**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Complaint survey from 01/05/2023 through 01/13/2023, the facility did not ensure that residents are informed and provided written information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This was evident for 1 of 2 residents reviewed for Advance directive out of a total sample of 42 residents (Resident #481). Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for Resident #481 upon admission. The findings are: The facility Policy and Procedures titled Advance Directives and Health Care Decision making dated August 26, 2014, last revised 08/27/12, documented that the facility will provide all newly admitted adult residents and/or family members following information concerning their right to execute advance directives: a) The New York State Department of Health (NYSDOH) form entitled planning in Advance for your Medical Treatment .Acknowledgement Form signed by the resident/family member attesting to the receipt of the above mentioned information is to be placed in the Advance Directives section of the medical record. Resident #481 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Peripheral Vascular Disease (PVD), Acquired Absence of Right and Left Leg above knee. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS also documented Resident #481 participated in the assessment and goal setting. On 01/05/23 at 11:22 AM, during the initial pool, Resident #481 was interviewed. Resident #481 stated that he/she has been in the facility about a month, and no one has had any discussion with them regarding Advance Directives. During the initial record review process on 01/05/23 at 03:24 PM, there was no documented evidence of advance directives in the Electronic Health Record (EHR) and on hard chart. The Nurses Note - New Admission dated 12/01/2022 documented Resident #481 was received by nursing staff with their belongings. The Physician (MD) and Assistant Director of Nursing were informed of the admission. The Social Worker Initial Assessment dated 12/05/2022 documented Resident #481 was alert and oriented, pleasant, cooperative, and had no viable discharge plan. The resident stated they would like to stay at the facility for long term care. Progress note Social Worker Plan of Care Note dated 12/14/2022 documented that Resident has friend listed in personal care section, resident has not listed any family members, if any changes occur, they will be made to the profile. No documented evidence that Advance directive was discussed. The Multidisciplinary Care Conference Social Work Summary dated 12/15/2022 documented Resident #481 had intact cognition, was new to the facility, and acclimating to the environment. There was no documented evidence in the medical record that advance directives were discussed with the resident or that information regarding advance directives was provided. There was no Comprehensive Care Plan (CCP) initiated for Advance Directives in the medical record. On 01/10/23 at 11:59 AM, an interview was conducted with the Registered Nurse/Head Nurse (HN #1). HN #1 stated that Resident #481 was newly admitted to the unit, and it is the Social Worker that is responsible for discussing and initiating Resident's Advance directive for new admission residents. HN #1 also stated that they don't actually know anything about the new residents' advance directive. On 01/10/23 at 12:15 PM, an interview was conducted with the Social Worker (SW #1). SW #1 stated that they usually have a conversation with the residents upon admission. SW #1 stated that if new residents have no Advance Directives, sometimes they need to educate them and explain the meaning and importance of Advance Directives to the resident and invite them for the meeting to discuss the details. SW #1 stated that they have not yet scheduled any meeting to discuss advance with Resident #481, but they are now going to meet with the resident to complete a Medical Orders for Life-Sustaining Treatment (MOLST) form. On 01/11/23 at 02:45 PM, an interview was conducted with the Director of Social Work (DSW). The DSW stated that upon admission, the person that does the admission usually discusses Advance Directives with the resident, which could be the nurse or the doctor. The Social Worker will discuss advance directives as soon as possible if the resident wishes to formulate one and ensures it is in place as per the resident's wishes. The DSW also stated that they believe there is a section in the SW assessment where the discussion and implementation of advance directives should be documented. The DSW stated they did not know why this was not done. On 01/13/23 at 02:28 PM, an interview was conducted with the Director of Nursing (DON). The DON stated upon admission, if a resident comes with an advance directive, the doctor will be notified so orders can be put in place. If the resident does not have an advance directive upon admission, the doctor and social worker will discuss advance directives with the resident or family. 415.3 (e) (2)(iii).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the record review and interviews conducted during a Recertification and Abbreviated (NY00293582) Survey, from 01/05/2023 to 01/13/2023, the facility did not ensure all alleged violations of abuse were thoroughly investigated. This was evident for 2 (Resident #199 and #357) of 10 residents reviewed for Abuse of 42 total sampled residents. Specifically, the investigation of resident-to-resident altercation involving Resident #199 and Resident #357 did not contain statements from staff witnesses. The findings are: The facility policy titled Abuse Prevention and Reporting and Management of Other Reportable Incidents last revised 11/01/2022 documented allegations must be investigated promptly. The supervisor immediately takes statements or ensures that statements are taken from all staff present in the unit at the time of the incident or allegation. Resident # 199 had diagnoses of chronic obstructive pulmonary disease and bipolar disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 199 was moderately cognitively impaired. The Accident Report dated 04/01/2022 documented Resident # 199 reported an abrasion to the right wrist after Resident #357 hit Resident #199 with their cane. Resident # 199 punched Resident #357 in the face. Housekeeping saw Resident #357 near the elevator and informed the head nurse. The Behavior Rapid Response Team was initiated by staff at 8:45 AM. The primary doctor, the psychiatrist, and the hospital police responded to the unit. Resident # 357 had diagnoses of dementia and hemiplegia. The MDS assessment dated [DATE] documented that Resident # 357 was moderately cognitively impaired and required supervision and cueing. The Accident Report dated 04/01/2022 documented Resident #357 was observed in the hallway at 8:48 AM bleeding on the right side of their face. Resident # 357 had a lacerated wound and bleeding on the right lower eyelid, bruise on the forehead, nose, cheek bridge, and scratch marks on the right and left upper arms. Several metallic rings on Resident #199's fingers aggravated Resident #357's injuries. The Risk Management Summary Report dated 04/01/2022 documented the facility concluded a resident-to-resident physical altercation between Resident #199 and Resident #357 occurred. There was no documented evidence the facility gathered statements from direct witnesses (housekeeping staff, nursing staff, and Resident #199) when investigating the resident-to-resident altercation between Resident #199 and Resident #357. On 01/11/2023 at 9:02 AM, an interview was conducted with the Housekeeping Staff (HS) #1 who stated that they saw Resident # 357 with blood in the eye and called the nurse. The nurse asked HK #1 what happened, but HS #1 was not asked to write a statement. On 01/11/2023 at 9:33 AM, an interview was conducted with the Certified Nursing Assistant # 3 (CNA # 3). CNA #3 was not there when the incident occurred. The residents were on the same unit, but they were not roommate. CNA # 3 heard that the residents had arguments before the fight. The residents had no verbal or physical altercation before the incident. Resident # 199 had no history of aggressive behavior. CNA # 3 was not asked to write a statement. On 01/12/2023 at 9:00 AM, an interview was conducted with the Head Nurse (HN) #1 and stated they observed Resident #357 sitting in their wheelchair in the hallway bleeding from their right eye. The resident was alone in the hallway and was aphasic but was able to motion that someone punched them in the eye. Resident #199 admitted to punching Resident #357 in the eye. HN #1 did not write a statement re: the incident. An interview was conducted on 01/12/23 at 9:09 AM, with Registered Nurse (RN) who stated RN #3 initiated the Accident Report. The Risk Manager followed through and completed the investigation. RN #3 did not write a statement. On 01/11/2023 at 3:39 PM, an interview was conducted with the Risk Manager (RM) who stated the RM reviewed the Accident Report to determine whether the incident between Resident #199 and Resident #357 was reportable to the New York State Department of Health (NYSDOH). The facility practice is not to collect statements, but it depends upon the type of incident. Resident-to-resident altercations are not treated as abuse allegations and the RM does not collect witness statements. The Accident Report, progress notes, and hospital police documentation is used to complete the RM's investigation. On 01/13/23 at 9:52 AM, an interview was conducted with the Director of Nursing (DNS) who stated the RM is supposed to complete the Risk Management Summary Report with statements from staff. Even if an incident is unwitnessed, the staff involved should have their statements included in the investigation. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 01/05/23 to 01/13/23, the facility did not ensure a resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident #481) of 42 total sampled residents. Specifically, Resident #481 did not receive a written copy of their BCP once developed and implemented. The findings are: The facility policy titled Care Plans - Baseline dated 10/012019 documented the BCP will be completed and implemented within 48 hours of a resident's admission. The Social Worker (SW) provides the resident a copy of the BCP if the resident is cognitively intact and documents in the resident's medical record. Resident #481 was admitted [DATE] with diagnoses of right above the knee amputation and peripheral vascular disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #481 was cognitively intact and participated in the assessment and goal setting. On 01/05/23 at 11:22 AM, Resident #481 was interviewed and stated they were admitted to the facility approximately 1 month ago and have not received their BCP in writing. BCP dated 12/05/2022 documented the Interdisciplinary Team (IDT) completed Resident #481's BCP. There was no documented evidence Resident #481 was provided with a written copy of their BCP dated 12/05/2022. On 01/10/23 at 11:59 AM, Head Nurse (HN) #1 was interviewed and stated Resident #481's BCP was completed by the IDT within 48 hours of the resident's admission. HN #1 could not recall if the resident was provided with a copy of the BCP and was unable to provide documented evidence Resident #481 received a copy of the BCP. On 01/10/23 at 12:15 PM, SW #1 was interviewed and stated the BCP was provided to residents in written form during their initial care plan meeting. SW #1 was unable to provide documented evidence Resident #481 received their BCP in writing. On 01/11/23 at 02:45 PM, the Director of SW was interviewed and stated the Nursing staff are responsible for providing residents with a copy of their BCP. On 01/13/23 at 02:28 PM, the Director of Nursing was interviewed and stated the SW is responsible for giving a written copy of BCP to residents and/or their representatives. The IDT discussed the need to provide the BCP to residents during morning meetings. 415.11 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 1/5/23 to 1/13/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to address a resident's needs. This was evident for 2 (Resident #488 and #489) of 42 total sampled residents. Specifically, 1) a CCP related to discharge planning was not developed or implemented for Resident #488 and 2) a CCP related to discharge planning was not developed or implemented for Resident #489. The findings are: The facility policy titled Interdisciplinary Care Plan Meeting dated 10/1/19 documented each discipline is responsible for completing and updating their specific sections of the resident's CCP. Social Workers (SW) are responsible for reviewing discharge plans and related impact upon resident adjustment. The facility policy titled Discharge Planning and Transfer dated 9/10/19 documented the SW, interdisciplinary team (IDT), and resident/family develop an individualized comprehensive person-centered discharge plan consistent with medical discharge recommendations and identified needs. 1) Resident #488 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus and Alzheimer's disease. and was discharged to community on 12/14/22. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #488 was severely cognitively impaired. SW Note dated 10/17/22 documented Resident #488 did not have an active discharge plan due to barriers like advanced dementia, cannot be alone due to safety issues, family unable to support and homelessness. SW Note dated 10/28/22 documented Resident #488 had no immediate plans for discharge. SW Note dated 11/21/22 documented Resident #488's family wanted the resident to be discharged home. Resident #488 will require post-discharge plan of care such as appropriate care/setting and physician clearance to ensure safe discharge. SW Notes dated 12/1/22 and 12/13/22 documented Resident #488's family continued to want the resident discharged home. SW Note dated 12/14/22 documented Resident #488's family decided to have the resident discharge Against Medical Advice (AMA) from the facility despite plan to facilitate resident's safe discharge home. On 01/13/23 at 09:20 AM, SW #2 was interviewed and stated discharge planning starts upon a resident's admission assessment. Resident #488 was admitted to the facility for long-term placement and did not have a plan for discharge. The resident's family later requested for Resident #488 to be discharged to their home. SW #2 discussed plans for discharge with the resident's family, but a CCP related to discharge planning was not developed for Resident #488. CCPs related to discharge planning are initiated when discharge is determined to be safe by the IDT. Resident #488 had discharge barriers that needed to be addressed before the resident's discharge could be determined safe. 2) Resident #489 was admitted to the facility on [DATE] with diagnoses of spinal fusion and obesity. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #489 was cognitively intact and their discharge plan included returning to the community. The Baseline Care Plan (BCP) dated 10/5/22 documented Resident #489's initial discharge goal was to return to the community. The SW Initial assessment dated [DATE] documented Resident #489 wants to return to community and has a viable discharge plan to return to the community upon completion of care. The SW Note dated 11/17/22 documented Resident #489 requested discharge to the community on 11/18/22. Resident's brother has unoccupied room and lives in an elevator building. Resident's transportation, medical appointment and medications have been confirmed for discharge instructions. The SW Note dated 11/18/22 documented Resident #489 requested discharge to their family's home until all services are in place for return to home. The Physician's Order dated 11/18/22 documented order for Resident #489 to be discharged home the same day. There is no documented evidence a CCP related to discharge planning was developed and implemented for Resident #489. On 01/13/23 at 09:37 AM, SW #3 was interviewed and stated Resident #489 was admitted for short-term rehabilitation and their discharge plan was initiated during the resident's admission assessment. Resident #489's discharge plans were documented in the SW Notes. SW #3 was unable to explain the reason a CCP related to discharge planning was not developed for Resident #489. On 01/13/23 at 10:14 AM, the SW Supervisor was interviewed and stated they are a new employee and had to consult with their Director re: the discharge planning process. The SW Supervisor stated discharge planning is initiated and developed for residents admitted to the facility for short-term rehabilitation. Discharge planning is not applicable to long-term residents of the facility. The CCP is initiated once a resident has a safe discharge plan. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the record review and interview conducted during a Recertification survey from 01/05/2023 to 01/13/2023, the facility did not ensure a resident and their representative was invited to participate in the comprehensive care plan (CCP). This was evident in 1 (Resident #78) of 42 total sampled residents. Specifically, Resident #78 was not invited to attend CCP meetings. The findings are: The facility policy titled Interdisciplinary Care Plan (ICP) Meeting dated 10/01/2019 documented the Social Worker (SW) is responsible for inviting the resident and resident representative to the ICP meeting, with advance notice prior to the date of the ICP meeting. Resident # 78 had diagnoses of chronic kidney disease and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident # 78 was cognitively intact. On 01/05/2023 at 11:50 AM, an interview was conducted with Resident # 78 who stated that sometimes they are not invited to their CCP meetings. Care Conference Notes dated 4/13/22, 7/03/22, and 9/22/22 documented CCP meetings were held for Resident #78. The resident's attendance signature was not documented. There was no documented evidence Resident #78 was invited to attend the CCP meetings scheduled 4/13/22, 7/03/22, and 9/22/22. On 01/10/2023 at 11:21 AM and 3:17 PM, the Social Worker (SW #2) was interviewed and stated they invite Resident #78 to the CCP meetings, but the resident does not always attend. Resident # 78 is usually at dialysis treatment during the CCP meetings because the meetings are scheduled every Thursday at 11 AM. SW #2 stated they believed there was documentation in the medical record that Resident #78 was invited to all CCP meetings, but after reviewing the medical record, SW #2 stated there was no documentation Resident #78 was invited to their CCP meetings. On 01/13/2023 at 8:49 AM, an interview was conducted with the Director of Social Services (DSS) who stated residents and designated representatives are invited to all CCP meetings and Resident #78 should have been invited to their CCP meetings. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during a recertification survey from 1/5/23 to 1/13/23, the facility did not ensure a resident was assisted with making appointments to maintain vision abilities. This was evident for 1 of 1 resident(s) reviewed for Communication of 42 total sampled residents (Resident #324). Specifically, optometry and ophthalmology appointments were not scheduled for Resident #324. The findings are: The facility policy titled Consultations/Specialty Referrals Processing dated 4/1/11 documented residents will receive specialty evaluations upon request by their primary care physicians. Resident #324 had diagnoses of glaucoma and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #324 had moderately impaired cognition and highly impaired vision. On 01/05/23 at 02:55 PM, Resident #324 was interviewed and stated they have problems with their vision and their eyeglasses have been missing for years. Resident #324 was seen by the eye doctor last year but did not have a follow-up appointment scheduled. The Comprehensive Care Plan related to impaired visual function initiated 8/27/21 and last reviewed 12/8/22 documented to arrange consultation for Resident #324 with eye care practitioner as required. The Optometry Consult dated 11/9/21 documented Resident #324 had chronic glaucoma, was referred to the ophthalmologist for an evaluation, and was to return in 6 months for follow-up with the optometrist. There was no documented evidence follow-up appointments for the ophthalmologist and/or optometrist were scheduled for Resident #324 after 11/9/21. On 01/10/23 at 10:26 AM, an interview was conducted with Registered Nurse (RN) who stated Resident #342 was not seen by the optometrist or ophthalmologist since 11/9/21. On 01/10/23 at 12:05 PM, the Attending Physician was interviewed and stated Resident #324 was not scheduled for an ophthalmology evaluation after the recommendation was made by the optometrist on 11/9/21 because there was an increase in COVID-19 cases at the time and Resident #324 was at high risk for contracting COVID-19. 415.12(3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure medications and biologicals in accordance with currently accepted professional principles and expiration date, if applicable. This was evident for 1 of 22 units (Unit C12). Specifically, (1) a multi-use vial of intramuscular (IM) Lorazepam was not discarded according to manufacturer recommendation. The findings are: The undated facility policy titled Storage of Medications documented when multidose injectable vial seal is broken, the vial will be dated (a) the nurse shall place a date opened sticker on the medication and enter the date opened and (b) if a vial or container is found without a date opened, the date will automatically default to the date dispensed and the expiration date will be calculated accordingly. On [DATE] at 11:14 AM, the C12 medication room refrigerator was observed with Registered Nurse (RN) #5 present and to contain an opened Lorazepam IM 20 mg/10 ml multi-use vial prescribed to Resident #412 with the following label: Rx # 77175824; Date Written: [DATE]; Electronic Repeat Dispensing ([NAME]): [DATE]; Inject 2 MG intramuscularly every 24 hours as needed for agitation 30 minutes before hemodialysis 5 days a week. The vial did not document the date it was opened or the date to be discarded. On [DATE] at 02:48 PM, Licensed Practical Nurse (LPN) # 1 was interviewed and stated the vial of Lorazepam did not contain parameters so LPN #1 called the pharmacy representative and was informed the vial of Lorazepam would expire after being opened for 90 days. On [DATE] at 12:06 PM, RN #5 was interviewed and stated the Lorazepam for Resident #412 should have been dated to prevent the resident from being given an expired medication. RN #5 contacted the facility pharmacy and was informed the vial of Lorazepam was good for up to 6 days when refrigerated. Resident #412's behavior has been stable, so the medication has not been administered recently. On [DATE] at 3:33 PM, the Director of Nursing (DON) was interviewed and stated any multi-use vial of medication should be labeled with the date it was opened. The medication should be discarded according to the pharmacy recommendations for the expiration date. On [DATE] at 04:35 PM, the Pharmacist was interviewed and stated that the multidose medication vial expires in 28 days from the date of the first puncture when kept in the refrigerator. 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #18 had diagnoses of traumatic brain injury (TBI) and vascular dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had severely impaired cognition, was totally dependent on staff to perform activities of daily living, and did not use physical restraints. On 01/05/23 at 09:49 AM and 02:55 PM and 01/06/23 at 10:14 AM, Resident #18 was observed in bed with 4 SRs raised. On 01/09/23 at 10:28 AM, Resident #18 was observed in bed with 3 (2 upper and 1 lower SR on resident's right side) out of 4 SRs raised. The Comprehensive Care Plan (CCP) related to SR use was initiated on 3/16/20 and last reviewed 10/18/22 documented Resident #18 had 2 upper SR raised due to diagnosis of dementia, impaired cognition, and seizures. MDO dated 10/23/20 documented Resident #18 was ordered 2 upper SRs while in bed for positioning due to diagnosis of seizures, dementia, impaired cognition, and no boundary awareness. The SR assessment dated [DATE] documented raising 2 upper SRs for positioning and turning of Resident #18. The SRs were not restricting Resident #18's movements and were not used as a restraint. On 01/11/23 at 03:40 PM, Certified Nursing Assistant (CNA) #5 was interviewed and stated Resident #18 holds on to the 2 raised upper SRs when turning in bed and the lower SRs are kept in the lowered position. A CNA on another shift possibly raised the lower SRs for Resident #18's protection. 3) Resident #68 had diagnoses of traumatic brain injury (TBI) and dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #68 had severely impaired cognition, was totally dependent on staff for activities of daily living (ADL), and did not use restraints. On 01/05/23 at 09:53 AM and on 01/09/23 at 10:27 AM, Resident #68 was observed in bed with 3 (2 upper and 1 lower SR on resident's left) of 4 SRs raised. On 01/06/23 at 10:17 AM, Resident #68 was observed in bed with all 4 SRs raised. A Comprehensive Care Plan (CCP) related to SR use initiated 3/17/20 and last revised 11/22/22 documented Resident #68 had 2 upper SRs for positioning and ADL support. MDO dated 1/20/22 documented order for Resident #68 to have 2 upper SRs raised for positioning, ADL support, and diagnosis of seizure disorder. The SR assessment dated [DATE] documented recommendation for Resident #68 to have 2 upper SRs for positioning due to diagnosis of dementia, impaired cognition, and no sense of boundary awareness. SRs were not used as a restraint. On 01/11/23 at 03:32 PM, Certified Nursing Assistant (CNA) #6 was interviewed and stated Resident #68 uses 2 upper SRs for bed boundaries and to grab during care. The CNAs raise the lower SRs sometimes to prevent falls because Resident #68 tends to slide down in bed. On 01/13/23 at 10:12 AM, Registered Nurse (RN) #4 was interviewed and stated most residents use 2 upper SRs for mobility and to grab during care. Sometimes, the CNAs raise the lower SRs during care even though the CNAs know they are not supposed to raise all 4 SRs. RN #4 periodically spot-checks the SRs and lowers the SRs that were not supposed to be raised. On 01/13/23 at 10:37 AM, associate director of nursing #2 was interviewed and stated SRs are used as enablers during care and it is physical restraint when 4 SRs are raised. Residents #18 and #68 were not supposed to have their lower SRs raised. The CNAs were trained on proper SR use. The beds are manufactured with 4 SRs attached and cannot be modified. The lower siderails cannot be detached or disabled. On 01/13/23 at 02:15 PM, the Director of Nursing (DON) was interviewed and stated SRs are not used for staff convenience or as a physical restraint. The DON was not sure whether CNAs raise the lower SRs during care. 415.4(a)(2-7) Based on observations, record review, and interviews conducted during the Recertification Survey from 1/5/23 to 1/13/23, the facility did not ensure residents remained free from physical restraints. This was evident for 3 of 3 residents reviewed for Restraints of 42 total sampled residents (Resident #s 47, 18, 68). Specifically, 1) siderails (SR) were not used with Resident #47, #18, and #68 in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Use of Restraints dated 12/23/19 documented restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 1) Resident # 47 had diagnoses of traumatic brain injury (TBI) and post-traumatic seizures. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 47 had severely impaired cognition, was totally dependent on two persons for bed mobility and transfer, and did not use physical restraints. Between 01/05/23 at 11:20 AM and 01/10/23 at 09:39 AM, there were multiple observations of Resident #47 lying in bed with 4 SRs raised. MDO initiated 12/10/2020 documented Resident #47 was ordered to use 2 upper SRs for positioning, per air mattress manufacturer's recommendation, and for diagnoses of TBI, seizure, hemiplegia, and pressure injury prevention. The SR assessment dated [DATE] documented bilateral upper SRs were used with Resident #47 for safety and episodically during care. The call button and lights were incorporated into the SRs. Resident #47 had a history of falling out of bed due to sliding, poor trunk control, no sense of bed boundary, and unpredictable restlessness and agitation. On 01/10/23 at 10:12 AM, Certified Nurse Aide (CNA) # 2 was interviewed and stated Resident # 47 was alert and disoriented in bed. Resident #47 was quiet and did not move a lot. The 4 SRs are raised to protect Resident #47 from falling out of bed. CNA #2 receives report on residents from the head nurse daily at the start of their shift and recalls the head nurse reporting Resident #47 has 4 SRs raised while in bed. On 01/10/23 at 11:05 AM, Head Nurse (HN) # 2 was interviewed and stated the MDO is for Resident # 47 to have 2 upper SRs raised because the resident had no sense of bed boundaries. HN #2 gives resident report to the CNAs in the morning and the CNA should know Resident #47 has an MDO for 2 upper SRs. Resident #47 should not have 4 SRs raised while in bed. During the interview, HN #2 observed Resident #47 in bed with 4 SRs raised and was unable to provide an explanation for 2 lower SRs being raised. HN #2 stated they make rounds on the unit paid attention to positioning when the resident is in bed. It is considered a physical restraint when 4 SRs are raised. On 01/13/23 at 11:17 AM, the Director of Nursing (DON) was interviewed and stated they considered all 4 raised SRs as a physical restraint if the resident was not able to lower them or get out of bed. The DON rounds daily on some units and did not observe Resident #47 with 4 raised SRs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) Resident # 251 had diagnoses of cerebral infarction and left hemiparesis. (NY00276114) The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 251 was cognitively intact. The Incident Report dated 5/22/2021 documented Resident #251 was observed with blisters on their chest and stated they burned themselves while smoking a cigarette at their bedside. The Health Emergency Reporting Data System (HERDS) report dated 5/24/2021 at 11:16 AM documented facility reported Resident #251's chest burns incident occurred on 5/22/2021 at 5:00 PM, more than 24 hours prior to facility's report to the NYSDOH. Nursing Note dated 6/22/2021 documented Resident # 251 was discovered with a second-degree burn to their abdomen. The HERDS report dated 6/25/2021 at 3:32 PM documented Resident #251's abdominal burn occurred on 6/22/2021 at 10:37 AM, more than 24 hours prior to the facility's report to the NYSDOH. On 01/09/23 at 03:31 PM, Associate Director of Nursing (ADON) # 1 was interviewed and stated the Resident #251's burn incidents on 5/22/21 and 6/22/21 should have been reported to the NYSDOH within 24 hours of occurrence. The charge nurse reports any incident to the ADON immediately. The ADON discusses the incidents with the Risk Manager (RM) and the Director of Nursing (DNS) to determine whether incidents are reportable to the NYSDOH. ADON # 1, the RM, and the DNS have access to the Health Commerce System (HCS) to report allegations of abuse and other reportable incidents to the NYSDOH. On 01/09/23 at 03:48 PM and 01/13/23 at 2:17 PM, Director of Risk Management (DORM) was interviewed and stated they were responsible for reporting allegations of abuse and other reportable incidents to NYSDOH through the HCS. The incidents involving Resident #251 should have been reported to the NYSDOH within 24 hours of occurrence and the DORM was unable to recall the reason reporting was delayed. The DORM previously believed all allegations of abuse had to be reported within 24 hours of occurrence. The DORM is now aware allegations of abuse should be reported no later than 2 hours after occurrence. On 01/13/23 at 02:21 PM and 03:28 PM, the DNS was interviewed and stated allegations of abuse, including resident-to-resident altercations are supposed to be reported to the NYSDOH within 2 hours of occurrence. The RM reports during the day and the ADON is responsible for reporting on the night shift. The DNS was trained on the HERDS procedure and was unaware there were facility reported incidents that were not reported to the NYSDOH within the acceptable timeframe. 415.4 (b)(1-2) 2.) Resident #245 had diagnoses of dementia and mood disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident #245 was severely cognitively impaired. Resident #347 had diagnoses of dementia and dysphagia. The MDS dated [DATE] documented Resident #347 the resident was moderately cognitively impaired and displayed physically, verbally, and other inappropriate behavior. A Nursing Note dated 10/4/2022 documented Resident #347 punched Resident #245 leaving a scratch mark on Resident #245's face on 10/04/2022 at 6:15 AM. The Aspen Complaint Tracking System (ACTS) intake (NY00303282) documented the facility reported the altercation between Resident #347 and #245 to the NYSDOH on 10/04/2022 at 2:18 PM, more than 2 hours after occurrence. On 01/13/2023 at 01:57 PM, the Risk Manager (RM) stated they were made aware of the incident involving Resident #347 and #245 on 10/04/2022 at 7:47 AM via email. The RM is unable to access the system to file facility reports with the NYSDOH from home. The RM and the Registered Nurse (RN) working during the incident on 10/04/2022 have access to NYSDOH reporting through the Health Commerce System (HCS). The facility was not reporting allegations of abuse to the NYSDOH within the 2-hour timeframe. Instead, the facility reported allegations of abuse to the NYSDOH within 12 hours of occurrence. Based on interviews and record review conducted during the Recertification and Complaint survey (NY00284350, NY00303282, and NY00276114) from 01/05/2023 to 01/13/2023, the facility did not ensure violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This was evident for 6 of 6 residents reviewed for Abuse out of 42 total sampled residents (Resident #s 278, 285, 170, 347, 245, and 251). Specifically, 1.) the facility reported resident-to-resident altercations involving Resident #278, #285, and #170 to the NYSDOH more than 2 hours after occurrence, 2.) the facility reported a resident-to-resident altercation involving Resident #347 and #245 to the NYSDOH more than 2 hours after occurrence, and 3.) the facility reported Resident #251's second-degree cigarette burns to the NYSDOH more than 24 hours after occurrence. The findings are: The facility policy titled Abuse Prevention and Reporting and Management of Other Reportable Incidents dated 11/01/2022 documented Risk Management is responsible for assessing and ensuring the reporting of eligible incidents per regulatory requirements. Accidents resulting in second-degree burns must be reported to the NYSDOH. Incidents that do not involve serious bodily injury are to be reported to the NYSDOH no later than 24 hours after forming the suspicion. 1.) Resident #278 had diagnoses of non-Alzheimer's dementia and traumatic brain injury. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #278 was moderately cognitively impaired. Resident #285 had diagnoses of non-Alzheimer's dementia and seizure disorder. The MDS dated [DATE] documented Resident #285 was cognitively intact. Resident #170 had diagnoses of coronary artery disease (CAD) and depression. The MDS dated [DATE] documented Resident #170 was moderately cognitively impaired. Nursing Note dated 10/06/2021 documented Resident #285 hit Resident #278 with a cane and Resident #278 sustained a left eye hematoma and left wrist abrasion. Health Emergency Reporting Data System (HERDS) report (NY00284350) dated 10/06/2021 at 3:42 PM documented a facility report the resident-to-resident altercation involving Resident #285 and Resident #278 occurred on 10/06/2021 at on 10/06/2021 at 5:15 AM, more than 2 hours prior to the facility report. Nursing Note dated 02/21/2022 documented the nurse resolved a dispute over headphones between Resident #278 and Resident #170. The nurse later responded to a noise in the bathroom and found Resident #278 kicking Resident #170. The HERDS report (NY00284350) dated 02/21/2022 at 10:57 PM documented a facility report of an altercation between Resident #278 and Resident #170 that took place on 02/21/2022 at 6:00 PM, more than 2 hours prior to the facility report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #314 was readmitted [DATE] with diagnoses of Disorganized Schizophrenia, Anxiety Disorder, Nicotine Dependence Unspecified and Other Specified Peripheral Vascular Disease. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #314 had intact cognition and required supervision/set up help with Activities of Daily Living (ADL). On 1/05/2023 at 10:53 AM, during the initial tour, Resident #314 opened their room door, and the resident's room smelled like smoke. On 1/09/2023 at 11:07AM, the surveyor observed staff report the smell of smoke in the Resident 314's room. The hospital campus police arrived to the room at 11:10AM to investigate. One used cigarette butt was observed under the resident's bed, and the smell of smoke was noted in the air in the resident's room and bathroom. The [NAME] Police Department Resident Call for Assistance forms documented that [NAME] Police were called to the resident's room for the smell of smoke, and cigarette or lighter were in the resident's possession. On 07/02/2022 Hospital Police (HP) did a room check after staff reported smelling smoke in Resident #314's room. On 07/22/2022 documented Resident #314 was given a lighter to smoke by another resident and upon requesting the lighter Resident #314 refused to return it and HP responded to retrieve the lighter. On 08/24/2022 documented the staff nurse reported resident smoking in their room. On 09/30/2022 documented that 11 cigarettes were confiscated and returned to Behavioral Health Associate (BHA). On 8/19/2022, 10/25/2022, 11/1/2022, 11/22/2022, 12/07/2022 documented 1 lighter was recovered and returned to Behavioral Health. On 12/14/2022 documented HP reported to the resident's room for a report that Resident #314 was smoking in their room. On 01/07/2023 documented 1 lighter was confiscated from the resident. There was no evidence of increased monitoring or new interventions implemented after these incidents. The Smoking Safety Evaluation forms done on 12/23/2020, 3/22/2021, 7/16/2021, 10/16/2021, 1/16/2022, 5/28/2022, 08/28/2022 and 12/5/2022 documented resident was a tobacco user. The Quarterly Smoking Safety Evaluation on 12/5/2022 documented the resident is a smoker, supervision will be required for all residents during designated smoking times and the resident has balance problems while sitting or standing. The smoking assessment did not state if resident #314 was identified as either a safe or unsafe smoker. The Smoking Care Plan dated 05/24/2022 documented the following interventions: , instruct resident about the facility policy on smoking: location, time, safety concerns, monitor behavior towards other residents, intervene timely when resident is agitated and call Behavioral Rapid Response Team (BRRT) when needed, orient resident with the location of the smoking room, assess/reassess ability to smoke independently and compliance with smoking policy, educate regarding smoking policy and designated smoking areas, offer smoking cessation, random environmental rounds when at bedside, instruct to report timely any injuries related to smoking, monitor compliance with smoking policy, observe clothing and skin for signs of cigarette burns, and requires supervision while smoking . On 5/29/2022 the CCP was updated with the intervention to store the resident's cigarettes in the smoking room. The CCP intervention for Behavior management staff to escort resident to smoking daily was added on 8/15/2022. On 1/07/2023, the CCP was updated with the intervention to conduct a body search and room check for posession of smoking materials by staff with hospital police and confiscate any materials found. A CCP note on 1/7/2023 at 1:12 PM documented Resident #314 was found smoking in their room. The BRRT was called, and the Hospital police did environmental check in order to confiscate lighter and cigarette. The Nurse supervisor made aware. The Progress notes for the resident on 8/19/2022 there is not documentation related to lighter being found. A Nursing note on 10/25/2022 at 3:28 PM documented a Behavioral Health Associate found a lighter in Resident #314's room and confiscated it. The Behavioral notes on 11/6/2022 and 11/11/2022 there is no documentation related to smoking. A Nursing Note dated 12/07/2022 at 10:13 AM documented a lighter was found in Resident #314's room. There are no progress notes on 11/1/2022 in relation to the lighter found for resident. A Nursing Note dated 1/7/2023 documented the Rapid Response Team (RRT) was called because the resident was found smoking in the room. The RRT reported to Resident #314's room at 1:00pm, and an environmental search was conducted by the hospital police. Resident #314 left the unit. A Nursing on 1/9/2023 at 11:29 AM documented the Tour 2 medication nurse notified the writer of the smell of cigarette smoke coming from Resident #314's room. Redirection and education were provided, and the resident was verbally abusive/threatening. Hospital police was called to assist with de-escalation. The Assistant Nurse Director (ADN) and Psychiatrist were notified of the resident's behavior. A lighter and cigarette were found in the resident's room. There was no documented evidence the facility reassessed Resident #314 for smoking after documented incidents of smoking in the room and lighters being found in the resident's possession. There was no documented evidence the facility provided adequate supervision to prevent smoking incidents after repeated noncompliance, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. During an interview on 01/09/2023 at 11:27 AM and 01/12/2023 at 08:50 AM, the assigned Certified Nursing Assistant (CNA #7) stated they smell smoke coming from Resident #314's 2-3 times per week. CNA #7 stated smoking has been an ongoing issue on the unit, and they are constantly calling campus police to look at Resident #314's room. Anytime we smell smoke, we do room checks, and we can smell the smoke while the door is closed. CNA #7 stated they have never seen burn marks on Resident #314's clothing. The Social Worker keeps Resident #314's smoking materials, and staff will offer soda in exchange for smoking materials. CNA #7 stated if they smell smoke, they report it to the nurse who reports it to the ADN and hopsital police. The hospital police serach the resident's room for smoking materials. Resident #314 is taken to smoke at 10AM and 2PM by staff, but the resident does not follow the rules and will also smoke in their room. CNA #7 stated they can smell the cigarette smoke through their N95 mask. On 01/09/2023 at 05:24 PM, an interview was conducted with CNA #8, a smoke room monitor. CNA #8 stated Resident #314 smokes at 5PM. Resident #314 is provided with a cigarette to smoke, and they are not given a lighter. On 01/10/2023 at 09:58 AM and 01/12/2023 at 09:14 AM, an interview was conducted with CNA #9, a smoke room monitor. CNA #9 stated Resident #314 comes with an escort to smoke. Resident #314's cigarettes are provided to the smoke room monitor daily by behavioral health. Resident #314 is not allowed to have a lighter. CNA #9 stated unsafe smokers are not allowed to hold their smoking materials and are on watch. CNA #9 stated the smoke room is locked outside of the designated hours. The room is open at 10AM, 11AM, and 2PM. On 01/11/2023 at 08:56 AM, an interview was conducted with LPN #1 who stated resident #314 smoking in their room and smoking cigarette smoke noted from room and when resident out check and always find smoke smell. Resident #314 goes to different floors. Resident goes with another staff to go smoke. Resident #314 went out 9 AM this morning but not sure if resident went to smoke. when noticed smoke smell they did not notify anyone. The Behavior Health Associates came to check on resident #314 as part of the psychiatry team. If smell cigarette reports, it and resident clothes smell like smoking. Resident #314 does not want anyone close to them and curses staff. Resident #314 is accompanied by psych team when they want to smoke. They have not noticed cigarette butts or lighters when cleaning resident room. No burns in resident clothing noted. Rounding is done at 9AM, 10AM, 12PM, 2PM and have Plan of Care (POC) where it is documented. Call the nurse in charge if they note any smoking behavior. They have had in-service on fire in 2022. They stated in 2021 that they noticed a lighter in the middle area of the resident's door and they threw it in the garbage and did not report this. There are no other smokers on the unit that they are aware of. and discriminatory words. On 1/11/2023 at 03:10 PM, the Licensed Practical Nurse (LPN #1) was interviewed and stated most of the time when CNA assigned next door and active to look at resident so when walk and smell cigarette call doctor and contact the police to search resident. LPN #1 stated they were instructed not to go inside without consent resident alert, with schizophrenia and confused sometimes. LPN #1 document behavior and if resident #314 is smoking in their room in nursing progress notes and resident #314 is not allowed to hold cigarette. They have scheduled smoking times in smoking room [ROOM NUMBER]AM and 2PM and they don't know where resident gets cigarette. When staff gave resident shower found a lighter on resident wheelchair. We cannot talk to the resident, and they curse staff. If there is an incident and they are working, they make note. We have a behavioral tracking for resident and if documented behaviors it would take up the whole chart. There is a smoke room in the facility and the smoke room provides the materials for the resident. LPN #2 stated that prior to October 15, 2022, they documented in progress notes any smoking behavior. LPN #1 stated that they were just informed on Monday resident smoked again. They have to call the police and can't go inside resident room and when reporting when searching could not find cigarettes and only the police can search the resident. Resident #314 is considered unsafe smoker resident smoked on unit and not sure how resident dispose of cigarette butt and when smell will call police right away and this behavior may cause a fire. We cannot notice lighter, or cigarettes resident #314 will hide it and was not holding anything and resident is prohibited from smoking in here and not sure how the resident gets the cigarette. On 01/11/2023 at 03:38PM, an interview was conducted with RN #5 who stated that they noticed the resident #314 smoked in their room and they were caught 2 times in the last few days. They normally deescalate situation if smell it knock on room smell smoke and if can come in 9 out of 10 times and deny smoking in their room and if verbally aggressive call hospital police and confiscate, They may have found a lighter and cigarette recently. Resident #314 is escorted to smoke, and they are not sure if this is done by the CNA or psychiatry team. Resident #314 is educated on smoking, and they call the psych to further educate and redirect resident. Resident #314 refused to sign smoking contract and they are not sure how long-ago contract done. Rounding every 1 hour for the resident when they are working on this unit. If any smoking incident and the [NAME] smoking form is filled out. Not sure if focused meetings for resident had behavior meeting and no meeting related to smoking, they are aware of. On 01/09/2023 at 11:12 AM, the Campus Police Officer (CPO) was interviewed and stated they are responding to a report of Resident #314 smoking in their room. The CPO stated a used cigarette butt was found under the bed. The CPO stated Resident #314 could not be searched because they left the unit. On 01/09/2023 at 11:24 AM, the Housekeeper was interviewed and stated that they clean the resident's room when the resident leaves due to resident being aggressive and they don't let anyone into their room, and they smell smoke in the room every time they clean the resident room. The Housekeeper stated that they have found cigarette butts and ashes in the resident's sink a couple of times while cleaning the room. They report this to the charge nurse on the unit. The Houskeeper stated they did not receive recent education on smoking or the smoking policy. On 01/11/23 at 03:01 PM, an interview was conducted with CNA #11 who stated that Resident #314 goes with another staff to go smoke. The BHA's come to check on resident and escort the resident to smoke. CNA #11 also stated that if they smell cigarette smoke, they report it and they have noticed the resident's clothes smelled like cigarette smoke. Resident #314 does not want anyone close to them and curses staff. CNA #11 further stated they have not noticed any cigarette butts or lighters when cleaning resident room and no burns in resident's clothing was noted. Rounding is done at 9AM, 10AM, 12PM, and 2PM and it is documented on the behavioral health monitoring sheet and they notify the nurses if they notice any smoking behavior. In 2021 they noticed a cigarette lighter in the resident's doorway and they threw it in the garbage. Resident #314 was smoking in their room and smell of cigarette smoke noted from room. CNA #11 stated they notify the doctor and call campus police to search the resident when they smell smoke from their room. Resident #314 goes to different floors, and they are escorted to smoke. On 01/11/2023 at 3:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated Resident #314 is alert and confused sometimes. If Resident #314 is smoking in their room it is documented in the nursing progress notes. Resident #314 is not allowed to hold their own cigarettes, have designated smoke time at 9 AM and 2 PM in the smoke room where smoking materials are provided for the resident, and they did not know where resident obtained cigarettes. When giving Resident #314 a shower, staff reported that they found a lighter on the resident's wheelchair. LPN #1 also stated it is difficult to communicate with Resident #314 due to their cursing behavior. Prior to October 15, 2022, any smoking behavior was documented in the progress notes. LPN #1 stated that they were just informed on Monday resident smoked again. When they did a search for Resident #314, they could not find cigarettes. Resident #314 is considered an unsafe smoker, smokes on unit and they are not sure how resident disposes of cigarette butt, but when they smell cigarette smoke will call police right away as this behavior may cause a fire. Resident #314 will hide the lighter or cigarettes, and materials cannot be visualized by staff. On 01/11/2023 at 03:38 PM, an interview was conducted with Registered Nurse (RN) #5 who stated that they noticed Resident #314 smoked in their room and they were caught two times in the last few days. They normally deescalate situation if they smell smoke in the resident's room, they knock on room door and resident will deny smoking in their room and if verbally aggressive call hospital police who will confiscate the smoking materials. Resident #314 is escorted to smoke. Resident #314 is educated on smoking, and they call the psych to further educate and redirect resident. Resident #314 refused to sign smoking contract and they are not sure how long ago the contract was done. If there is a smoking-related incident, the [NAME] smoking form is filled out. RN #5 also stated that they were not aware of any care plan meeting related to smoking. On 01/11/2023 at 03:47 PM, the Behavioral Health Associate (BHA) #1 was interviewed and stated that Resident #314 is an unsafe smoker due to their diagnosis and they are not allowed to keep own cigarettes so they take Resident #314 to smoke at 9 AM. They come to the unit to get Resident #314 if they are not already in the smoke room, and then escort them back to the unit. We always keep lighter, and we walk with Resident #314 in the morning and light cigarette for resident. Resident #314 may get a lighter from other residents and we educate other residents not to give Resident #314 cigarette or lighters. BHA #1 also stated we make sure we do a weekly search on Resident #314 and have found a lighter on the resident between one and five times but have not found any cigarettes. Resident #314 was educated on smoking and advised not to smoke in their room as this was not safe and they are only allowed to smoke in the smoke room. Resident #314 is taken outside to smoke anytime they want to by the Behavioral Health Supervisor. Smoking materials are purchased for Resident #314, provided to the resident and then behavioral health keeps the remaining cigarettes. On 01/11/2023 at 03:59 PM, an interview was conducted with Associate Director of Mental Health Services (ADMHS) who stated Resident #314 is an active smoker and they have tried ways to curb and control the resident's smoking habit. Resident #314 cannot keep cigarette and lighter due to delusions and is an unsafe smoker due to smoking in undesignated areas. Smoking is used to prevent emotional distress and to get Resident #314 to comply with taking medications, ADL care and injections. We have to monitor Resident #314 room in relation to smoking. The concern is keeping resident safe and others safe ongoing issues. The ADMHS also stated the smoking contract needs to be revisited for resident and they understand that the resident is the most watched case. The ADMHS further stated there is a smoking committee and smoking cessation is offered to residents. A smoking cessation program for smokers was offered during quarantine. On 01/11/2023 at 4:12 PM, the Behavioral Health Associate (BHA #2 was interviewed and stated they also escort Resident #314 to smoke at times. BHA #2 also stated they have not found cigarettes only lighters and since 2021 to present they have found 4-5 lighters on resident. BHA #2 further stated they have some documentation in a notebook in their office but they do not document their findings in the resident's electronic medical record. BHA #2 stated after finishing room cleaning, they write down observations and were not told that they needed to document as the hospital police and nursing do the documentation so we will have evidence as to what was found in the resident's room during cleaning. On 01/12/2023 at 10:28 AM, an interview was conducted with the Administrator who stated that residents who smoke may obtain smoking materials by purchasing in the community, or family or peers may provide. The Administrator also stated that they may need to look at their ability to do room searches and bag checks to monitor the process and be more vigilant about what is brought back into the facility. We have to look at how to safely store and distribute smoking paraphernalia. The smoking policy was put in place a long time ago in the past Plan of Correction (POC). We are monitoring in smoking in bathroom and psychiatry is included in problem solving related to smoking. On 01/12/2023 at 10:28 AM, an interview was conducted with Director of Nursing (DON) who stated for unsafe smokers, smoking materials are not provided and some may go outside to get smoking materials unless there is an order for them not to go outside of the facility. A resident can be an unsafe smoker and can navigate community. We assume residents are buying paraphernalia and we are dealing with a challenging population and some residents put cigarettes in their underclothing so we have to look to see how stringent we can be with process and rules about smoking and not take away their rights. There is a logbook for when residents depart and enter the facility. There is no identification band for smokers. In relation to smoking materials- some residents go out great lengths to keep on their body; high risk residents smoking materials are provided by the BHA's. There is an opportunity to look at the smoking policy. The Hospital Police also do rounds. The DON also stated the smoking contract is offered and currently there are no rules for the violation of the criteria for smoking privileges. When cigarettes are taken away BHA is informed and care planning and Behavioral Rapid Response Team (BRRT) assist the clinical team to deal with behaviors and attempt to remove items as it may be become difficult to manage. BHAs are on unit and do rounds and develop relationships with residents so they can have discussions. BHA is an integral part of process in place and included in the management of challenging residents. 415.4(a)(2-7) sues. Investigation comple Based on observation, record review, and interviews conducted during the Recertification and Complaint survey (NY00305646, NY00276114) from 01/05/2023 through 01/13/2023, the facility did not ensure residents were adequately supervised to prevent smoking accidents. Specifically, the facility failed to provide adequate supervision and interventions to address unsafe smoking incidents in undesignated areas. Additionally, incidents of unsafe smoking were not investigated to determine adequate interventions to prevent a recurrence. This was evident for 2 of 6 residents reviewed for smoking out of 42 sampled residents. (Resident #s 314 and 78) The findings include but not limited to: The facility's policy and procedure titled Smoking Control, with the last revised date 10/05/2022, documented that Smoking is prohibited in all facility vehicles, on the facility grounds, and within the building- except in designated resident smoking areas. A smoking area has been designated. Residents are permitted to smoke only in this designated smoking area. The policy further documented that the purpose is to advise residents of the conditions of their privilege to smoke and their responsibilities to smoke in a safe manner and only in designated areas. The non-compliant smoker shall have their cigarettes, lighters, and other ignition sources confiscated by the Hospital Police and may be issued a summons. The resident shall no longer be allowed to maintain cigarettes at the bedside and be informed that they will be subject to random environmental searches from the beside area conducted by Hospital police. 1) Resident #78 was readmitted on [DATE] at 12:43 AM post amputation of the left second digit with diagnoses that include Chronic Kidney Disease, Peripheral Vascular Disease, Diabetes Mellitus, and Blindness in one eye. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 78 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The Comprehensive Care Plan for Smoking, initiated on 11/13/2019 and updated on 11/17/2022, documented the resident was an unsafe smoker due to smoking in undesignated areas. The smoking safety assessment dated [DATE], completed upon readmission, identified the resident had no safety concerns. The Smoking Control Form dated 11/20/2022 documented Resident #78 was found smoking in the room with Resident #346 by the charge nurse. The room was searched, and no smoking materials were found. The Smoking CCP was revised on 11/23/2022, and no new interventions were added. Resident #78 did not have a Behavior Care Plan to address noncompliance with smoking per facility policy. There was no documented evidence the resident was referred to the Behavioral Management Committee to address the continued noncompliance. A Nursing Note dated 11/17/2022 at 12:58 PM documented that Resident #78 was noted with a burnt area on the dressing applied on the left-hand post left index finger amputation. The resident was noted with a closed blister 1x2cm-left-hand dorsal aspect base of the 1st digit. A facility investigation report dated 11/17/2022 documented that Resident #78 sustained a second-degree burn because of a smoking accident related to a change in functionality from the finger amputation. The investigation did not include staff statements or an attempt to determine where the accident occurred (smoking room or undesignated area). The investigation documented a new smoking evaluation was conducted and determined the resident could smoke safely. A Nursing Note dated 11/20/2022 at 9:17 PM documented that Resident #78 was smoking in the room with another resident (Resident #346). The Hospital Police were called at 9:15 PM and informed nursing staff that they could not conduct a room search because they did not see the residents smoking. On 01/09/2023 at 3:10 PM, an interview was conducted with Certified Nursing Assistant #4 (CNA #4). CNA #4 stated that Resident #78 is a smoker, and sometimes, the resident goes outside early in the morning to smoke. Resident #78 buys and keeps the smoking materials at the bedside. Resident #78 never smokes in the room. CNA #4 had never heard that the resident sustained burns while smoking. On 01/09/2023 at 3:24 PM, an interview was conducted with Head Nurse #3 (HN#3). HN #3 stated that Resident #78 is a heavy smoker and non-compliant with the smoking policy. The resident was seen smoking in the shower room. They called the Hospital police to search and searched the bedside but did not find any cigarettes at the bedside. HN #3 educated the resident not to smoke in the shower room. Resident #78 goes outside the building to smoke, but at times the resident goes to the smoking room. Resident #78 had burns to the left hand while smoking before, but it is healed. The resident admitted that the injury on 11/17/2022 occurred from smoking. On 01/11/2023 at 2:16 PM, a follow-up interview was conducted with HN #3. HN #3 stated that the smoking assessment was done upon re-admission. Resident #78 was identified as an unsafe smoker because the resident had an amputation of the index finger and was smoking in the undesignated area. The smoking assessment means that the resident is a safe smoker but is noncompliant with the smoking policy. Resident #78 was able to light a cigarette and hold a cigarette, so the resident was a safe smoker. Non -compliant residents can keep smoking materials at the bedside. They monitor the residents every two hours. On 01/10/23 at 2:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing department oversees the residents who smoke and the smoking room. The DON is aware that Resident #78 is an unsafe smoker. The intervention is to have hospital police check the resident and orient the resident to the smoking room. They offered the resident smoking cessation, but the resident refused. The residents keep their smoking materials. Unsafe smokers are not allowed to keep smoking materials at the bedside. Safe smokers are allowed to keep smoking materials at the bedside. On 01/12/23 at 10:10 AM, a follow-up interview was conducted with the Director of Nursing (DON). The DON stated that a smoking assessment is completed upon admission and reassessed every three months. It is documented in the resident's electronic medical record. The criterion for an independent smoker is that they can hold the cigarette by themselves. The facility does not provide smoking materials to residents. The smoking materials are obtained/purchased by the residents themselves. On 01/12/2023 at 10:09 AM, an interview was conducted with the Associate Executive Director (AED). The AED stated that non-independent/unsafe smokers ambulate throughout the facility and befriend unsafe smokers. Some residents leave the facility on therapeutic leave. If we know they smoke and suspect they have smoking materials, the facility police intervene. The resident's room will be searched and confiscated if any smoking materials are found. They do not suspend the smoking privilege. Residents are not searched; therefore, they may hide cigarette materials on their bodies. They recognized an issue with unsafe smoking, and it has been challenging to control this problem. 01/12/2023 at 10:23 AM, an interview was conducted with the Administrator. The Administrator stated that the smoking issue had been brought up in the past. The smoking policy and procedure were last revised as a plan of correction for the past deficiency. It is reviewed every three months, last reviewed in October 2022. Monitoring of unsafe smokers is done by rounding by the hospital police. Psychiatry will also work with the Interdisciplinary Team (IDT) team to develop plans for those with unsafe smokers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews conducted during a recertification survey, the facility did not ensure that it treated each resident with respect and dignity and cared for each resident in a manner and in an environment that promoted, maintained or enhanced his or her quality of life. Specifically, (1) a label with the resident's name was placed on the wall in a common area and, (2) the resident was placed on a wheelchair platform that was soiled and dirty with chipped paint. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 38 residents. The findings are: Resident #207 was admitted to the facility with diagnoses that included Cerebral Palsy and Quadriplegia. The Minimum Data Set, dated [DATE] documented resident with severe cognitive impairment. On 11/14/19 at 11:33 AM, Resident #207 was observed seated in a wheelchair in dayroom/dining room. On the wall directly behind the wheelchair was a white label with the resident's name written in bold black lettering. The label measured approximately 2 inches by 10 inches. A wheelchair platform was observed placed in the area of the wall directly under the label. Both sides and the base of wheelchair platform was observed with dust, dried on cream/brown colored substances caked and chipped paint chipped in places. On 11/15/19 at 10 AM, while walking through the dayroom, a label with the resident's name was observed on the wall. The resident was not in the dayroom at this time and was observed in his bedroom in night wear. A wheelchair platform was observed placed in the area of the wall directly under the label. Both sides and the base of wheelchair platform was observed with dust, dried on cream/brown colored substances caked and chipped paint chipped in places. On 11/15/19 at 11:19 AM, 11/18/19 at 10:36 AM, and on 11/19/19 at 12:25 PM, the resident was observed seated in wheelchair in the dayroom/dining room. A label with resident's name was affixed to the wall behind the wheelchair. The wheelchair platform was observed placed in the area of the wall directly under the label. Both sides and base of wheelchair platform continued to be observed with dust, dried on cream/brown colored substances caked on and chipped paint in places. On 11/19/19 at 12:11 PM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA #1 stated the label on the wall behind the resident's chair has been there for a long time, more than a year. CNA #1 also stated the label is placed there so floaters will know that this is where the resident sits. The resident has to sit in that spot because he has behaviors where he will reach out to hit or pull at staff and residents. When his chair is in that spot, he is not able to do that, so the sign is there so everyone knows. CNA#1 also stated that housekeeping is responsible for cleaning the platform and she had not reported it to anyone. On 11/19/19 at 12:16 PM, an interview was conducted with RN #2. RN #2 stated that he is often in the dayroom and makes rounds frequently. RN #2 also stated that on occasion he feeds the resident and knows that he has a specific spot where he sits in the dayroom. RN #2 further stated that he could not recall seeing a label and was unsure of whether he saw the label or not. I do not know why it is there, but it is probably to let staff know where to put him because he has behaviors. On 11/19/19 at 12:25 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated she makes rounds on the unit daily and as needed. The CNO also stated that she had fed the resident on multiple occasions however, had never noticed the label on the wall. The CNO further stated she did not know why the label had been placed there. The CNO stated that the platform should not be in this condition and certainly not with the resident seated there. Housekeeping is responsible for making sure that resident areas are clean. The resident should not be put in something that looks like that. On 11/19/19 at 12:31 PM, an interview was conducted with the Recreation Therapist (RT). The RT stated that about a year ago there was a lot of new staff. Residents were positioned in a certain area in the day room because the residents lacked judgement and their positioning in the day room was very important for them. The RT also stated we wanted to maintain consistency and make sure staff knows where to place the resident as new people may not have known. It was our way of keeping them safe because they do not know boundaries. The RT did not explain why only one resident's name was placed on the wall. On 11/19/19 at 12:57 PM, an interview was conducted with the Housekeeping Aide (HA). The HA stated that she works on this unit in conjunction with another housekeeper. The HA also stated that they both are responsible for cleaning the dayroom and this includes sanitizing the tables, sweeping the floors and mopping the floor. The HA further stated that she is not responsible for cleaning the platform-she moves it and cleans around it. The housekeeping supervisors send someone to clean that during the night shift. On 11/19/19 at 01:00 PM, the Housekeeping Supervisor (HSKS) was interviewed. The HSKS stated that he makes rounds frequently on the unit to ensure that everything is being cleaned on the floor. The housekeepers assigned to the floor are supposed to make sure that everything is clean. The HSKS also stated sometimes we give special assignment when items are very dirty. He was not aware of the condition of the platform. On 11/19/19 at 01:02 PM, the Director of Housekeeping was interviewed. The Director stated that he makes rounds on the units with the supervisors and we look for urine smells and dirt. Once a week we do a special assignment and the platform would be something that is cleaned then. Nursing should be helping us out by cleaning up spills as they happen. The Director also stated the platform is very dirty. We used to have four or five of those but now we only have one. We cleaned everything else, but we missed it, we will clean it right now and engineering will re-paint it. 415.3 (c)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident's right to personal privacy was respected. Specifically, the residents name was observed displayed on the wall in the dayroom. This was evident for 1 of 1 resident reviewed for Privacy out of a sample size of 38 residents. (Resident #207) The findings are: Resident #207 was admitted to the facility with diagnoses that included Cerebral Palsy and Quadriplegia. The Minimum Data Set, dated [DATE] documented resident with severe cognitive impairment, On 11/14/19 at 11:33 AM, Resident #207 was observed seated in a wheelchair in dayroom/dining room. On the wall directly behind the wheelchair was a white label with the resident's name written in bold black lettering. The label measured approximately 2 inches by 10 inches. On 11/15/19 at 10 AM, while walking through the dayroom, a label with the resident's name was observed on the wall. The resident was not in the dayroom at this time and was observed in his bedroom in night wear. On 11/15/19 at 11:19 AM, 11/18/19 at 10:36 AM, and on 11/19/19 at 12:25 PM, the resident was observed seated in wheelchair in the dayroom/dining room. Label with resident's name was affixed to the wall behind the wheelchair. On 11/19/19 at 12:11 PM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA #1 stated the label on the wall behind the resident's chair has been there for a long time, more than a year. CNA #1 also stated the label is placed there so floaters will know that this is where the resident sits. The resident has to sit in that spot because he has behaviors where he will reach out to hit or pull at staff and residents. When his chair is in that spot, he is not able to do that, so the sign is there so everyone knows. On 11/19/19 at 12:16 PM, an interview was conducted with RN #2. RN #2 stated that he is often in the dayroom and makes rounds frequently. RN #2 also stated that on occasion he feeds the resident and knows that he has a specific spot where he sits in the dayroom. RN #2 further stated that he could not recall seeing a label and was unsure of whether he saw the label or not. I do not know why it is there, but it is probably to let staff know where to put him because he has behaviors. On 11/19/19 at 12:25 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated she makes rounds on the unit daily and as needed. The CNO also stated that she had fed the resident on multiple occasions however, had never noticed the label on the wall. The CNO further stated she did not know why the label had been placed there. On 11/19/19 at 12:31 PM, an interview was conducted with the Recreation Therapist (RT). The RT stated that about a year ago there was a lot of new staff. Residents were positioned in a certain area in the day room because the residents lacked judgement and their positioning in the day room was very important for them. The RT also stated we wanted to maintain consistency and make sure staff knows where to place the resident as new people may not have known. It was our way of keeping them safe because they do not know boundaries. The RT did not explain why only one resident's name was placed on the wall. 415.3 (d)(1)(ii)

Based on observations and staff interviews conducted during the recertification survey, the facility did not ensure that a safe sanitary environment was provided. Specifically, a wheelchair platform was observed to be heavily soiled and dirty with chipped paint in places. This was evident during multiple observations made in the dayroom/dining room on Unit C 11-C 12. The findings are: The facility policy and procedure titled cleaning of Resident Care Unit and Equipments dated April 26, 2019 documented all areas of the facility must be kept clean and sanitary. The sanitary condition of the environment of care shall be maintained to include resident rooms, floors, horizontal surfaces, resident equipment. On 11/14/19 at 11:33 AM, a resident was observed seated in a wheelchair in dayroom/dining room which was placed on a wheelchair platform. Both sides and the base of wheelchair platform were observed with dust, dried on cream/brown colored substances caked and chipped paint chipped in places. On 11/15/19 at 10 AM, the wheelchair platform was observed in the dayroom/dining room. Both sides and the base of wheelchair platform were observed with dust, dried on cream/brown colored substances and chipped paint chipped in places. On 11/15/19 at 11:19 AM, 11/18/19 at 10:36 AM, and on 11/19/19 at 12:25 PM additional observations were made of the wheelchair platform. Both sides and base of wheelchair platform continued to be observed with dust, dried on cream/brown colored substances caked on and chipped paint in places. On 11/19/19 at 12:11 PM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA#1 stated that housekeeping is responsible for cleaning the platform and she had not reported it to anyone. On 11/19/19 at 12:25 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated that the platform should not be in this condition and certainly not with the resident seated there. Housekeeping is responsible for making sure that resident areas are clean. The resident should not be put in something that looks like that. On 11/19/19 at 12:57 PM, and interview was conducted with the Housekeeping Aide (HA). The HA stated that she works on this unit in conjunction with another housekeeper. The HA also stated that they both are responsible for cleaning the dayroom and this includes sanitizing the tables, sweeping the floors and mopping the floor. The HA further stated that she is not responsible for cleaning the platform-she moves it and cleans around it. The housekeeping supervisors send someone to clean that during the night shift. On 11/19/19 at 01:00 PM, the Housekeeping Supervisor (HSKS) was interviewed. The HSKS stated that he makes rounds frequently on the unit to ensure that everything is being cleaned on the floor. The housekeepers assigned to the floor is supposed to make sure that everything is clean. The HSKS also stated sometimes we give special assignment when items are very dirty, and he was not aware of the condition of the platform. On 11/19/19 at 01:02 PM, the Director of Housekeeping was interviewed. The Director stated that he makes rounds on the units with the supervisors and we look for urine smells and dirt. Once a week we do a special assignment and the platform would be something that is cleaned then. Nursing should be helping us out by cleaning up spills as they happen. The Director also stated the platform is very dirty. We used to have four or five of those but now we only have one. We cleaned everything else, but we missed it and we will clean it right now and engineering will re-paint it. 415. 5 (h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that when the use of restraints is indicated, the ongoing re-evaluation of the need for restraints was documented. Specifically, a resident's with bilateral hand mitten did not receive ongoing re-evaluation of the need for restraints. This was evident for 1 of 3 residents reviewed for Restraints out of a sample of 38 residents. (Residents #377). The findings are: Resident #377 was admitted to the facility with diagnoses that included Cerebral Palsy, Seizure Disorder, and Aphasia. On 11/14/2019 at 11:00 AM, resident was observed seated in a wheelchair in the hallway. Bilateral mittens were observed. On 11/15/19 at 10:13 AM, resident was observed in bed with bilateral hand mittens on. There were no signs of distress or discomfort noted. Resident was non-verbal and did not respond when greeted. On 11/15/19 at 12:05 PM, resident was observed in day room area in wheelchair, watching television. Bilateral hand mittens were in place. On 11/18/19 at 10:39 AM, resident observed sleeping in bed in room with bilateral mittens on hands. On 11/19/19 at 09:50 AM, resident observed in bed asleep. Mittens were observed on both hands. The Quarterly Minimum Data Set, dated [DATE] documented resident with severely impaired cognition and was totally dependent on 2 staff persons for Activities of Daily Living. The MDS also documented the resident had impairment on both sides of upper and lower extremity. The MDS did not document that resident had a restraint. Physician's orders dated 10/21/19 documented apply bilateral mittens to hand and release every 2 hours to prevent oral fixation and self-inflicting behavior. Release every 2 hours for skin check. Physician Visit Summary dated 4/2/19, 5/3/19, 5/28/19, 7/30/19, and 8/27/19 contained no documentation in the field Restraints, Indication. The notes also documented continue mittens to prevent from scratching face. Provider Comprehensive assessment dated [DATE] and 10/29/19 documented wear bilateral mittens all the time. Restraints Flow Sheet dated 6/1/19 to 6/30/19 documented apply bilateral mittens to hands and release q 2 hours for skin check. There were no other restraint flow sheets provided for review. Nursing Assessment, Screen and Observation Form dated 7/3/19 documented seatbelt is used for positioning and mittens are used as a restraint to prevent pulling GT/self-injury. The form further documented if device is used as a restraint, see Restraint Assessment and Order Form for medical justification. There was no documented evidence that the Restraint Assessment and Order Form had been completed. Nursing Evaluation Summary dated 10/10/19 documented that resident is not using trunk, limb or other restraint. There was no documented evidence that an assessment was completed prior to the initiation of mittens or that periodic evaluation was done to determine the continued need for use of the restraint occurred. On 11/19/19 at 11:07 AM, an interview was conducted with Certified Nursing Assistant #2. CNA #2 stated the resident is quiet and likes to play with the feeding tube so that is why he has the hand mittens. CNA #2 also stated that she was assigned to the unit in June 2018 and the resident has always had mittens. The mittens are removed every two hours to check for redness and this is documented in the electronic medical record. CNA #2 further stated that the resident will lift up his shirt to show off the feeding tube if the mittens are not in place. On 11/19/19 at 11:23 AM, an interview was conducted with Registered Nurse (RN) #2. RN #2 stated the resident attempts to pull out his feeding tube and mittens are used to prevent him from pulling out tube and to prevent him from rubbing his face. RN#2 stated that as the mittens are used to prevent the resident from doing certain things it would be considered a restraint. The Nursing Assessment Form is completed quarterly and can be done by any RN and there is a restraint assessment form that should be done. RN#2 further stated that he was unable to locate a current or type of restraint assessment or evaluation form for this resident and did not know if one had been completed. On 11/19/19 at 12:03 PM, an interview was conducted with the Attending Physician. The physician stated the resident has severe Cerebral Palsy and Mental Retardation and uses mittens because he rubs his eyes and rubs his skin. The physician also stated the mittens are to prevent the resident from removing his feeding tube also. Mitten is a restraint and it is necessary for this resident. We have to put the indication in our notes. Since I took over care of the resident, he was in the mittens all the time. The physician further stated that he should have been documented more clearly and we will have a meeting to make sure we document more clearly that it is a restraint. On 11/20/19 at 11:39 AM, an interview was conducted with RN #4 Head Nurse. RN #4 stated the mittens were not considered as a restraint but as a protective device. The resident vomits when he puts his hands in the mouth and since he was admitted here, he has been using the device. RN #4 also stated anything that restricts movement is a restraint, but we were always told that these things were not a restraint. It was considered a supportive device so was not picked up by our MDS. The nurse documented incorrectly on the assessment as we were not using it for the feeding tube, but it was to prevent him from oral fixation. RN #4 further stated we did not do a meeting together to discuss why we are using the mitten for this resident. The restraint assessment was not completed. On 11/20/19 at 01:41 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she provides supervision for the unit and residents should be evaluated for the use of restraints. The team will discuss and if indicated the MD will write an order, nurse will implement, and we follow the procedure for restraint-releasing schedule. We also do continuous evaluation to see whether the restraint needs to be continued. The ADON also stated there is a restraint assessment form that we do quarterly. Mittens are now considered a restraint. Before, if we used the mittens for protection of the resident, we didn't think it was a restraint. In reviewing the definition, we are now looking at it as a restraint, so we are re-evaluating mitten use and putting the process in place now. 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during a recertification survey, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, 1) the Minimum Data Set (MDS) assessment did not identify the use of a physical restraint (mittens). This was evident for 1 of 3 residents reviewed for Physical Restraint (Resident #377). The findings are: The facility policy and procedure titled MDS 3.0 dated October 26, 2018 documented all disciplines that make entries on the MDS 3.0 will be responsible to electronically signed and date The electronic signature indicates that the section was reviewed and attests to the accuracy of the items. Resident #377 was admitted to the facility with diagnoses that included Cerebral Palsy, Seizure Disorder, and Aphasia. On 11/14/2019 at 11:00 AM, resident was observed seated in a wheelchair in the hallway. Bilateral mittens were observed. On 11/15/19 at 10:13 AM, resident was observed in bed with bilateral hand mittens on. There were no signs of distress or discomfort noted. Resident was non-verbal and did not respond when greeted. On 11/15/19 at 12:05 PM, resident was observed in day room area in wheelchair, watching television. Bilateral hand mittens were in place. On 11/18/19 at 10:39 AM, resident observed sleeping in bed in room with bilateral mittens on hands. On 11/19/19 at 09:50 AM, resident observed in bed asleep. Mittens were observed on both hands. The Quarterly Minimum Data Set, dated [DATE] documented resident with severely impaired cognition and was totally dependent on 2 staff persons for Activities of Daily Living. The MDS also documented the resident had impairment on both sides of upper and lower extremity. The MDS did not document that resident had a restraint. MDS assessments dated 7/10/19, 6/13/19, and 3/21/19 documented in Section P no restraint of any kind was in use. Physician's orders dated 10/21/19 documented apply bilateral mittens to hand and release every 2 hours to prevent oral fixation and self-inflicting behavior. Release every 2 hours for skin check. Physician Visit Summary dated 4/2/19, 5/3/19, 5/28/19, 7/30/19, and 8/27/19 contained no documentation in the field Restraints, Indication. The notes also documented continue mittens to prevent from scratching face. Provider Comprehensive assessment dated [DATE] and 10/29/19 documented wear bilateral mittens all the time. Restraints Flow Sheet dated 6/1/19 to 6/30/19 documented apply bilateral mittens to hands and release q (every) 2 hours for skin check. There were no other restraint flow sheets available for review. Nursing Evaluation Summary dated 10/10/19 documented that resident is not using trunk, limb or other restraint. On 11/19/19 at 11:07 AM, an interview was conducted with Certified Nursing Assistant #2. CNA #2 stated the resident is quiet and likes to play with the feeding tube so that is why he has the hand mittens. CNA #2 also stated that she was assigned to the unit in June 2018 and the resident has always had mittens. The mittens are removed every two hours to check for redness and this is documented in the electronic medical record. CNA #2 further stated that the resident will lift up his shirt to show off the feeding tube if the mittens are no in place. On 11/19/19 at 11:23 AM an interview was conducted with Registered Nurse (RN) #2. RN #2 stated the resident attempts to pull out his feeding tube and mittens are used to prevent him from pulling out tube and to prevent him from rubbing his face. RN#2 stated that as the mittens are used to prevent the resident from doing certain things it would be considered a restraint. On 11/19/19 at 12:03 PM, an interview was conducted with the Attending Physician. The physician stated the resident has severe Cerebral Palsy and Mental Retardation and uses mittens because he rubs his eyes and rubs his skin. The physician also stated the mittens are to prevent the resident from removing his feeding tube also. Mitten is a restraint and it is necessary for this resident. We have to put in our notes the indication. Since I took over care of the resident, he was in the mittens all the time. On 11/19/19 at 11:49 AM, an interview was conducted with RN #3. RN #3 stated that she is responsible for doing MDS assessments. When doing an assessment, we observe staff doing care during look back period to see how much care the resident needs. We look at the resident from head to toe, review orders and treatment records. RN #3 also stated that she did observe the resident wearing mittens and did not code it as restraint as that was not the practice. We have been re-educated on the RAI manual on how to code restraints in the past year and so are in the process of doing corrections for residents who have not been coded correctly. On 11/20/19 at 10:49 AM, an interview was conducted with the Post-Acute Care Director of Clinical Reimbursement (PACDCR). The PACDCR stated that she currently oversees the MDS department at the facility. We identified there were inaccuracies in the coding on the MDS. Education was done and is ongoing. Staff did not understand the meaning of restraint so had to re-educate. This is going back a year. We had to do an in-house audit to identify the restraints that were being used, so we are in the process of coding accurately. This has been the practice for years, so we are correcting moving forward as new MDS assessments are completed. 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility did not ensure that Comprehensive Care Plans were reviewed and revised after the quarterly assessment. Specifically, a care plan to address mitten use had not been revised and had not been included with current care plans in the electronic medical record. This was evident for 1 of 3 residents reviewed for Restraints out of a sample of 38 residents. (Resident #377) The findings are: The facility policy and procedure Comprehensive Resident Assessment and Care Planning with a revision date of January 18, 2017 documented members of the interdisciplinary team must be prepared to participate in the review and evaluation of the effectiveness of the plan of care and the review must not exceed 90 days. Resident #377 was admitted to the facility with diagnoses that included Cerebral Palsy, Seizure Disorder, and Aphasia. On 11/14/2019 at 11:00 AM, resident was observed seated in a wheelchair in the hallway. Bilateral mittens were observed. On 11/15/19 at 10:13 AM, resident was observed in bed with bilateral hand mittens on. There were no signs of distress or discomfort noted. Resident was non-verbal and did not respond when greeted. On 11/15/19 at 12:05 PM, resident was observed in day room area in wheelchair, watching television. Bilateral hand mittens were in place. On 11/18/19 at 10:39 AM, resident observed sleeping in bed in room with bilateral mittens on hands. On 11/19/19 at 09:50 AM, resident observed in bed asleep. Mittens were observed on both hands. The Quarterly Minimum Data Set (MDS) dated [DATE] documented resident with severely impaired cognition and was totally dependent on 2 staff persons for Activities of Daily Living. Physician's orders dated 10/21/19 documented apply bilateral mittens to hand and release every 2 hours to prevent oral fixation and self-inflicting behavior. Release every 2 hours for skin check. Provider Comprehensive assessment dated [DATE] and 10/29/19 documented wear bilateral mittens all the time. Review of care plans in the electronic medical record documented no care plans related to the use of mittens. Care Plan titled resident needs seatbelt in w/c (wheelchair) for positioning and trunk support since no sitting balance and trunk control due to no cognition secondary to MR balance, bilateral mitten to prevent oral fixation was dated 7/18/19 and documented apply seatbelt in w/c, make sure seatbelt is not too tight, release devices with 1:1 attention if discomfort, skin check when releasing devices. There was no revision date documented on the printed care plan and the care plan was not available for review in the Electronic Medical Record (EMR). Care Plan titled use bilateral mittens to prevent self injury and gagging due to oral fixation and physical aggression due CP (Cerebral Palsy)/MR (Mental Retardation)-resident always try to remove mittens by shaking hands and pull and bite off dated 7/18/19 documented apply mittens on both hands as ordered, release mittens every 2 hrs and PRN, skin check when release, no mittens when sleep if possible. There was no revision date documented on the printed care plan and the care plan was not available for review in the EMR. On 11/19/19 at 11:23 AM, an interview was conducted with Registered Nurse (RN) #2. RN#2 stated the resident attempts to pull out his feeding tube and mittens are used to prevent him from pulling out tube and to prevent him from rubbing his face. Care plans are reviewed every quarter and the head nurse usually does the care plans. Any nurse can do the care plan. RN#2 stated he did not see a care plan for mitten use in the EMR and could not tell when the printed care plan had been updated. On 11/20/19 at 11:39 AM, an interview was conducted with RN #4 Head Nurse. RN #4 stated the resident has used mittens since he was admitted , and they are used as a protective device as he vomits when he puts his hands in the mouth. RN#4 also stated that she is responsible for making sure that care plans are done. Care Plans are revised every quarter. This was created in July 2019. We are not experts in the computer because it is new to us and things can be missing. RN#4 further stated the care plan was not revised in October. It was not added when we moved to the computer. I think we missed that. Everything did not make it. We really have to go back and check because things can be missed. It was a mistake. On 11/20/19 at 01:41 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated RNs are responsible for completing the care plans. Revision of care plans are done quarterly. The ADON also stated that the head nurses are primarily responsible for checking the care plans. The supervisors check as well as the MDS staff also check to make sure care plans are in place and are complete. The ADON further stated that it was difficult to keep track of care plans before, but it is easier now in the EMR. the care plan for mittens should be checked monthly and quarterly. 415.11 (c)(2)(i-iii)

Based on record review and staff interview conducted during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, quarterly and annual assessments were not transmitted within 14 days after completion. This was evident for 5 of 9 residents reviewed for Resident Assessment task out of a sample of 38 residents. (Resident #1, #8 and #5, #7 and #9) The findings are: The facility policy and procedure titled MDS 3.0 dated October 26, 2018 did not contain documentation pertaining to the timely submission of MDS assessments. 1. Resident # 1: Quarterly MDS with an Assessment Reference Date (ARD) of 3/21/2019 which was completed on 3/25/2019 and submitted on 4/10/2019. 2. Resident #8: Quarterly MDS with an ARD of 1/24/2019 was completed on 1/30/2019 and submitted on 2/26/2019. 3. Resident #5: Quarterly MDS with an ARD of 1/21/2019 was completed on 1/25/2019 and submitted on 2/26/2019. 4. Resident #9: Annual MDS with an ARD of 1/24/2019 was completed on 1/28/2019 and submitted on 2/26/2019. 5. Resident #7: Annual MDS with an ARD of 1/23/2019 was completed on 1/30/2019 and submitted on 2/26/2019. On 11/20/19 at 10:49 AM, an interview was conducted with the Post-Acute Care Director of Clinical Reimbursement (PACDCR). The PACDCR stated that she currently oversees the MDS department at the facility and in conducting audits identified that there were late assessments. The clerk that was responsible for processing submissions was only submitting MDS's once a month. Staff were re-educated to move into compliance with the guidelines. On 11/20/19 at 11:22 AM, the Coordinating Manager (CM) was interviewed. The CM stated she is responsible for scheduling of MDS assessments. Weekly schedules were sent out to all the disciplines involved in MDS completion. Once completed I did submissions. The CM also stated that she had been instructed by her former supervisor to do them monthly up until October 2018 when we got new management. I did see different warning messages and I would tell my supervisor who instructed me to give the reports to the nursing staff. The CM further stated that she is no longer involved in MDS submissions as it is now done directly through PCC. 415.11