or more the system alerts staff for possible intervention which is mostly for a re-weigh. This interview also revealed that the Unit Manager was not aware of the weight loss until the surveyor brought it to her attention. The resident's plan of care and the facility's weight protocol were not followed to prevent significant unplanned weight loss. 2. Resident #166 has diagnoses of Dementia, Constipation, Renal Insufficiency and Depression. The annual MDS dated [DATE] showed that the resident had severe cognitive impairment, required supervision with eating and weighed 126 lbs. The Care Area Assessment summary, an extension of the MDS, noted that the resident had inadequate intake and was at risk for weight loss. The most recent physician's orders included medications that triggered the need for sufficient fluids: two psychoactive medications that can cause constipation, Mirtazapine 7.5 mg daily for depression and Quetiapine 12.5 mg x 2 daily for delusions; three medications for the treatment of constipation--Polyethylene glycol Powder 17 gm daily, Senna tablets 2 two times daily and Lactulose 30 ml one time daily ; and the use of a diuretic, Furosemide 20 mg daily for heart failure. A review of the comprehensive care plan revealed no specific goals for hydration/sufficient fluids. The nutrition care plan revealed goals for the resident's intake to be greater than or equal to 75 percent. The intervention to achieve this goal included: extra sandwich at lunch and dinner, monitor food intake, encourage intake greater than or equal to 75%, and evaluate labs as ordered. A review of the CNA documentation revealed that the resident's total intake at meal times for the past 30 days was as follows: 00 to 25% - 11 times 26 to 50% - 33 times 51 to 75% - 24 times 76 to 100% - 11 times The amount of fluids consumed was not distinguished or separated from the amount of solids consumed. Therefore, amount of fluids being consumed could not be determined. A review of the medical record revealed no laboratory values indicative of the resident's hydration status. Two meal observations showed the following: - 01/03/20 at 12: 57 PM the resident refused the meal offered. - 01/09/20 at 12:26 PM the resident was served 8 oz tea, 6 oz milk, pork, sauerkraut, baked beans, and a peanut butter & jelly sandwich. She ate all the beans, refused the additional solids, drank all the tea and took a few sips of milk. The Registered Dietitian (RD) assigned to the resident was interviewed on 1/9/20 at 3:40 PM. He was asked to address how the adequacy of the resident's daily fluid intake was being addressed in light of consumption of meals noted to be usually 50% or less most of the time, the ongoing use of a diuretic, the use of three medications for constipation, and the fact that there was no distinction between the amount of food and fluids consumed at meal times. The RD stated that this should have been done by nursing and that he would put a plan in place. 3. Resident #216 was admitted to the facility on [DATE] with diagnoses and conditions of cancer and congestive heart failure (CHF) and renal insufficiency (RI) . The admission MDS dated [DATE] showed that the resident was feeling depressed, had cognitive impairment and reported frequent moderate pain. The CCP dated 12/26/19 addressed CHF, RI and hydration. The CHF care plan noted that the resident's fluid intake would be monitored and the hydration care plan noted that the goal for the resident was to be adequately hydrated. The interventions to achieve this goal included: evaluate labs as available, ensure access to fluids, food service to provide 1575-1600 fluids, and nursing to offer 240 ml with medication pass. A note written by a social worker on 12/26/19 stated that over the past 2 weeks the resident had felt very depressed due to physical decline and that she had a poor appetite with no desire to eat. According to the Medication Administration Record, on 12/27/19 the resident was administered one diuretic, Furosemide 40 mg. Two diuretics, Spironolactone 25 mg and Furosemide 40 mg were administered from 12/28/19 to 12/30/19. On 12/29/19 nursing documented that the resident had low blood pressure and unresponsive episodes. The recommendation was to send the resident to the hospital. On 12/30/19 nursing documented that the hospital called to report that the resident was admitted to the intensive care unit for the treatment of acute kidney injury (AKI), sepsis and CHF. (The resident was not re-admitted to the facility.) In light of the diagnosis of AKI, the use of two diuretics, and report of poor appetite, the surveyor reviewed the resident's clinical record to determine how much fluid the resident was consuming daily. There was no documented evidence that the amount of fluids consumed between meals was monitored. Also, the CNA documentation showed no evidence that the resident's fluid intake at meal times was being monitored daily as planned in the renal care plan mentioned above. The CNA documentation showed that meal consumption was recorded for only one meal daily from 12/26/19 to 12/29/19 and was as follows: 12/26 at 22:51 - 0 to 25% 12/27 at 21:02 - 26 to 50% 12/28 at 22:14 - 26 to 50% 12/29 at 20:59 - refused The Unit Manager (RN #3) and a unit Licensed Practical Nurse (LPN #3) were interviewed on 1/8/20 at 1:25 PM. This interview revealed that the CNAs were not instructed to monitor the resident's fluid intake and that this should have been done by the admission Nurse. 415.12(i)(1)(j)

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that a comprehensive assessment of the psychosocial needs of 1 of 5 residents (#135) reviewed for unnecessary medications was conducted to determine to the extent possible, the underlying causes for the ongoing use of an antidepressant medication and the need for supportive counseling. The findings are: Resident #135 was admitted to the facility on [DATE] for rehabilitation services. The resident's diagnoses included Major Depressive Disorder, Insomnia, and Cerebrovascular Accident. The resident's admitting orders included Sertraline (Zoloft) 100 mg, (an antidepressant; a psychotropic medication) which continued to be prescribed for the treatment of depression as of 2/8/18. The physician's progress note of 12/12/17 showed that the resident reported feeling somewhat down but denied depression. This note did not indicate why the resident was feeling down. The Initial Minimum Data Set (MDS; a resident screening and assessment tool) dated 12/12/17 revealed that the resident reported, during an interview pertaining to her mood, that she was feeling down (or depressed), had trouble sleeping, and had little energy. This MDS also revealed that the resident had no cognitive impairment and was on an antidepressant. The Care Area Assessment Summary, which showed that the need for an in-depth assessment of the resident's mood did not trigger. It did show that an in-depth assessment for the use of psychotropic medications did trigger. The summary note dated 12/14/17 stated that psychotropic drugs were being used for anxiety (Lorazepam), depression (Sertraline), and insomnia (Luesta) which placed the resident at risk for falls, safety concerns, mood, behavior, and nutritional concerns. There was no documented evidence in this summary note or other parts of the medical record of any attempt made to determine the possible underlying cause(s) of the depression which triggered the need for the antidepressant Zoloft and the duration for the use of Zoloft prior to admission to the facility. Also, there was no documented evidence that an assessment for the need for supportive counseling was done. The Director of Social Services and the current social worker assigned to the resident were interviewed on 2/8/18 at 2:25 PM. They were asked if the root cause(s) for the resident's depression, history for the use of the antidepressant, and need for supportive counseling were determined. They were unable to provide any evidence that this were done. The resident was interviewed on 2/8/18 at 2:40 PM and was asked what was the cause of her depression. She stated that she had lost her father, mother and dog and became depressed after these losses. Currently, she feels good but at times sad because she wants to go home. The plan was for her to stay in the facility and that makes her sad at times. The resident stated she would feel better talking about it with somebody. 415.11(a)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey survey, the facility did not develop a person-centered care plan with measurable objectives, time frames and appropriate interventions based on comprehensive assessments for 1 of 2 residents (#29 ) reviewed for range of motion, positioning and mobility and for 1 of 1 resident (#110) reviewed for physical restraints. Specifically, there were no care plans to address the use of a knee brace as skin protective device for Resident #29 and the use of a seatbelt, seatbelt alarm and tray table for Resident #110. The findings are: 1. Resident #29 has diagnoses including Dementia, Depression, and Heart Failure. The Annual MDS (Minimum Data Set; a resident assessment and screening tool) of 6/28/17 revealed the resident had no cognitive impairment; required supervision of one person with bed mobility; independent with transfer, walking, and locomotion; extensive assistance with dressing, eating and toilet use; and had no functional limitation of range of motion. The resident was subsequently assessed on the Quarterly MDS dated [DATE] and revealed the resident had severely impaired cognition, required extensive assistance of one staff with activities of daily living including transfers, dressing, toilet use, and personal hygiene; extensive assistance of two staff with bed mobility; had no functional limitation in range of motion; and used a walker. The resident was observed sitting in her room on 2/02/18 at 02:37 PM with a brace on the right knee that was covering the shin, calf area, and ankle. The assigned Certified Nursing Aide (CNA) was interviewed and she stated that the resident needed it for arthritis. The eTAR (Electronic Treatment Administration Record) Treatment Documentation dated 11/20/17 indicated to apply the right knee brace with stockinette for skin protection three times a day during the day, evening, night. Review of the resident's clinical record revealed there was no documented evidence that a comprehensive resident-centered care plan with measurable objectives, timeframes and appropriate interventions, to prevent possible complications based on clinical evidence and recommendation, was initiated to address the use of the right knee brace. The unit manager was interviewed on 2/12/18 at 12:00 PM and stated he was responsible for developing the care plans and that he was unable to locate a care plan addressing the use of the right knee brace. 2. The facility policy and procedure for Restraints, revised on December 2010, stated that the use of restraints must be documented on the comprehensive care plan, the physician's interval progress notes and the CNA Care Guide and that the restrictive device assessment form will be completed quarterly at each MDS assessment and prior to comprehensive care planning meeting for all residents who utilize restraints. Resident # 110 has diagnoses including Dementia with behavioral disturbance, Anemia, and Vitamin Deficiency. According to the Annual MDS of 11/22/17, the resident has severely impaired cognitive skills; requires extensive assistance of two staff members with most aspects of activities of daily living; and uses a wheelchair. This MDS further documented that the resident does not use any type of physical restraints including the use of any chair, bed, or other alarms. Observations were made on the following dates and times and showed that the resident was using a wheelchair seatbelt, seatbelt alarm and a tray table simultaneously: - on the morning of 2/2/18, the resident was in the unit's common area sitting in her wheelchair with a seatbelt, seat belt alarm and a tray table in place and at 12:45 PM, revealed the resident was at lunch in the unit dining room being assisted by a staff member with a wheelchair seatbelt, seatbelt alarm, and tray table in place during this meal. - further observations were made during lunch on 2/6/18, 2/7/18, and on 2/8/18 between 12:00 PM and 12:45 PM and revealed the resident to be in the unit dining room being assisted by a CNA and the wheelchair seatbelt, seatbelt alarm, and tray table remained in place during these meals. The resident was observed earlier during the day on 2/8/18 at 10:00 AM to be in the common area sitting in her wheelchair with a wheelchair seatbelt, seat belt alarm, and a tray table and was calm. CNA #1 was interviewed on 2/8/18 at 12:45 PM and she stated that the seatbelt, seatbelt alarm and tray table were never removed including during meals because the resident has seizures. The assigned Licensed Practical Nurse (LPN#1) was interviewed on 2/8/18 at 1:05 PM and she stated that she have not observed the seatbelt, tray table and seatbelt alarm removed during meals. When asked how they identify residents who use these devices, LPN #1 stated there is a white folder and task list for the unit which is a quick reference for anyone that is new to the unit. The February 2018 CNA care guide and the Task List Assigment (a record used by nursing aides to obtain information about the type of care the resident needed and where they document completion of this task) did not include the use of a tray table, seatbelt or seatbelt alarm. There were no instructions for the CNAs to follow as to when to apply and remove the said devices, including other related care areas while these devices were being used by the resident. Further review of the resident's clinical record including, but are not limited to, the comprehensive care plan, physician orders, and CNA Care Guide revealed no documented evidence to address the use of the seatbelt alarm, seatbelt alarm, and tray table. The unit Registered Nurse (RN#1) unit manager was interviewed on 2/8/18 at 1:15 PM and stated that the care plan to address the use of the above devices was not done because he was waiting for therapy to give him a directive prior to application of these devices which is a typical protocol. RN #1 stated that he is responsible for developing the care plans in his unit and did not provide further explanation why the care plan for the use of these devices was not initiated. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that treatment and services were provided in accordance with the resident's plan of care for 1 of 2 residents (#169) reviewed for positioning, mobility and range of motion. Specifically, resident #169 did not have her left arm immobilizer applied per the physician's order and comprehensive care plan as a protective device. The findings include: Resident #169 has diagnoses including Dementia, Diabetes Mellitus, and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) of 12/16/17 indicated the resident has severely impaired cognition, required extensive assistance of two staff members with bed mobility, transfers, dressing, eating, and toilet use. The Physician's Order Sheet of 1/5/18 had an order for a left arm immobilizer to be worn when out of bed (OOB) in a wheelchair and during Hoyer lift (a mechanical lift) transfers from Sunday through Saturday, days, evenings and nights. The care plan for Actual Skin Impairment, to address a hematoma on the left forearm, dated 1/05/18 had goals indicating that the resident's bruise will heal in 14 days and that the resident will have no signs and symptoms of discomfort. The interventions to achieve these goals included application of left arm immobilizer to be worn daily when OOB and during transfer. A review of the CNA (Certified Nursing Aide) Tasks Completed form for February 2018 indicated that the left arm immobilizer was to be worn when OOB in the wheelchair and during Hoyer lift transfers. The following observations were conducted and revealed there was no immobilizer applied to the left arm: - 2/2/18 at 10:00 AM, the resident was in the unit common area sitting in her wheelchair with her left arm resting on her tray table; - 2/6/18 at 12:00 PM, the resident was in the unit dining room with her left arm below the tray table on her wheel chair; and on - 2/8/18, in the afternoon, the resident was observed in the [NAME] dining room sitting in her wheelchair with her left arm resting on her tray table. The assigned CNA #3 was interviewed on 2/8/18 at 1:40 PM and stated she puts on the left arm immobilizer on the resident during transfers via the Hoyer lift and does not keep it on the resident when she is in her wheelchair. Further interview of CNA #3 was conducted on 2/13/18 at 12:40 PM and was asked how she gets direction for the care of the residents on her assignment. She said she looks at the task sheet and she asks the nurse. CNA #3 said she was shown during training on how to care for residents on her assignment. She said she did not clarify with the nurse or nurse manager regarding when to apply and remove the left arm immobilizer. CNA #2 was interviewed on 2/8/18 at 1:50 PM and stated that when she cares for the resident, she applies the left arm immobilizer and when she returns to her throughout the day, someone comes along and takes it off. CNA #2 stated she does not know who takes it off. When asked as to who is responsible for applying the immobilizer, she stated that the CNAs were supposed to do that. CNA #2 was further interviewed on 2/9/18 at 1:30 PM and stated that the nurse was responsible in assuring that the CNAs were providing cares to the residents in accordance with the care guide. 415.11(c)(3)(ii)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that an audiology evaluation was performed as ordered by the medical provider for 1 of 1 resident (#29) reviewed for vision and hearing. The finding is: Resident #29 has diagnoses including Heart Failure, Non-Alzheimer Dementia, and Hypertension. The Quarterly MDS (Minimum Data Set; a resident assessment and screening tool) dated 11/3/17 indicated that the resident scored 6 out of 15 on the BIMS test (Brief Interview Mental Status; used to measure memory recall and orientation) which suggested that the resident has severe cognitive impairment. This MDS further indicated that the resident has moderate hearing loss and does not use hearing aids. A care plan initiated on 8/31/16, for Communication, documented that the resident displays aggressive and or receptive deficits in communication as evidenced by being hard of hearing. One of the interventions included audiology examination as needed. The Nurse Practitioner (NP) ordered on 12/19/17 for an audiology evaluation for hearing aid. The NP progress note dated 12/19/17 stated that it was discussed with the resident and was agreeable with the ear treatment; would like her hearing checked; and would like a hearing aid. The resident was interviewed on 2/2/18 at 2:27 PM and stated she has difficulty hearing and needed a hearing aid. The resident stated that she was told by nursing she would get her hearing checked but it has not happened. The unit Registered Nurse (RN #1) was interviewed following interview with the resident on the same date at 2:45 PM regarding the NP's order dated 12/19/17 for audiology evaluation for possible use of hearing aids. RN #1 stated he thought the resident was seen already for an audiology consult. RN #1 was unable to find any request for consultation. The resident's family member was interviewed by phone on 2/12/18 at 2:30 PM and stated that he was told by the staff that the resident would see an audiologist and not just have her ears cleaned. He said that he was informed further that the earwax was the problem and that his mom would need a hearing aid. The audiologist was interviewed by telephone on 2/12/18 at 3:45 PM and stated he was never notified of the need to see this resident for hearing evaluation. He said he usually comes in every six weeks and has not been made aware that the resident required an audiology evaluation. 415.12(3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that 1 of 3 residents (#53) reviewed for hydration was provided the appropriate care to prevent dehydration and maintain electrolyte balance. Specifically, the resident's total daily fluid intake was not monitored and assessed for adequacy in light of ongoing elevated laboratory data indicative of possible insufficient fluid intake. The findings are: Resident #53 has diagnoses that include Dementia and Depression and was admitted to the facility on [DATE]. The admission Minimum Data Set (a resident assessment and screening tool) of 11/1/17 indicated that the resident was severely cognitively impaired, required extensive assistance with eating, and had problems with dehydration and a urinary tract infection. The initial comprehensive care plan dated 11/3/17 noted that one of the goals for the resident was to be adequately hydrated. The interventions to achieve this goal included evaluate labs as available, food service to provide adequate amount of thickened fluids, and nursing to provide 240 cc fluids with each medication pass. The corresponding nutrition care plan noted that the resident's oral intake to be recorded on flow sheets. A review of laboratory data revealed the following: - 10/26/17 - Blood Urea Nitrogen (BUN) =12 (normal range is 8-23) and BUN/Creatinine Ratio - 10.5 (normal range is 10 - 28; elevated BUN and BUN/Creatinine Ratio may be due to insufficient fluid); - 11/10/17 BUN =21 and BUN/Creatinine Ratio = 21.6 - 1/16/18 BUN = 43 and BUN/Creatinine Ratio = 44.8 - 1/23/18 BUN = 40 and BUN/Creatinine Ratio= 38.1 The last dietary note dated 1/17/18 showed that according to the intake record, the resident was consuming 800-900 cc fluid at meal times and snacks, which was approximately 70% of her estimated needs. (Daily requirement would be about 1200 cc.) The fluid intake record for the period of 2/2/18 - 2/7/18 showed incomplete data of fluid intake at meal times; amounts recorded in cubit centimeters (cc) were limited to the day shift as follows: 2/2 - 270 2/3 - 270 2/4 - 870 2/5 - 270 2/6 - 630 2/7 - 250 Meal observation on 2/12/18 at 12:50 PM showed that the resident was served 6 oz thickened tea, 8 oz thickened milk, pureed meat and vegetables, mashed potatoes, and ice cream. The resident drank all the tea and about 2 oz milk added to the tea and consumed spoonfuls of the the remaining food items served. The medication nurse (RN#2) was interviewed on 2/12/18 at 2:30 PM and she stated that on 2/12/18, the resident was offered 240 cc fluid with her medications and drank about 150 cc. The Registered Dietitian was interviewed on 2/12/18 at 2:10 PM and she stated that the amount of fluid consumed with and between meals was not consistently documented (or monitored) after a resident was in the facility for a awhile. It cannot be determined if the resident was offered and was consuming sufficient fluid necessary to prevent dehydration and maintain electrolyte balance. 415.12(i)(1)

Based on observation, record review and interview, the facility did not ensure that its staff demonstrated competency in providing the necessary care to meet the needs of 1 of 1 resident (#110) reviewed for restraints and positioning. Specifically, the Certified Nursing Aides (CNA) did not report the ongoing use of wheelchair seatbelt, seatbelt alarm and tray table that were not listed in the resident's CNA Care Guide (a record that provides instructions to the CNAs of the type of care and services that residents need on a daily basis). The resident was observed on multiple occasions during the survey to be using these devices The facility policy and procedure for Restraints, revised on December 2010, stated that the use of restraints must be documented on the comprehensive care plan, the physician's interval progress notes and the Certified Nursing Aide (CNA) Care Guide. The findings are: Resident #110 has diagnoses including Dementia with behavioral disturbance, Anemia, and Vitamin Deficiency. According to the Annual MDS of 11/22/17, the resident has severely impaired cognitive skills; requires extensive assistance of two staff members with most aspects of activities of daily living; and uses a wheelchair. This MDS further documented that the resident does not use any type of physical restraints including the use of any type of chair, bed, or other alarms. Observations were made on the following dates and times and showed that the was using, simultaneously, a wheelchair seatbelt, seatbelt alarm and a tray table: - on the morning of 2/2/18, the resident was in the unit's common area sitting in her wheelchair with a seatbelt, seat belt alarm and a tray table. Between 12:00 PM and 12:45 PM on the same date, the was ay lunch in the unit dining room being assisted with her meal by a staff member with the continued use of the wheelchair seatbelt, seatbelt alarm, and tray table; -2/8/18 at 10:00AM, the resident was common area sitting in her wheelchair with a wheelchair seatbelt, seat belt alarm, and a tray table. At around 12:00 PM, the resident at lunch in the unit dining room being assisted with her meal by a staff member with the continued use of the wheelchair seatbelt, seatbelt alarm, and tray table. CNA #1 was interviewed 2/8/18 at approximately 12:45 PM and she stated that the seatbelt, seatbelt alarm and tray table were never removed including during meals because the resident has seizures. The assigned Licensed Practical Nurse (LPN#1) was interviewed on 2/8/18 at 1:05 PM and she stated that she have not observed the seatbelt, tray table and seatbelt alarm removed especially during meals. When asked how they identify residents who use these devices, LPN #1 stated there is a white folder and task list for the unit which is a a quick reference for anyone that is new to the unit. Following initial interviews with CNA #1 and LPN #1, additional observations on 2/9/18 between 12:00 PM and 12:45 PM were conducted and revealed the resident at lunch in the unit dining room being assisted with her meal by a staff member with the continued use of the wheelchair seatbelt, seatbelt alarm, and tray table. The February 2018 CNA care guide and the Task List Assignment (a record used by nursing aides to obtain information about the type of care the resident needed and document completion of this task) did not include the use of a tray table, seatbelt or seatbelt alarm. There were no instructions for the aide to follow as to when to apply and remove the said devices, including other related care areas while these devices were being used by the resident. Interviews were conducted on the following dates and times regarding the use of the above devices: - 2/8/18 at 12:45 PM, CNA #1 stated that the seatbelt, seatbelt alarm and tray table were never removed including during meals because the resident has seizures; - 2/8/18 at 1:15 PM, RN #1 unit manager stated that the care plan to address their use was not done because he was waiting for therapy to give him a directive on the use of the wheel chair seatbelt, seat-belt alarm and the tray table, which is a typical protocol prior to application of these devices. He stated that the tray table was put on recently when the Speech Therapist was evaluating the resident. The resident was dropping food on the floor and on herself and the table gives her room. He said that the tray table was used because of a recent seizure and helps with positioning. He said the seatbelt did not prevent her from getting up because she does not walk and was originally placed as a positioning device which would not cause restriction. He said the seatbelt alarm was supposed to be discontinued and he that thought it was removed. - 2/8/18 at 1:25 PM, Licensed Practical Nurse (LPN#2) was asked how often and under what conditions the seatbelt, seat-belt alarms, and tray tables are removed, LPN #2 stated they should be removed every two hours and for cares, and that the nurses are responsible for making sure they are removed. - 2/12/18 at 1:50 PM, director of rehabilitation (rehab), stated that there was no documentation in her office that an actual assessment was done with regards to the use of the wheelchair seatbelt and seatbelt alarm. She stated she does not know where the seatbelt originated from. The director of rehab stated that the Interdisciplinary Rehabilitation Screen Form is only used as a communication form and not an assessment. -2/13/18 at 12:40 PM, CNA #3 was asked where she gets instructions for the resident's daily care. CNA #3 stated she checks the task sheet or she asks the nurse. She said that during training she was shown how to apply the seatbelt and the seatbelt alarm to this resident daily. She said that when she did not find any directions or instructions for the use of the wheelchair seatbelt, seat-belt alarm and tray table listed on the CNA Tasks Completed Form. CNA #3 further stated that she should have clarified with the nurse manager about their use but she did not. She said that in the future she will read the task sheet daily and will pay better attention to the directions it gives. -2/13/18 at 12:45 PM, CNA #2 stated she reads the CNA Task Completed Form daily before starting work on her shift. CNA #2 was unable to show where she was directed to use a wheelchair seat-belt, seatbelt alarm or tray table for this resident. She said that since working on this unit back in May 2017 the resident has had a seatbelt in the wheel chair with a seatbelt alarm. She said that after having a seizure in January she also has a tray table in place. She said the resident always tried to get out of the seatbelt in the past. When she was asked to explain why she applied the seatbelt and seatbelt alarm when there were no instructions to do so, she said she put them on because they were on her chair. CNA #2 further stated she never alerted the nurse or the nurse manager about the CNA task sheet not providing directions for the use of these devices. -2/13/18 at 2:30 PM, the Medical Director was asked about the use of these devices. He stated that the facility has systems in place for the use of restraints and positioning devices. The decision to initiate their use involves the nurse managers, the attending physicians, and the physical therapists. 415.26(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that the facility staff followed proper hand hygiene to prevent cross contamination and prevent the spread of infection. Specifically, three Licensed Practical Nurses (LPNs) did not perform proper hand hygiene during medication pass to Residents #53, #188, and #217 on the Catskill, [NAME], and Esopus units, respectively. This was evident on 3 of 6 units. The findings are: 1. Resident #53 has diagnoses including Anemia, Coronary Artery Disease, and Congestive Heart Failure. The unit medication LPN #5 was observed on 2/6/18 at 8:25 AM administering medications to resident #53 on the Catskill Unit. LPN #5 placed her finger inside the medication cup on three occasions prior to giving the medication to the resident. During this same medication pass, LPN #5 crushed the medication then put her finger inside the package with the crushed medication to pry open the package, potentially contaminating its contents before pouring the contents into a medication cup to give to the resident. LPN #5 was interviewed following the medication pass at 8:41 AM and she stated that she should have held the cup at the bottom and used gloves to open the package. 2. Resident #188 has diagnoses including Hypertension, Major Depressive disorder, and Schizophrenia. The unit medication LPN #4 was observed on 2/6/18 at 8:51 AM administering medications to resident #188 on the [NAME] Unit. While giving the medication to the resident, LPN #4 placed two medication cups directly on top of the medication cart without cleaning the top of the cart. LPN #4 then filled each cup with a tablet and then picked up one of the cups and stacked it into the other cup, potentially contaminating the contents of the bottom cup. LPN #4 was further observed to put her finger inside the cups prior to giving the medications to the resident. LPN#4 was interviewed immediately following the medication pass at 8:58 AM and she stated that she contaminated the whole thing. 3. Resident #217 has diagnoses including Hypertension, Acute Cerebrovascular Insufficiency and Constipation. The unit medication LPN #6 was observed on 2/6/18 at 9:09 AM administering medications to resident #217. The LPN touched and brushed through her hair and then proceeded to put her finger inside the medication cup potentially contaminating the medications of the resident. LPN #6 then proceeded to the resident's room and sat on the resident's bed while administering the medications to the resident. As she proceeded to give the medication to the resident, one of the pills fell from the resident's hand onto the bed. The LPN picked up the pill with her bare hand and gave it back to the resident. LPN #6 was interviewed following the above observation at 9:40 AM and stated that she didn't realize that she touched her hair and contaminated the cup. She further stated that she should have thrown the pill away. 415.19(b)(4)