Every finding on record at Acadia Center For Nursing And Rehabilitation

Based on observations, record review, and interviews, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for two (Resident #94 and Resident #122) of four residents reviewed for Accident Hazards. Specifically, 1) Resident #94 had a physician's order for bilateral floor mats when in bed. On multiple observations Resident #94 was observed in bed without the use of the floor mats. 2) Resident #122 was admitted to the facility on [DATE] with Cholecystostomy tube (a catheter that is placed through the skin directly into the gallbladder to drain trapped fluids), and there was no documented evidence that a care plan was initiated for the use and care of the Cholecystostomy tube.The findings include: The facility policy titled Care Planning, last reviewed 06/2025, documented the care plan will include measurable objectives and timeframes addressing the resident's medical, nursing, functional, nutritional, behavioral, psychosocial, rehabilitative, and discharge planning needs. The care plan will be reviewed and revised when the resident's condition, preference, goals, treatment or discharge plan changes. Team members will implement and document assigned interventions. The facility policy titled Fall Prevention last reviewed March 2026 documented identify resident at risk for falls and altered safety. Interventions included floor mats, and nursing was responsible for updating certified nursing assistant instructions. The facility policy titled Seizure Precautions and Care las reviewed December 2025 documented consider the following care planning, bedside floor mats may be needed to protect the resident. 1) Resident #94 was admitted with diagnoses that included epilepsy (repeated unprovoked seizures, abnormal electrical activity and changes in awareness or behavior), fractured one rib left side, and coronary arterial disease (major blood vessels supplying the heart become narrow or blocked). The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview Mental Status score of 8, indicating Resident #94 had moderate cognitive impairment. The Minimum Data Set assessment further documented Resident #94 had a fall in the past month prior to admission. The nursing admission assessment dated [DATE] documented reason for most recent hospitalization was due to fall. A Comprehensive Care Plan, risk for falls dated 06/30/2026 did not document an intervention of bilateral floor mats while in bed. A physician's order dated 07/01/2026 documented bi-lateral floor mats when in bed everyday 11:00 PM-7:00 AM, 3:00 PM-11:00 PM, 7:00 AM-3:00 PM. A Comprehensive Care Plan for seizure disorder dated 07/01/2026 did not document the intervention of bilateral floor mats while in bed. A Comprehensive Care Plan, activities of daily living last revised 07/09/2026 did not document an intervention of bilateral floor mats while in bed. The Certified Nursing Assistant instructions for Resident #94 did not document the use of bilateral floor mats while in bed. During an observation on 07/22/2026 at 10:27 AM, Resident #94 was in bed. Resident #94 stated they were not ready to get out of bed yet. There were no floor mats on the floor near the bed. Two floor mats were observed rolled up and stored on each side of the bed at the head of the bed. During an observation and interview on 07/22/2026 at 11:03 AM, Resident #94 was in bed, stating they were not ready to get up out of bed, and they would let their certified nursing assistant know when they were ready to get up. There were two floor mats observed that were rolled up and stored by the head of the bed. Resident #94 stated the floor mats should be on the floor to protect them, if they had a fall. During an interview on 07/22/2026 at 11:08 AM, Certified Nursing Assistant #1 stated they were regularly assigned to care for Resident #94. The floor mats should be on the floor when the resident is in bed. Certified Nursing Assistant #1stated they had picked the mats off the floor, when they previously came to get Resident #94 out of bed; however, the resident did not want to get up at that time and they (Certified Nursing Assistant #1) did not put the floor mats back on the floor and they should have. During an observation on 07/23/2026 at 06:30 AM, Resident #94 was in bed sleeping. There was only one floor mat placed on the floor on the right side of the bed. During an interview on 07/23/2026 at 06:55 AM, Certified Nursing Assistant #2 stated when they went into Resident #94's room at the start of the shift at 11:00 PM, they saw one floor mat on the floor. Certified Nursing Assistant #2 was not aware Resident #94 required two floor mats, because the certified nursing assistant instructions did not indicate use of the floor mats. During an interview on 07/23/2026 at 7:07 AM, Registered Nurse Unit Manager #1 stated Resident #94 required two mats in place when they are in bed due to risk for falls. Registered Nurse Unit Manager #1 stated they were responsible for initiating and updating the care plans. Registered Nurse Unit Manager #1 stated the floor mats were not added as an intervention for Resident #94 therefore, the certified nursing assistant instructions also did not include the use of the floor mats. During an interview on 07/24/2026 at 11:02 AM, the Director of Nursing Services stated the nurse on the unit is responsible for ensuring that the floor mats are in place. The Nurse who receives the physician's order, should be transcribing the order onto the certified nursing assistant instructions and updating the care plans. The floor mats are used for safety to reduce risk of injury due to falls and for seizure precautions. Resident #94 should have the floor mats in place when in bed. 2) Resident #122 was admitted with diagnoses that included colon and skin cancer, diabetes mellitus, and acute cholecystitis (inflamed gallbladder). A 5-Day admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score as 12, which indicated the resident had moderately impaired cognition. The resident had no behavioral symptoms and required assistance from staff for all areas of daily living except for eating, oral hygiene, and personal hygiene. A nursing admission assessment dated [DATE] documented the resident was admitted status post gallbladder removal and had a cholecystostomy (a thin plastic catheter placed through the skin directly into the gallbladder to drain infected bile and fluid) tube. A Physician's order dated 04/29/2026 documented to monitor cholecystostomy tube output every shift. The history and physical dated 05/01/2026 documented the resident had acute cholecystitis and underwent ultrasound guided paracentesis (a medical procedure where ultrasound is used to find and drain extra fluid from inside the belly through a thin needle or soft plastic tube) and percutaneous cholecystostomy tube placement (a minimally invasive medical procedure where a small drainage tube (catheter) is placed through the skin directly into the gall bladder under ultrasound or X-ray guidance). During an interview on 07/27/2026 at 1:45 PM, Registered Nurse #4 stated that there are basic care plans (care plan bundle) that are initiated on admission such as skin condition. Registered Nurse #4 stated that the admission registered nurse would initiate the basic care plans and the next day they (Registered Nurse #4) would review the care plan and initiate all other care plans that should be in place within 72 hours. The care plan related to cholecystectomy tube was not part of the basic care plan bundle. During an interview on 07/27/2026 at 2:10 PM, the Director of Nursing Services stated that generally any registered nurse can initiate the care plans. The Director of Nursing Services stated that there are basic care plans (care plan bundle) that are initiated by the admission nurse. All other care plans outside of the care plan bundle should be initiated by the registered nurses on the second shift and the third shift following the resident's admission. The care plan related to cholecystectomy tube was not part of the basic care plan bundle and the nurses on the other shift should have initiated the care plan related to the cholecystectomy tube. The Director of Nursing Service stated that within 72 hours the care plan for the monitoring of the cholecystectomy tube should have been initiated and implemented for Resident #122. 110 New York Code Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews, during the recertification survey initiated on [DATE] and completed on [DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, expired and opened containers of food were observed in the refrigerator; The freezer was observed with frozen food products out of their original packaging with no label or date. Additionally, stored dry goods were unlabeled and undated in the basement dry storage area. The finding is: An undated facility policy titled Food Storage documented foods received shall be properly stored to maintain high quality and sanitary conditions. Items may be utilized until the date of expiration, based on the production date and item shelf life. Dry bulk foods such as flour, rice, or pasta, once opened, shall be stored in a plastic container with a cover. All items should be dated and labeled. All goods will be rotated properly using the first in, first out method. A kitchen tour was conducted with the Food Service Director on [DATE] at 10:15 AM. The refrigerator section of the combination walk-in refrigerator/freezer was observed with three expired, open containers of cottage cheese. Two containers were observed with an expiration date of [DATE] and one container with an expiration date of [DATE]. The freezer section of the combination walk-in refrigerator/freezer was observed with three packages of French toast sticks which were out of the original packaging and had no label or date. Additionally, six bags of frozen broccoli that were out of the original packaging were observed without a date. The basement dry storage area and a basement walk-in combination refrigerator/freezer were observed with the Food Service Director on [DATE] at 10:29 AM. In the dry storage area, six bags of cake mix were observed that were removed from their original packaging and had no date. In the refrigerator section of the walk-in combination refrigerator/freezer, there were unlabeled and undated packages of chicken, three bags of shredded pizza cheese, and five bags of shredded cheddar cheese. In the freezer section of the walk-in refrigerator/freezer, there was an open bag of pancakes and an unidentified bag of food without a label and date. The Food Service Director was interviewed on [DATE] at 10:50 AM and stated that the containers of expired cottage cheese were left in the refrigerator because the dietary aides did not rotate or take out the old containers. The Food Service Director stated that the dietary aides and the cooks should read the expiration dates and discard the outdated items. The Food Service Director stated the person who placed the chicken in the basement refrigerator/freezer should have labeled and dated the packages or the tray they were stored on. The Food Service Director stated the dietary aide assigned to the storeroom or any person who takes something out of the original packaging is responsible for labeling and dating the food items. The Food Service Director stated it is important for food items to be labeled and dated so that kitchen staff know what the food item is and when to prepare the food item. The Food Service Director stated food should not be left open in the freezer because the food item can get freezer burn if not properly stored. The Food Service Director stated it is important to check the expiration dates of food to ensure that the food is not spoiled. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/11/2024 and completed on 9/18/2024, the facility did not ensure medications were properly stored in medication carts. This was identified for two (Unit A and Unit C) of four units reviewed during the Medication Storage Task. Specifically, loose unidentifiable medications were observed in medication carts in Unit A and Unit C; residents' hearing aids, hearing aid batteries, and nail clippers were stored in medication carts in Unit A and Unit C; and the Unit C Medication Storage Room refrigerator had a dried pink substance spilled on the refrigerator shelf. The findings are: The facility Medication cart policy, revised in March 2024, documented all medication carts will remain free from all non-medication items (i.e. hearing aids, nail clippers). The nursing staff is responsible for checking the medication cart for any loose medications every shift. The Medication Rooms policy, revised in March 2024, documented all medication rooms will be maintained in a state of cleanliness and ensure the refrigerator is clean and the freezer is defrosted as per schedule. The Blister Packs and Newly Opened Medications policy, revised in 1/2023, documented that nurses should initial and date the blister pack as the first dose of medication is administered. The new bottle of liquid medication or any Over The Counter/ House Stock medication should be dated when first opened. Unit A Medication Cart #2 was observed on 9/12/2024 at 4:58 PM with Licensed Practical Nurse #3. There were three large nail clippers, hearing aids, and hearing aid batteries stored in the top drawer of the medication cart. Licensed Practical Nurse #3 was interviewed immediately after the observation on 9/12/2024 and stated the nail clippers were used for clipping the diabetic residents' nails and that they should not have kept them in the medication cart. Licensed Practical Nurse #3 stated the medication cart should not be used to store items other than the medications, such as hearing aids and hearing aid batteries. Unit A Medication Cart #1 was observed on 9/12/2024 at 5:04 PM with Licensed Practical Nurse #4. There were 18 unidentified loose medications, including capsules and tablets, observed on the base of the second drawer of the medication cart. Licensed Practical Nurse #4 was interviewed immediately after the observation on 9/12/2024 and stated there should not be any unidentified loose pills in the cart. Licensed Practical Nurse #4 stated they did not know there were loose tablets and capsules in the medication cart before the observation. The Unit C Medication Cart was observed on 9/12/2024 at 5:13 PM with Licensed Practical Nurse #5. There were 24 unidentified loose medications, including capsules and tablets noted on the base of the second drawer of the medication cart. There were two large nail clippers, hearing aids, and hearing aid batteries stored in the first drawer of the medication cart. The Unit C Medication Storage Room was observed on 9/12/2024 at 5:15 PM with Licensed Practical Nurse #5. There was an opened and undated 12-ounce bottle of Geri Lanta (an antacid medication) on the shelf in the medication storage room. The medication storage room refrigerator was observed with a pink dried substance spilled at the bottom of the second shelf. Licensed Practical Nurse #5 was interviewed immediately after the observation on 9/12/2024 and stated the pink residue in the refrigerator must be from a medication stored in the refrigerator. Licensed Practical Nurse #5 stated the nurses should have cleaned the refrigerator. Licensed Practical Nurse #5 stated they didn't know who opened the undated Geri Lanta and it should have been discarded after a month from when it was first opened. Licensed Practical Nurse #5 stated they should not have kept any items other than the medications in the treatment carts. Licensed Practical Nurse #5 stated they did not realize the medication cart had loose medications. Licensed Practical Nurse #5 stated all nurses should make sure there are no loose medications in the medication carts. The Director of Nursing Services was interviewed on 9/18/2024 at 12:30 PM and stated it was not acceptable to have loose medications, nail clippers, and hearing aid batteries in the medication cart. The nail clippers and the hearing aid batteries should be stored in the treatment cart. The Director of Nursing Services stated the nurses should keep the medication carts and medication storage rooms clean. The Director of Nursing Services stated open medication bottles should be labeled to determine when to discard the medication. 10 NYCRR 415.18 (d)(e)(1-4)

Based on record review and interview during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that Admission and Annual Minimum Data Set (MDS) assessments were completed within 14 calendar days after admission and not less than once every 12 months for 13 (Resident #4, #9, #22, #26, #59, #71, #73, #86, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, three (Resident #86, #106 and #107) of 19 Residents did not have an Admission MDS completed within 14 calendar days of admission and 10 (Resident #4, #22, #26, #59, #71, #73, #94, #95, and #98) of 19 had an Annual MDS assessment completed less than once every 12 months. Additionally, the facility provided a report titled Overdue MDS, which revealed that 18 Admission and 6 Annual MDS Assessments were not completed as of 2/2/23 which included two (Resident #9 and 71) of 19 Residents reviewed for Resident Assessments. The findings include but are not limited to: The Facility MDS 3.0 Completion policy dated 4/2008 documented that the facility will utilize the Center for Medicare and Medicaid (CMS) Minimum Data Set (MDS) 3.0 for resident assessment. The MDS required data elements are transmitted to New York State according to CMS requirements. The MDS assessment, which will be used to develop the resident's Comprehensive Care Plan (CCP), will be completed at the time of admission, whenever there is a significant change, and at least quarterly. The admission (Initial) assessment (Comprehensive) MDS must be completed by the 14 th calendar day of the resident's stay, may be combined with the discharge assessment as indicated. The Annual (Comprehensive) MDS must be completed within 366 calendar days of the Assessment Reference Date (ARD) of the last comprehensive assessment. The facility report entitled, Overdue MDS dated [DATE] documented 103 MDS assessments were overdue facility wide. The report indicated that Residents #9 and #71 had an overdue Annual MDS assessment. -Resident #9's Annual MDS assessment dated [DATE] was not completed as of 2/2/2023. -Resident #71's Annual MDS assessment dated [DATE] was not completed as of 2/2/2023. The Overdue MDS report also documented Resident #106's Admission MDS assessment with an assessment reference date of 9/1/2022 was not completed until 11/7/2022. The MDS Coordinator was interviewed on 2/2/2023 at 1:22 PM. The MDS Coordinator stated that they (MDS Coordinator) have been the MDS Coordinator since October 2021. The MDS Coordinator stated that they were the only person completing MDS's for the whole facility. In early September 2022, the MDS Coordinator informed the Director of Nursing Services (DNS) that they were falling behind on their work and MDS assessments were not completed on time. The DNS hired a part-time MDS Coordinator mid-September 2022 to assist with catching up on the MDS assessments. The Part-time MDS Coordinator works 3 days a week. The MDS Coordinator stated that even with the part- time MDS Coordinator they are still behind and are still catching up. The MDS Coordinator stated that they reviewed the medical records for Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107 on 2/1/2023 and their MDS assessments were not yet completed. The MDS Coordinator stated that there was a mix of Annual, Quarterly, Death entries MDS assessments due for all 19 residents. The MDS Coordinator stated that they began to work on the list of 19 residents brought to their attention and are in the process of completing their MDS assessments. The DNS was interviewed on 2/2/2023 at 1:41 PM. The DNS stated that they (DNS) were made aware that the MDS Coordinator was behind on MDS assessments in September 2022. The DNS stated that when the MDS Coordinator showed them a report of overdue MDS's in September 2022, there were about 300 outstanding MDS assessments. The DNS hired a part-time MDS Coordinator 3 days a week to assist in response to the MDS Coordinator's report. The DNS stated that they have a case manager who started to organize the care plan meetings and morning report meeting to free up the MDS Coordinator to work on the over-due MDS assessments. The DNS stated that in another week or two, they expect the facility to be caught up. The DNS stated that the facility just did a submission of MDS assessments that were completed in December 2022. The DNS was re-interviewed on 2/3/2022 at 2:24 PM. The DNS stated that the part-time MDS Coordinator was hired on 9/20/22. The DNS provided a report entitled Overdue MDS dated [DATE]. The DNS stated that they reviewed the overdue and incomplete MDS assessments, and the facility was currently behind on 103 MDS assessments as of 2/2/2023. The DNS was re-interviewed on 2/6/2023 at 9:42 AM and stated that the completion of Annual and Admission MDS assessments are due 14 days from the assessment reference date and the care plan completion is 7 days from the MDS completion date. The transmission to CMS is no later than 14 days the care plan completion date or 35 days from the assessment reference date. The DNS stated that the Unit Managers complete the care plan assessments and organize the care plan meetings within the 21 days of the assessment date. The Unit Managers complete the care plans by reviewing the medical records and their assessments on the units. The MDS Coordinator then reviews the data and completes the MDS assessments after the Unit Managers complete their assessments. The DNS stated that the Unit Managers are not directly involved in the MDS completion. The DNS stated that they are looking to hire full time MDS Coordinators and have placed job openings online to recruit. The DNS stated that they (DNS) are having a hard time finding an MDS Coordinator. The Administrator was interviewed on 2/6/2023 at 10:50 AM. The Administrator stated that the DNS informed them (Administrator) that the MDS Coordinator was behind in September 2022. The Administrator stated that they responded to the problem by hiring a part-time MDS Coordinator. The Administrator stated that they (Administrator) did an MDS submission in December 2022 and received a validation report with a message which indicated that the facility was overdue by way too many MDS's; however, the Administrator could not recall an exact number. The Administrator was not aware it was that bad in September 2022. The Administrator stated that the facility ensured that care plans were completed by the Unit Managers so care plan completion was not affected by the overdue MDS assessments. The Administrator stated that they reviewed the report of 103 overdue MDS assessments and they expect to have the assessments to be completed with the help of the part-time MDS Coordinator. The part-time MDS Coordinator needed some time to learn the electronic medical record system in September 2022, so they were not able to quickly assist with catching up on the MDS assessments. The Administrator decided that the facility had to place an advertisement to get two more full time MDS Coordinators. The Administrator further stated that they believe it would be best to have MDS Coordinators assigned to the units and solely focus on the care plans and the MDS completion. 10NYCRR 415.11(a)(3)(i)

Based on record review and interview during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that Quarterly Minimum Data Set (MDS) assessments specified by the state and approved by the Center for Medicare and Medicaid Services (CMS) were completed not less frequently than once every 3 months for 19 (Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, the facility did not complete Quarterly Minimum Data Set Assessments at least every 92 days following the previous assessment for all 19 Residents sampled for Resident Assessment. Additionally, the facility provided a report titled Overdue MDS, which revealed that 28 Quarterly MDS Assessments were not completed as of [DATE] which included 6 (Res #55, #59, #61, #71, #95 and #98) of 19 Residents reviewed for Resident Assessments. The finding is but not limited to: The Facility MDS 3.0 Completion policy dated ,d+[DATE] documented that the facility will utilize the Center for Medicare and Medicaid (CMS) Minimum Data Set (MDS) 3.0 for resident assessment. The MDS required data elements are transmitted to New York State according to CMS requirements. The MDS assessment, which will be used to develop the resident's Comprehensive Care Plan (CCP), will be completed at the time of admission, whenever there is a significant change, and at least quarterly. Quarterly Assessment reference date of the previous assessment of any type + (plus) 92 calendar days at maximum. The facility report entitled Overdue MDS dated [DATE] documented 103 MDS assessments were overdue facility wide. The report indicated Resident #55, #59, #61, #71, #95 and #98 had an overdue Quarterly MDS. Examples include but are not limited to: -Resident #55's Quarterly MDS dated [DATE] was not completed as of [DATE]. -Resident #61's Quarterly MDS dated [DATE] was not completed as of [DATE]. -Resident #90's Quarterly MDS with the assessment reference date of [DATE] was not completed until [DATE]. Resident #90 expired on [DATE] and Resident #90's Death in Facility Tracking Record dated [DATE] was not completed until [DATE]. The MDS Coordinator was interviewed on [DATE] at 1:22 PM. The MDS Coordinator stated that they (MDS Coordinator) have been the MDS Coordinator since October of 2021. The MDS Coordinator stated that they were the only person doing MDS's for the whole facility. In early [DATE], the MDS Coordinator informed the Director of Nursing Services (DNS) that they were falling behind on their work and MDS' were not completed on time. The DNS hired a part-time MDS Coordinator mid-[DATE] to assist with catching up on the MDS assessments. The part-time MDS Coordinator works 3 days a week. The MDS Coordinator stated that even with the part-time MDS Coordinator they are still behind and are catching up. The MDS Coordinator stated that they reviewed the medical records for Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107 on [DATE] and their MDS assessments were not completed yet. The MDS Coordinator stated that they began to work on the list of 19 residents brought to their attention and are in the process of completing their MDS assessments. The DNS was interviewed on [DATE] at 1:41 PM. The DNS stated that they (DNS) were made aware that the MDS Coordinator was behind on MDS's in [DATE]. The DNS stated that they could not recall the exact date and it was within two weeks of hiring the part-time MDS Coordinator to assist. The DNS stated that when the MDS Coordinator showed them a report of overdue MDS's in [DATE], there were about 300 outstanding MDS assessments. The DNS hired a part-time MDS Coordinator 3 days a week to assist in response to the MDS Coordinator's report. The DNS stated that they have a case manager who started to organize the care plan meetings and morning report meeting to free up the MDS Coordinator to work on the over-due MDS assessments. The DNS was re-interviewed on [DATE] at 2:24 PM. The DNS stated that the part-time MDS Coordinator was hired on [DATE]. The DNS provided a report entitled Overdue MDS dated [DATE]. The DNS stated that they reviewed the overdue and incomplete MDS report, and the facility was currently behind on 103 MDS assessments as of [DATE]. In a subsequent interview with the DNS on [DATE] at 9:42 AM the DNS stated that the completion of the Annual and Admission MDS assessments are due 14 days from the assessment reference date (ARD) and the care plan completion is 7 days from the MDS completion date. The transmission of the MDS assessments to CMS is no later than 14 days of the care plan completion date or 35 days from the assessment reference date. The DNS stated that the Unit Managers complete the care plan assessments and organize the care plan meetings within the 21 days of the assessment date. The Unit Managers complete the care plans by reviewing the medical records and their assessments on the units. The MDS Coordinator then reviews the data and completes the MDS after the Unit Managers complete their assessments. The DNS stated that they are looking to hire full time MDS Coordinators and have placed job openings online to recruit. The DNS stated that they (DNS) are having a hard time finding an MDS Coordinator. The Administrator was interviewed on [DATE] at 10:50 AM. The Administrator stated that the DNS informed them (Administrator) that the MDS Coordinator was behind in [DATE]. The Administrator stated that they responded to the problem by hiring a part-time MDS Coordinator. The Administrator stated that they (Administrator) did an MDS submission in [DATE] and received a validation report with a message which indicated that the facility was overdue by way too many MDS's; however, could not recall an exact number. The Administrator stated that the facility ensured that care plans were completed by the Unit Managers so care plan completion was not affected by the overdue MDS assessments. The Administrator stated that they reviewed the report of 103 overdue MDS assessments and expected to have the assessment completed with the help of the part-time MDS Coordinator. The part-time MDS Coordinator needed some time to learn the electronic medical record system in [DATE], so they were not able to quickly assist with catching up on MDS assessments. The Administrator decided that the facility had to place an advertisement to hire two more full-time MDS coordinators. The Administrator further stated that they believe it would be best to have MDS Coordinators assigned to the units and solely focus on the care plans and the MDS completion. 10 NYCRR 415.11(a)(4)

Based on observation, interviews, and record reviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #64) of two residents reviewed for Pain Management. Specifically, during the medication administration observation task on 2/1/2023 for Resident #64, the resident complained of inadequate pain control to Licensed Practical Nurse (LPN) #2 medication nurse; however, there was no documented evidence that this was reported by the nurse to the resident's Physician until the next day (2/2/2023). Additionally, the resident's pain was not consistently assessed and monitored before and after administration of the pain medications to identify the effectiveness of the resident's pain management. The finding is: The facility's policy titled Pain Assessment and Management, revised 10/2015, documented the facility recognizes the right of every resident to be free of pain. The physician must be immediately notified if the resident has no relief from the medication and continues to have pain. Additional pain medication may be needed for breakthrough pain. For as-needed (PRN) medications, after every administration, the nurse evaluates the effectiveness of the medication. If the resident is still experiencing pain, the nurse notifies the physician and documents in the medical record. Resident #64 was admitted with diagnoses including Idiopathic Peripheral Autonomic Neuropathy, Cellulitis of the Right and Left Lower Limbs, and Arthritis. The 1/22/2023 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident frequently had pain, pain affected daily function, and the worst pain over the previous 5 days was 10 on a scale of 0-10, with 10 being the worst pain. A Comprehensive Care Plan (CCP) effective 1/20/2023 titled Pain Management-Acute Pain, documented the resident had pain related to Chronic Pain Syndrome. Interventions added to the care plan on 2/2/2023 included to administer medications per physician orders; ongoing assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain, and alleviating and aggravating factors; and to monitor side effects and adverse reactions resulting from the interventions rendered. The physician's orders dated 1/20/2023 documented the following: Administer Oxycodone, 5 milligram (mg) tablet, give one tablet every 6 hours as needed (PRN) for pain. Administer Naproxen 500 mg tablet, give 1 tablet every 12 hours as needed (PRN) for pain. Administer Gabapentin 800 mg tablet, give 1 tablet every 8 hours for Idiopathic Peripheral Autonomic Neuropathy. Administer Acetaminophen 325 mg tablet, give two tablets (650 mg) every 6 hours as needed (PRN) for pain. Administer Pregabalin 100 mg capsule, give 1 capsule three times a day for Idiopathic Peripheral Autonomic Neuropathy. Review of the January 2023 Medication Administration Record (MAR) revealed the following: The PRN (as needed) 5 mg Oxycodone was given every day in January since admission on 1/20/2023 with inconsistent pain monitoring. On 1/20/2023 at 5:54 PM and 11:55 PM; 1/21/2023 at 8:38 AM; 4:31 PM, and 11:27 PM; 1/22/2023 5:55 AM and 6:10 PM; and 1/23/2023 12:31 AM and 10:01 AM; 1/24/2023 at 12:55 AM there was no there was no pain monitoring prior to and after the administration of the medication. The following was documented for other oxycodone administrations: On 1/25/2023 at 8:57 AM the pain was assessed as 6 out of 10; however there was no assessment after the medication administration. On 1/26/2023 at 4:57 PM the pain was assessed at 10 out of 10 with a follow up of 7 out of 10 after the medication administration; On 1/27/2023 at 8:47 AM the pain assessment was documented as 6 out of 10 and there was no assessment post medication administration, at 5:05 PM the pain assessment was documented as 10 out of 10 and a follow-up pain assessment of 9 out of 10 after the medication was administered; and on 1/31/2023 at 1:39 AM the pain assessment documented pain level of 10 out of 10 with a follow up assessment with a pain level of 8 out of 10 after the medication administration, at 4:53 PM the pain level was documented as a 10 out of 10 with a follow up pain level of 9 out of 10 after the pain medication administration. The MAR also revealed that Naproxen 500 mg was administered on 1/21/2023, 1/22/2023, 1/23/2023, 1/26/2023, 1/27/2023, and 1/31/2023 with no pain monitoring prior to and after the administration of the medication. The MAR also revealed that Acetaminophen 325 mg, 2 tabs (650 mg) was administered on 1/22/2023 for pain level of 6 with no follow up; 1/25/2023 for pain of 6 with no follow up; 1/26/2023 for pain of 10 with follow up of 7; and 1/27/2023 for pain of 10 with follow up of 9 out of 10 after the pain medication administration Resident #64 was interviewed on 1/31/2023 at 10:42 AM and stated they (Resident #64) have Neuropathy and Cellulitis of both lower legs. The best pain relief they (Resident #64) get is 5 out of 10 on their present medication regimen. A Medication Administration Observation was conducted with Licensed Practical Nurse (LPN) #2 on 2/1/2023 at 9:39 AM. Resident #64 reported to LPN #2 that 5 mg of Oxycodone was not effective and was providing little pain relief. LPN # 2 stated they (LPN #2) would talk to the doctor right after the medication pass. The resident stated their (Resident # 64) pain level was 10/10 from their shoulders to their feet. The resident stated 5 mg of Oxycodone did not help, but the resident took the 5 mg oxycodone that was offered for now. The resident also stated the Acetaminophen was not effective. Resident #64 was interviewed on 2/2/2023 at 8:50 AM. The resident stated there has been no other new pain control medication offered since reporting the pain control issues to LPN #2 yesterday on 2/1/2023. The resident stated no one came to see them after they told LPN #2 yesterday that the current pain medications were not relieving their pain. Review of the medical record revealed no documentation that LPN #2 communicated the pain control concerns to the Nursing Supervisor or the physician. LPN #2 was interviewed on 2/2/2023 at 8:53 AM and stated they (LPN #2) spoke to a Physician Assistant (PA #1) on 2/1/2023 and that PA #1 suggested alternating Acetaminophen with the Oxycodone. LPN #2 stated they (LPN #2) did not enter a progress note after talking to PA#1 on 2/1/2023 and should have. A nursing progress note dated 2/2/2023 at 9:06 AM (entered as late), written by LPN #2, documented Resident #64 had pain level of 10/10 on 2/1/2023. The resident states their pain was from their shoulders to their feet. Oxycodone 5 mg given with positive effect. Resident stated the medication was not effective all the time. PA made aware with suggestion of alternating oxycodone and Tylenol for pain management. PA #1 was interviewed on 2/2/2023 at 11:18 AM and stated that LPN #2 did not talk to them (PA #1) on 2/1/2023. PA #1 stated they (PA #1) were in the facility yesterday (2/1/2023) but did not see Resident #64 because the resident was not due to be seen and LPN #2 did not talk to them (PA #1) about this resident. PA #1 stated the resident should be seen by our pain management service. PA #1 stated the resident is on a significant amount of pain medications, but the pain medications can be adjusted for instance, the dosages and frequency, while we wait for pain management service. A nursing progress dated 2/2/2023 at 1:00 PM, written by LPN #2, documented Resident #64 was complaining of pain from their arms to their feet. Oxycodone 5 mg was given with no effect. A new order was received for Oxycodone 10 mg every 6 hours as needed for pain. A Physical Medicine and Rehabilitation (PMR) progress note dated 2/2/2023 documented increased pain, generalized in joints, recommend increasing Oxycodone to 10 mg every 6 hours. The Director of Nursing Services (DNS) was interviewed on 2/3/2023 at 1:31 PM. The DNS stated if a resident is complaining of pain, the nurse should notify the PA, and if the PA is not around, then notify the Registered Nurse (RN) Supervisor who will do an assessment and notify the doctor. There should have been a progress note written on 2/1/2023 after the resident complained about pain to LPN #2. RN #2 (Inservice Coordinator) was interviewed on 2/3/2023 at 2:47 PM. RN #2 stated if a resident is complaining of pain, the LPN should have reported the resident's pain to the RN Supervisor so an an assessment could be completed and the findings reported to the physician. RN #2 stated the nurse must document actions and conversations and follow up after a PRN medication is given to determine if the pain medication was effective. 10NYCRR 415.12

Based on observations, record review and interviews conducted during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that each resident was free from significant medication errors. This was identified for one (Resident #271) of five residents reviewed for Unnecessary Medication. Specifically, Resident #271 had a Physician's order for Midodrine (medication used to treat low blood pressure) with Blood Pressure (BP) parameters to hold the medication if the systolic BP was greater than 110 Millimeters of Mercury (mmHg). The facility staff administered Midodrine on one occasion to Resident #271 when the medication was supposed to be held and held the medication twice when the medication was supposed to be administered. The finding is: The Policy and Procedure for Medication Administration: General Policies and Practices, dated March 2017 documented a resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: Excessive dose including a duplicate drug. The Staff nurse reviews the Electronic Medication Administration Record for accuracy after all medications for a specific resident have been prepared. Resident # 271 was admitted with diagnoses including Orthostatic Hypotension (low blood pressure), Hypertension and Atrial Fibrillation. The Minimum Data Set (MDS) was not available due to the resident being a newly admitted resident at the facility. The Physician's order dated 1/28/2023 documented to administer Midodrine 2.5 milligrams (mg) tablet, give 1 tablet (2.5 mg) by oral route every 8 hours, every day at 10:00 PM; 2:00 PM; 6:00 AM, and monitor blood pressure (BP) and hold the medication if the Systolic BP (SBP) is greater than (>) 100 millimeters of Mercury (mmHg). The Physician order dated 1/30/2023 for Midodrine was changed to administer Midodrine 2.5 mg tablet, give 1 tablet (2.5 mg) by oral route every 8 hours every day at 10:00 PM; 2:00 PM; 6:00 AM. HOLD FOR SBP > (greater than) 110 mmHg Protocol: HOLD SBP < (less than) 110 mmHg for Orthostatic Hypotension. This order was entered by Licensed Practical Nurse (LPN) # 6 on 1/30/2023 at 9:51 AM. The Physician order dated 2/01/2023 at 6:53 AM documented to administer Midodrine 2.5 mg tablet, give 1 tablet (2.5 mg) by oral route every 8 hours. HOLD FOR SBP > (greater than)110 mmHg every day at 10:00 PM; 2:00 PM; 6:00 AM. The January 2023 Medication Administration Record (MAR) documented on 1/30/2023 Midodrine 2.5 mg, give 1 tablet (2.5 mg) by oral route every 8 hours HOLD FOR SBP > (greater than) 110 mmHg. Protocol: HOLD SBP < (less than) 110 mmHg for Orthostatic Hypotension and Monitor blood pressure, Start Date: 1/30/2023. On 1/31/2023, Midodrine was held at 6 AM with a Blood Pressure (BP) reading of 96/60 mmHg and on 1/31/2023, Midodrine was administered at 10 PM with a BP reading of 117/81 mmHg. Review February 2023 MAR documented Midodrine 2.5 mg tablet, give 1 tablet (2.5 mg) by oral route every 8 hours HOLD FOR SBP > (greater than)110 mmHg. Protocol: hold for SBP > (greater than)110 mmHg. On 2/2/2023 at 6 AM, the medication was held with a BP reading of 94/58 mmHg. The package insert for Midodrine medication documented a warning: Supine Hypertension: The most potentially serious adverse reaction associated with Midodrine hydrochloride therapy is marked elevation of supine arterial blood pressure (supine hypertension). It is essential to monitor supine and sitting blood pressures in patients maintained on Midodrine hydrochloride. Uncontrolled hypertension increases the risk of cardiovascular events, particularly stroke. The package insert also documented that the supine and standing blood pressure should be monitored regularly, and the administration of Midodrine Hydrochloride Tablets, USP should be stopped if supine blood pressure increases excessively. LPN# 6 was interviewed on 2/2/2023 at 2:10 PM and stated the directions entered into the computer were an input error and should have read to hold if the SBP was over 110 mmHg as per the Physician's order. The Director of Nursing Services (DNS) was interviewed on 2/7/2023 at 2:25 PM and stated there was an input error for the medication Midodrine. The DNS stated that it is also the responsibility of the Medication Nurses to know the medications. If the directions were not clear, the medication nurse should have questioned the directions. Medication nurses should check the medication orders for accuracy prior to administration. The Physician Assistant #2 was interviewed on 2/7/2023 at 2:35 PM and stated Midodrine is given for Hypotension and nurses should hold the medication when the SBP was above 110 mmHg. The Electronic Medical Record (EMR) has standardized parameter protocols for BP medications and the nurses should check the parameters and that the directions are correct when they (nurses) are entering the BP medication orders in the EMR. After this medication error was identified, the facility is making sure the nurses write out greater and less than instead of using the symbols. 10NYCRR 415.12(m)(2)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023 the facility did not ensure that an infection prevention and control program was established to maintain a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #272) of four residents observed for medication administration. Specifically, during the medication pass observation, Licensed Practical Nurse (LPN) #1, the medication nurse, did not wear appropriate Personal Protective Equipment (PPE) while administering medications for Resident #272, who was on contact and droplet precautions for Respiratory Syncytial Virus (RSV), and was observed coughing. Additionally, LPN #1 did not appropriately remove their PPE before exiting the resident's room when the medication administration was completed. The finding is: The facility's policy titled Control of Communicable Disease-RSV (Respiratory Syncytial Virus) revised 9/2022, documented RSV is spread through contact with droplets from the nose and throat of infected people when they cough and sneeze. Utilize proper personal protective equipment (PPE) for contact and droplet precautions. Upon entry to the room all staff must don the following PPE (gown, gloves, mask, and eye protection) and prior to exit all PPE must be doffed (taken off). Resident #272 was admitted with diagnoses including Hip Fracture, Heart Failure, and Hypertension. The 1/17/2023 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's order dated 1/30/2023 documented to maintain Droplet and Contact precautions/isolation every shift for positive RSV infection. A nursing progress note dated 1/30/2023 at 11:12 AM documented the resident's cough increasing with an audible wheeze. The physician assistant (PA) was made aware and new orders for a respiratory panel were obtained. A nursing progress note dated 1/30/2023 at 1:28 PM documented that a call was received from the laboratory. Resident #272 was positive for RSV. The isolation protocol was in place. During an observation on 2/1/2023 at 9:13 AM LPN #1 performed medication administration for Resident #272. The resident's room door had signs indicating the room was on contact and droplet precautions. The droplet precaution sign documented everyone must make sure their eyes, nose, and mouth are fully covered before room entry (illustration included either a face shield or goggles). The sign documented to remove face protection before room exit. After LPN #1 prepared the resident's medications, they (LPN #1) donned a gown and gloves. LPN #1 was wearing an N95 mask (there was no surgical mask covering the N95). LPN #1 did not put on a face shield or goggles. LPN #1 then entered the room and provided the medications to Resident #272, who was sitting in a wheelchair. The resident was not wearing a mask and was observed coughing. After LPN #1 administered the medications, they (LPN #1) removed their gown and gloves and sanitized their hands. The nurse did not remove and change the N95 mask before exiting the resident's room. LPN #1 was interviewed on 2/1/2023 at 9:20 AM after LPN #1 exited Resident #272's room. LPN #1 stated they (LPN #1) do not wear goggles or face shield when working with RSV residents and do not change the N95 face mask after working with RSV residents. LPN #1 stated they would wear a face shield or goggles and change the N95 only if the resident was COVID-19 positive. LPN #1 then proceeded to another resident's room. Registered Nurse (RN) #1, who was the Assistant Director of Nursing Services (ADNS) and the Infection Preventionist (IP), was interviewed on 2/2/2023 at 8:30 AM. RN #1 stated that RSV infection spreads the same way as COVID-19 infection through droplets and direct contact. Residents who are diagnosed with RSV infection are required to be placed on contact and droplet precautions. RN #1 stated staff must wear goggles or a face shield when caring for RSV-infected residents and that LPN #1 should have changed the N95 mask if it was not covered by a surgical mask because of the potential for contamination from the RSV droplets. RN #2, the Inservice Coordinator, was interviewed on 2/2/2023 at 2:08 PM. RN #2 stated RSV infection spreads like COVID-19. RN #2 stated LPN #1 should have been wearing goggles and should have changed their N95 mask. The Director of Nursing Services (DNS) was interviewed on 2/3/2023 at 1:30 PM. The DNS stated that droplet precautions do not just apply to COVID-19; RSV infection spread is similar to COVID-19. The DNS stated LPN #1 should have worn facial protection when administering the medications. The DNS further stated that LPN #1 should have changed the N95 mask after completing the medication pass because the N95 mask was not covered by a surgical mask and was considered potentially contaminated. 10NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that resident who need respiratory care, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #224) of two residents reviewed for oxygen. Specifically, Resident #224 had a Physician's order for continuous oxygen at two liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen). On two separate occasions, the resident was observed not receiving oxygen therapy as prescribed by the resident's Physician. The finding is: The facility's Policy and Procedure for Physician's orders last updated on 1/5/2018 documented that the nursing staff must follow the orders of the Physician (MD)/Physician Assistant (PA)/Nurse Practitioner (NP), and if clarification is needed, the staff must communicate with the resident's MD/PA/NP. Resident #224 was admitted with diagnoses that included COVID-19 infection, Hypertension, and Acute Cough. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated the resident had intact cognition. The resident had no behavioral symptoms and did not reject care. The resident was non-ambulatory and required extensive assistance of two staff members for transfers. A Comprehensive Care Plan (CCP) for Oxygen Use dated 10/26/2022 documented the resident required supplemental oxygen due to episodes of shortness of breath related to a history of COVID-19 infection. Interventions included to check for the proper placement of oxygen tubing and to provide oxygen as ordered by the MD. A Physician's order dated 12/4/2022 documented to administer oxygen via a nasal cannula (NC) at two liters per minute continuously every shift at 11:00 PM-7:00 AM, 3:00 PM-11:00 PM, and 7:00 AM-3:00 PM. The Treatment Administration Record (TAR) dated 1/2023 documented oxygen therapy was administered continuously as per the physician's orders as indicated by staff signatures. Resident #224 was observed on 1/31/2023 at 11:52 AM lying in bed awake and responsive to their name and greetings. The nasal cannula was observed laying on the bed away from the resident still attached to the concentrator while the concentrator was on. The resident was unable to explain why the tubing was laying on the bed. Licensed Practical Nurse (LPN) #8, who cared for the resident on the 7:00 AM-3:00 PM shift on 1/31/2023, was made aware of the observation on 1/31/2023 at 11:53 AM. LPN #8 stated that Resident #224 is on continuous oxygen and sometimes removes their oxygen tubing; however, staff should monitor the resident to ensure that the oxygen tubing is in place. LPN #8 replaced the nasal cannula on the resident. Resident #224 was observed on a second occasion on 2/1/2023 at 10:26 AM. Resident #224 was asleep in bed without the oxygen nasal cannula in place. The oxygen tubing was observed coiled and tucked under the oxygen concentrator handle and the oxygen concentrator was on. LPN #7, who cared for the resident on 2/1/2023 during the 7:00 AM-3:00 PM shift, was interviewed on 2/1/2023 at 10:26 AM. LPN #7 stated that the resident sometimes removed their oxygen tubing; however, the resident could not have coiled the oxygen tubing and tucked the tubing under the oxygen concentrator handle. LPN #7 stated that they could not say who removed the resident's oxygen tubing. LPN #7 stated that the resident is on continuous oxygen as per the physician's orders and should have been wearing the nasal cannula. Certified Nursing Assistant (CNA) #3 was interviewed on 2/7/2023 at 12:26 PM and stated that they were assigned to care for the resident on 1/31/2023 and 2/1/2023 and were responsible to ensure that the resident was wearing the nasal cannula to receive their oxygen. CNA #3 stated at times the resident removes their nasal cannula; however, the resident was not able to ambulate and therefore could not have coiled the oxygen tubing and tucked the tubing under the oxygen concentrator handle. The Director of Nursing Service (DNS) was interviewed on 2/7/2023 at 12:40 PM and stated Resident #224 can be non-compliant with their oxygen therapy at times; however, the staff should be checking to ensure the resident was receiving continuous oxygen as per their Physician's orders. Physician Assistant (PA) #2 was interviewed on 2/7/2023 at 3:21 PM and stated that they expected that staff should carry out the Physician's order as written and that the resident should have been wearing their nasal cannula and receiving supplemental oxygen as per the Physician's orders. PA #2 further stated that if the resident was identified to be removing the nasal cannula the staff should have monitored the resident to ensure the resident was receiving oxygen as ordered. 10NYCRR 415.12(k)(6)

Based on observation, interviews, and record review during a Focused Infection Control Survey conducted on 10/27/20, the facility did not ensure it established and maintained an infection control prevention protocol designed to help prevent the development and transmission of COVID-19 on 1 of the 3 units. Specifically, Nurses and Certified Nursing Assistants (CNAs) were sharing isolation gowns in contact/droplet isolation rooms. The Finding is: The Centers for Disease Control and Prevention (CDC) guidelines titled Strategies for Optimizing the Supply of Isolation Gowns, updated 10/9/20, documented that regarding the re-use of isolation gowns, Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP (Health Care Personnel) and patients that likely outweigh any potential benefits. Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms (e.g., C. auris) among patients. However, unlike extended use, repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. The Facility Policy titled Infection Control Procedure, revised on 10/14/20, documented that extended use of gowns on COVID-19 units would require frontline staff to wear yellow reusable gowns as their base layer when on the unit (one per shift, unless it is soiled). In the entrance of each room will be hooks that a white/clear re-usable gown will be hung. Upon entering a COVID-19 positive room staff are to don one of the white/clear reusable gowns. After the shift, or when these (reusable) gowns become soiled, they are to be sent down to laundry to be washed. On non-COVID-19 units, staff are to use disposable isolation gowns (blue/yellow/white). The Director of Nursing Services (DNS) was interviewed on 10/27/20 at 9:30 AM and stated that the whole facility was on Transmission Based Precaution (contact/droplet precautions) due to one positive COVID-19 resident in the facility. On 10/27/20 at 11:47 AM two resident rooms (rooms [ROOM NUMBERS]) were observed on the B unit. Each room had two residents residing within the room. Upon entering Room # 228, surveyors observed 2 yellow (reusable) gowns hanging on the wall on hooks. Room # 226 was observed with 1 yellow (reusable) gown and 1 blue (disposable) gown. Both rooms had a contact/droplet precaution sign. The 7 AM-3 PM shift Unit B Registered Nurse (RN) Nurse Manager was interviewed on 10/27/20 at 11:59 AM and stated that each resident is designated a disposable gown. The Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA) wear the same gown in each room when caring for the residents every time they enter the room. The disposable gowns do not get cleaned in between use but when the gown is soiled it is discarded right away. The RN stated when a resident requires assistance of 2 persons, the staff would use the 2 gowns that are hanging on the hooks in the resident's room. The Licensed Practical Nurse (LPN) #1 on Unit B was interviewed on 10/27/20 at 12:20 PM and stated that the gowns in the room are not for a specific resident. LPN #1 stated that any staff entering the room can use the two gowns to care for any of the residents in the room. LPN #1 further stated that the gowns are not cleaned after each use and that other staff members will use the same gowns when providing care in that room. LPN #2 on Unit B was interviewed on 10/27/20 at 3:17 PM and stated that she usually brings her own gown from the pile of the newly washed gowns at the start of her shift; however, she will also use whatever gown is available in the residents' room. She also stated that when she performs care, she would use a gown found hanging on a hook when entering a room and hang it back up for other staff to use. LPN #2 stated she does not clean the gown after use. The Infection Control Preventionist (ICP) RN was interviewed on 10/27/20 at 4:37 PM and stated that the facility has an ample supply of gowns. She stated it is okay for a staff member to use a gown that was used by another staff member. If it is a quick in and out like giving a pill, dropping off a tray, and if staff is in the room for less than 15 minutes they can use the gown again. The ICP stated that the gowns do not need to be cleaned in between use because the gowns did not leave the room. The ICP stated that the facility policy does not address their current procedure on the extended use of gowns and needs to be updated. In a subsequent interview with the DNS on 10/27/20 at 5:02 PM he stated that the facility has enough supply of gowns. He stated the practice of extending the use of gowns was implemented to conserve the facility's supply of PPE. However, the staff should not be sharing gowns. Each staff member should label their gown and place it on hook inside the resident's room. The DNS stated that the COVID-19 policies on extended use of gowns still documents that the yellow gown is to be utilized as the base layer which was done during the height of COVID-19 and this practice is not what is done at the present time. He further stated that the facility no longer utilizes clear gowns and the policy needs to be updated. 415.19(a)(1-2),(b)(1-2)

Based on observation, record review and staff interviews during the Recertification survey, the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed to address the resident's medical and nursing needs. This was identified for two (Resident #134 and Resident #[AGE]) of two residents reviewed for restraints. Specifically,1) Resident #134 did not have a CCP developed for the use of a bed alarm; and 2) Resident # [AGE] did not have a CCP developed for the use of a chair alarm. The findings are: 1) Resident #134 has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] did not document the use of alarms in the Restraints and Alarms section of the MDS. An Annual MDS dated [DATE] documented the use of a bed alarm restraint. A physician's orders [REDACTED]. The Resident Care Profile, which provides direction to the Certified Nursing Assistants (CNA) for resident care needs, from October 2019 to February 2020 documented the use of a bed alarm and daily checks for placement and functioning. The medical record was reviewed, including the CCPs, since 5/24/19 and there was no documented CCP for the use of the bed alarm. The Director of Nursing Services (DNS) was interviewed on [DATE] and stated he would develop a CCP for the use of the bed alarm. The DNS was re-interviewed on 2/24/20 at 9:44 AM. The DNS stated that a CCP for the bed alarm was not initiated until [DATE]; however, the Resident Care Profile documented the use of the bed alarm when first ordered on [DATE]. He stated that the unit Registered Nurse (RN) managers are responsible to initiate the CCPs. He stated that the resident was on unit E and was moved to unit C on 7/18/19. The DNS further stated that the C unit RN Manager does not work here any more and the E unit RN manager started working here only two months ago. The C unit RN manager was interviewed on 2/24/20 at 10:00 AM and was not aware that there was not a CCP developed for the use of the bed alarm. She stated that the team last reviewed the CCPs in a meeting held on 2/10/20. The MDS Coordinator was interviewed on 2/24/20 at 10:32 AM. She stated the bed alarm should have been documented in the MDS dated [DATE]. She also stated that the CCP team should have identified that there was no bed alarm CCP in place during the CCP meeting held for the resident on 2/10/20. 2) Resident #[AGE] has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severely impaired cognition. The MDS documented that a chair alarm was used daily. Resident #[AGE] was observed on [DATE]20 at 8:01 AM with a chair alarm in place. The physician's orders [REDACTED]. A Certified Nursing Assistant (CNA) profile record dated 2/2020 documented to place a chair alarm on the resident's wheel chair. There was no documented evidence a CCP was developed for the use of the chair alarm. An interview was held with the Registered Nurse (RN) MDS Coordinator on 2/24/20 at 11:00 AM. The RN stated a CCP was not developed for the use of the chair alarm. An interview was held with the Assistant Director of Nursing (ADNS) on [DATE] at 11:15 AM. The ADNS reviewed the CCPs and stated there was no CCP developed for the use of the chair alarm. An interview was held with the RN unit manager on [DATE] at 2:00 PM. The RN stated a CCP was not developed. The RN stated they were not aware that a chair alarm required a CCP. 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards and the comprehensive person-centered care plan. This was identified for one (Resident #13) of two residents reviewed for dignity and one (Resident #99) of one resident reviewed for skin condition. Specifically, 1) Resident #13 had an order for [REDACTED]. condition; and 2) Resident #99 was identified with a large area of discoloration to the inner upper right arm. The medical record lacked documented evidence that the Physician was notified of the discoloration, or that the area of discoloration was assessed by an RN. The findings are: 1) Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 15 which indicated intact cognition. The resident had no behavior symptoms, and required extensive assist of one staff member for transfers, toileting, and personal hygiene. A Treatment Administration Record (TAR) dated 2/2020 documented on [DATE], [MEDICATION NAME] 1% topical cream, apply by topical route. The TAR documented to cleanse the buttocks with soap and water and to apply cream for Skin Eruption. The Progress notes dated 2/10/2020 to [DATE] were reviewed on [DATE] at 11:30 AM. There was no documented evidence of an assessment regarding the excoriation to the resident's buttocks. The resident's CCP was reviewed on [DATE] at 11:30 AM and there was no documented evidence of a CCP developed for impaired skin. A CCP for skin integrity dated [DATE] documented the resident had an excoriation to the buttock area. Interventions including to assess the skin every shift and to provide treatment as ordered. The resident was observed on [DATE] at 10:05 AM with the RN Unit Manager. Three medication cups containing a white cream were observed on the sink counter in the resident's room. The RN stated the cream was [MEDICATION NAME] and that the [MEDICATION NAME] cream should not have been left in the resident's room. The RN further stated the [MEDICATION NAME] was a physician's orders [REDACTED]. The Licensed Practical Nurse (LPN) was interviewed on [DATE] at 10:15 AM. The LPN stated the resident receives [MEDICATION NAME] treatment to her buttocks and the treatment is to be applied by the nurse and was not to be left in the resident's room. The LPN stated that she had not done the treatment for [REDACTED]. During the interview the LPN asked the resident who had left the cups containing the cream on the sink. The resident wrote on her clipboard that the night nurse had left the cream in her room. A fourth cup of cream was observed in the drawer of the resident's night table. The LPN stated the cream was left for the CNA to apply after providing care. The 7:00 AM - 3:00 PM Certified Nursing Assistant (CNA) was interviewed on [DATE] at 10:30 AM. The CNA stated that most of the time she used A and D ointment on the resident after providing peri-care. The CNA stated that if she was performing AM care the nurse would bring the [MEDICATION NAME] cream at that time and she (the CNA) would apply the cream to the resident's buttocks. The Director of Nursing Services (DNS) was interviewed on [DATE] at 1:42 PM. The DNS stated that creams ordered for treatment should not be left at the bed side. The DNS stated when there was a change in the resident's skin condition the RN should be notified, and an assessment of the area should be completed. Additionally, the DNS stated the RN should have notified the Physician, obtained a treatment order if warranted, and documented her assessment in a progress note. The DNS further stated that a CCP should have been initiated or updated. The Nurse Practitioner (NP) was interviewed on [DATE] at 2:55 PM. The NP stated today, [DATE], he received a call for an order for [REDACTED]. 2) Resident #99 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 14 which indicated the resident was cognitively intact. The resident had no behavior problems and required extensive assist of one staff member for bed mobility and transfers. The resident required set up help only for locomotion on and off the unit. The resident was observed on 2/18/2020 at 3:05 PM. A large bruised area was observed to the right upper inner arm. The resident stated that he was receiving blood thinners. A Comprehensive Care Plan (CCP) for Skin Integrity dated [DATE] documented the resident was at high risk for skin breakdown related to decreased mobility, incontinence, [MEDICAL CONDITIONS], or malnourishment. Interventions included Certified Nursing Assistant (CNA) evaluation of the resident's skin condition daily during care and to report any skin abnormalities to the nurse. A CCP for Anticoagulant Therapy dated 11/12/19 documented interventions that included to: administer anticoagulant therapy as per the MD order, assess for signs and symptoms of bleeding, avoid bumping, handle the resident gently when providing hands on care, report any changes in skin condition (ecchymosis/discoloration), report signs of abnormal bleeding or side effects of medication to the physician, and to perform skin checks every shift. A physician's orders [REDACTED]. Resident #99 was interviewed on [DATE] at 10:20 AM. The resident stated that he uses the upper side rails to pull himself up in bed and that he bumps his arm on the side rail during the process. The resident stated that he told the LPN that he bumps his arm on the side rail when he pulls himself up in bed using the side rails. The CNA was interviewed immediately on [DATE] at 10:22 AM and stated that she could not recall the date; however, the CNA stated that she saw the discoloration last week and reported the discoloration to the Licensed Practical Nurse (LPN) medication nurse. The LPN medication nurse was interviewed on [DATE] at 10:24 AM. The LPN stated she was informed by the CNA that there was an area of discoloration to the resident's upper right arm. The LPN stated the resident mentioned the area to her and that she reported the discoloration to the Registered Nurse (RN) Manager and the Physician. The LPN further stated that she did not document the area of discoloration in the progress note and should have. The RN Manager was interviewed on [DATE] at 10:40 AM. The RN Manager stated she was made aware of the area of discoloration but did not assess the area. The RN Manager stated that she should have assessed the area when she was notified, initiated interventions as needed, and documented her assessment in the progress note. Additionally, the RN Manager stated that she will complete an assessment and initiate padding for the side rail. The Nurse Practitioner (NP) was interviewed on [DATE] at 3:02 PM. The NP stated that he was notified today, [DATE], of the discoloration to the resident's right upper arm. 415.12

Based on interviews and record review during an abbreviated survey (Complaint # NY 945), the facility did not ensure resident rights to be free from abuse for one (Resident #1) of three residents reviewed for abuse. Specifically, a Licensed Practical Nurse (LPN) was witnessed by a Certified Nursing Assistant using foul language and hitting a legally blind resident with cognitive impairment twice on his forehead. The findings were: The facility's policy titled Abuse Prevention and Reporting dated 1/23/17 documented all residents will be free from verbal, sexual, physical and mental abuse. Abuse is defined as the willful infliction of injury, .or punishment with resulting physical harm or pain or mental anguish. Physical abuse is defined as hitting and slapping. Verbal abuse is defined as any oral, written or gestured language that included disparaging and derogatory terms to residents, regardless of their age, ability to comprehend, or disability. Resident # 1 was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 2/1/19 documented severe cognitive impairment with short and long term memory impairment. The Comprehensive Care Plan (CCP) dated 4/18/18 documented Resident #1 had behaviors of calling out for her friend being physically and verbally abusive and gets agitated without warning. Interventions included to provide a quiet environment with low stimuli, provide non-pharmacological interventions prior to giving any medication, i.e offer snacks, remove to a quiet area, provide soft music and TV. LPN # 1 was an agency nurse. The LPN was in-serviced on abuse/neglect on 5/4/18. The LPN was terminated immediately after the incident on 12/10/18. The incident report dated 12/10/2018 documented on 12/10/2018 at 3:30 PM CNA#1 reported that LPN #1 was swearing at the resident and repeatedly shoved his forehead back. CNA#1 stated she felt this was done because resident was yelling out. LPN #1 was immediately removed from the unit. The resident was immediately assessed, no injuries were noted. The camera was reviewed on 12/10/18 and 12/11/18 and the findings were validated. LPN #1 appeared to get into a verbal altercation with Resident #1 and then proceeded to strike with an open hand and pushed him on the forehead twice. LPN #1 was terminated immediately. The LPN stated she must have been joking around with the resident. The LPN was unable to be reached for an interview. The LPN denied abusing/hitting the resident in a written statement to the facility. The Nursing progress notes dated 12/10/18 by the 3-11 PM Registered Nurse (RN) supervisor documented , the resident was assessed with [REDACTED]. The resident was calm and cooperative. No complaint of pain /discomfort. The social worker progress note dated 12/12/18 documented the resident had no recollection of event. The video surveillance was reviewed with the DON on 10/23/19 at 4:45 PM and revealed on 12/10/18 at approximately 3:29 PM CNA # 1 was at the nurse's station. LPN # 1 approached the resident to obtain blood pressure. LPN #1 was observed pushing at the resident's forehead with her hands. LPN#1 appeared yelling at the resident. CNA # 1 turned her head to look at LPN #1. One minute later, LPN #1 was again observed hitting the resident's forehead. The Resident stopped the LPN by grabbing and pushing her hand away. There was no audio recording. CNA #1 was interviewed on 10/23/19 at 6:35 PM and stated she heard LPN #1 yelling profanity at the resident. The LPN punched the resident in the forehead. She further stated the LPN was not joking and cursed at the Resident. The CNA stated she reported the incident immediately to the RN Manager. The DON was interviewed on 10/23/19 at 4:40 PM and stated that he was informed of the incident the same day. LPN #1 was immediately removed from her assignment. The facility concluded that LPN #1 abused the Resident. There were no reports of her being abusive or inappropriate to any residents prior to the incident. 415.4(b)

Based on interview and record review conducted during an Abbreviated survey (Complaints # NY 945), the facility did not ensure that all alleged violations of abuse were reported immediately but not later than 2-hours after the allegation was made to the facility administrator and to other officials (including to the State Survey Agency) for one (Resident #1) of three residents reviewed for abuse. Specifically, Resident #1 was abused by LPN #1 on 12/10/19 and this was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The findings are: Review of the facility's policy titled Abuse Prevention and Reporting dated 1/23/17 documented, any staff who witnesses or suspects an incident of abuse, neglect, mistreatment, misappropriation of the residents' property must immediately report the alleged violation to their supervisor who will in turn, report the alleged violation to the Administrator or the Director of Nursing (DON). When determined that credible evidence of abuse, neglect, mistreatment has occurred, submit the electronic reporting to the Department of Health. Resident # 1 was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 2/1/19 documented severe cognitive impairment with short- and long-term memory impairment. The incident report dated 12/10/2018 documented on 12/10/2018 at 3:30 PM. CNA#1 reported that LPN #1 was swearing at the resident and repeatedly shoved his forehead back. CNA#1 stated she felt this was done because resident was yelling out. LPN #1 was immediately removed from the unit. The resident was immediately assessed, no injuries were noted. The camera was reviewed on 12/10/18 and 12/11/18 and the findings were validated. LPN #1 appeared to get into a verbal altercation with Resident #1 and then proceeded to strike with an open hand, pushed him on the forehead twice. LPN #1 was terminated immediately. The incident was reported 24 hours after the abuse violation via the Health Commerce System to the NYS DOH on 12/11/18 at 3:18 PM. The video surveillance was reviewed with the DON and revealed on 12/10/19 at approximately 3:29 PM CNA # 1 was at the nurse's station. LPN # 1 approached the resident to obtain blood pressure. LPN #1 was observed pushing at the resident's forehead with her hands. LPN#1 appeared yelling at the resident. CNA # 1 turned her head to look at LPN #1. One minute later, LPN #1 was again observed hitting the resident's forehead. The Resident stopped the LPN by grabbing and pushing her hand away. There was no audio recording. CNA #1 was interviewed on 10/23/19 at 6:35 PM and stated she heard LPN #1 yelling profanity at the resident. The LPN punched the resident in the forehead. She further stated the LPN was not joking and cursed at the Resident. CNA #1 reported the incident to the Registered Nurse Supervisor (RNS) immediately. The DON was interviewed on 10/23/19 at 4:40 PM and the LPN was immediately removed from assignment. The RN immediately started an investigation. The facility concluded that LPN #1 abused the resident. The incident was reported to the Dept. of Health on 12/11/18. 415.4(b)(4)

Based on observation, record review and interviews during the recertification survey the facility did not ensure that the resident's plan of care was reviewed, revised or re-assessed after the completion of a physician's orders [REDACTED].#106) of three residents reviewed for skin conditions. Specifically, Resident #106 sustained a right shin skin tear. The skin tear was not assessed after the completion of the 10 day treatment. The finding is: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition. There was no skin alteration documented on the MDS. The resident was observed on 11/15/18 at 9:30 AM with a bandage on her right lower leg shin area. Resident #106 was observed on 11/18/18 at 10:30 AM and on 11/19/18 at 10:43 AM with a Xeroform dressing on her right shin. The resident stated that she hit her leg on the bed during a transfer. An Accident and Incident (A/I) Report dated 10/28/18 documented the resident sustained [REDACTED]. The A/I report documented that the resident hit her right shin on the bed frame and that a treatment was ordered. A physician's orders [REDACTED]. A Treatment Administration Record (TAR) dated 10/28/18 through 11/7/18 documented to apply Xeroform petroleum dressing to the right shin purpura skin tear, then apply a dry clean dressing for 10 days. A Comprehensive Care Plan (CCP) dated 10/28/18 documented Alteration in Skin Integrity skin tear to right shin Purpura. The CCP documented the resident sustained [REDACTED]. The CCP documented to administer the treatment as ordered and to educate the staff on safety. There is no documented evidence that the right shin skin tear was re-assessed after the completion of the treatment on 11/7/18. An interview was held with the Registered Nurse (RN) Charge Nurse on 11/20/18 at 10:40 AM. The RN reviewed the medical record and stated that the right shin skin tear treatment and physician's orders [REDACTED]. The RN stated that there was no documented evidence the skin tear was re-assessed after the completion of the treatment and the RN could not explain why the right shin was covered with a dressing. An interview was held with the RN Charge Nurse on 11/20/18 at 10:43 AM. The RN and surveyor observed the resident's right shin dressing. The RN stated that the dressing was dated 11/19/18 and the RN would investigate why the dressing was in place. An interview was held with the Director of Nursing Services (DNS) on 11/20/18 at 10:30 AM. The DNS stated that the Licensed Practical Nurse (LPN) should not have completed the treatment without a physician's orders [REDACTED]. An interview was held with the RN Unit Manager on 11/20/18 at 10:40 AM. The RN stated that he assessed the resident's right shin skin tear on 11/20/18 and that the skin tear was still present. 415.11(c)(2)(i-iii)

Based on record review and staff interview during the recertification survey the facility did not ensure that the Minimum Data Set (MDS) Assessment accurately reflected the resident's diagnosis. This was evident for one of one resident (Resident #70) reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, Resident #70's annual MDS documented an inaccurate [DIAGNOSES REDACTED]. The finding is: Resident # 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the resident had a [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented a BIMS score of 14 indicating the resident had intact cognition. The MDS dated [DATE] had no documented evidence that the resident had a [DIAGNOSES REDACTED]. A review of the medical record revealed that there is no documented evidence that the resident had a [DIAGNOSES REDACTED]. An interview was held with the Registered Nurse (RN) MDS Coordinator on 11/19/18 at 1:45 PM. The RN stated that the resident does not have a [DIAGNOSES REDACTED]. 415.11(b)

Based on observations and staff interview during the Recertification Survey, the facility did not ensure that sanitary conditions were being maintained in the main kitchen area. Specifically, the dish machine final rinse water temperature was not operating at the required 180 degrees Fahrenheit (F). The employee responsible to wash the pots reported that the sanitizer for the three compartment sink was 500 parts per million (ppm) this morning (required range of 150 to 400 ppm), and there were several identified maintenance issues which required either repair or cleaning. The findings are: During the initial tour of the main kitchen area on 5/17/17 at 9:15 AM the following was noted: 1) Three observations on 5/17/17 between 9:15 AM and 9:30 AM revealed that the dish machine final rinse water temperature was not running at the required 180 degrees F. 2) Two exterior open windows had screens in disrepair creating a portal of entry for insects and were in need of replacement. 3) One large live fly was noted in the dish machine area. 4) A ceiling vent in the dry goods storeroom had a heavy build up of dust and was in need of thorough cleaning. 5) The dietary staff member operating the three compartment sink reported that he tested the sanitizer in the morning and found it at 500 ppm. The same employee did not report that water was added to bring the sanitizer down to the required range of 150 to 400 ppm. 6) Multiple wall tiles surrounding one of three exterior kitchen windows were missing exposing wall cement and were in need of replacement. 7) Several ceiling fans in the kitchen were observed to be soiled with a build up of dust and were in need of cleaning. An interview with the Food Service Director (FSD) on 5/17/17 at 9:30 AM was held. The FSD stated that all of the identified concerns would be addressed. An interview with the Director of Maintenance on 5/17/2017 at 10:30 AM revealed that the screens on the kitchen window are replaced every Spring and that he will replace the screens. 415.14(h)

Based on record review, resident and staff interviews during a Recertification survey, the facility did not ensure that services are provided in accordance with each resident's written plan of care. This was noted for 1 of 22 Stage 2 residents reviewed (Resident #14). Specifically, there was no documented evidence that Resident #14 received two showers per week as documented in the Comprehensive Care Plan (CCP). The finding is: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's Admission Minimum Data Set Assessment ((MDS) dated [DATE], and quarterly MDS assessments dated 1/23/17 and 4/23/17 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and decision making skills. The Activities of Daily Living (ADL) section documented that the resident required physical assist with bathing. Resident #14 was interviewed on 05/23/2017 at 9:27 AM and stated that she is supposed to get a shower twice weekly on Mondays and Thursdays and stated that she does not get showers often enough. She stated that she would like to get at least one shower a week if not two. She stated that she has never told her family or any staff here that she is not getting two showers as scheduled. She stated that one evening at 8:00 PM the Aide told her she was coming back to take her for a shower and never returned. A CCP dated 9/22/16 for ADL's documented that the resident was assisted as needed for bathing. The Unit Licensed Practical Nurse (LPN) was interviewed on 05/23/2017 at 9:58 AM. The LPN stated that the resident receives showers twice weekly on the evening shift. He stated that they did not hear anything from the resident about missing showers. The Unit RN Manager for 7:00-3:00 PM shift was interviewed on 05/23/2017 at 10:48 AM. Resident #14's Certified Nurses Assistant (CNA) Accountability records were reviewed for January, February, March, April and May 2017. A Resident Care Profile (RCP), revised on 5/20/17, documented that the resident is bathed on Mondays and Thursdays on the 3:00 PM-11:00 PM shift. The records did not consistently document that showers were provided twice a week. The bathing column was blank for the entire month of January 2017. Two bed baths and two showers were documented for the month of February 2017. One shower was documented for the month of March 2017. One bed bath, 3 showers and one refusal was documented for April 2017. Three showers and one refusal were documented between May 1 - 22, 2017. The RN stated that she was not aware that the resident was getting inconsistent showers. She stated that she did not know if the resident was refusing showers. She stated that the CNAs should also document the refusals in the CNA Accountability Records. She stated that she and a Nurse would normally monitor the CNA accountability records. The 3:00 PM-11:00 PM LPN Unit Manager was interviewed on 05/23/17 at 12:39 PM and stated that the resident's CNA informed her a couple of times that the resident was refusing shower due to being busy or tired. She stated that she spoke with the resident to encourage her. The LPN also stated she did not document these episodes because this was not a frequent occurrence. The 3:00 PM-11:00 PM assigned CNA was interviewed on 05/23/17 at 10:04 AM. The CNA stated that she was assigned to the resident since admission and the resident is supposed to receive two showers a week, on Mondays and Thursdays. She stated that she works every Monday and every alternate Thursdays and that occasionally the resident refused showers. The CNA stated that when a resident refuses care the CNA is supposed to write it down in the CNA Accountability Record and also inform the unit Nurse Manager. She stated that she may not always remember to write it down or tell the Nurse. She stated that she remembered telling the 3:00 AM-11:00 PM LPN/Unit Manager a couple of times about the shower refusals by the resident. 415.11(c)(3)(ii)

Based on observation, record review and staff interviews during the recertification survey the facility did not ensure that each resident's drug regimen must be free from unnecessary medication. This was evident for one (Resident #76) of five residents reviewed for unnecessary medication in a total of twenty two Stage 2 residents. Specifically, Resident #76 had a physician's orders [REDACTED]. The finding is: Resident # 76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 9 which indicated the resident's cognition was moderately impaired. The resident had no symptoms of [MEDICAL CONDITION], no potential indicators for [MEDICAL CONDITION] (Hallucinations, Delusions), and no behavioral symptoms. The resident's Mood Interview revealed symptoms that included feeling down, depressed or hopeless; feeling tired or having little energy; and moving or speaking so slowly that other people could have noticed; or the opposite, being fidgety or restless that the resident has been moving around a lot more than usual. The MDS documented [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented a BIMS Score of 9 which indicated the resident's cognition was moderately impaired. The resident had no symptoms of [MEDICAL CONDITION], no potential indicators for [MEDICAL CONDITION] (Hallucinations, Delusions), and no behavioral symptoms. The resident Mood Interview revealed symptoms that included feeling down, depressed or hopeless; and moving or speaking so slowly that other people could have noticed; or the opposite, being fidgety or restless that the resident has been moving around a lot more than usual. The resident received Antipsychotic and Antianxiety medications for seven days prior to this assessment, and received Antidepressant medication for five days prior to this Assessment. A Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 9/12/16 documented that the resident required the use of [MEDICAL CONDITION] medication due to [DIAGNOSES REDACTED]. Interventions included to reduce dosage per the Physician and to evaluate effects. On 3/22/17 it was documented in the Evaluation section of the CCP that the resident was pleasant and cooperative. The resident cries and at times becomes anxious stating she had a beautiful apartment and friends who used to visit. There is no documented evidence in the CCP of behaviors or indications for the continued use of [MEDICATION NAME]. On 3/25/17 it was documented in the Approaches and Interventions section of the CCP that the resident was seen by the Psychiatrist and the resident is to continue medications to prevent destabilization. A CCP for Mood State dated 9/12/16 documented the resident's problems as: Agitation, Anxiousness, Withdrawal, Depression, Paranoia and Fabricates stories. Goals include that resident will demonstrate reduced symptoms of agitation, repetitive comments, anxiety, tearfulness, and reduced social interaction. In the Evaluation section of the CCP it was documented on 4/7/17 that the resident was having difficulty accepting long term care placement and was noted with increased confusion and agitation. A CCP for Psychosocial Well Being dated 9/16/16 documented the resident has a problem with adjustment to placement, fabricates stories, is paranoid and agitated at times. It was documented in the Evaluation section of the CCP that the resident is focused on going home and needs redirection. There is no documented evidence in the CCP of behaviors or indications for the continued use of [MEDICATION NAME]. A physician's orders [REDACTED]. A review of the hospital discharge medication list dated 9/12/16 documented [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg po daily. A Psychiatric Consultation dated 3/25/17 documented the resident has high levels of Anxiety and has prior mental Illness that was treated with psychiatric medication. The resident's mood unravels easily, is downcast and helpless. The resident's memory is partly intact, is positive for forgetfulness and is oriented times three (person, place and time). The resident is receiving [MEDICATION NAME] for Major [MEDICAL CONDITION]. A Review of the Monthly Physician Examinations dated 1/16/17 to 3/22/17 revealed that there was no documented evidence of behavior that warranted the continued use of [MEDICATION NAME]. A Review of the Interdisciplinary Progress Notes dated 11/1/16 to 5/20/17 revealed there was no documented evidence of behavior that warranted the continued use of [MEDICATION NAME] or of an attempt to reduce the medication. An interview was conducted on 5/23/17 at 4:22 PM with the evening shift Certified Nursing Assistant (CNA). The CNA stated that the resident does not require much help with Activities of Daily Living, is very sociable and enjoys being social with her friends. The CNA stated that the resident has no behavior symptoms but often wants to speak to her grandson on the phone. The CNA stated the only behavior he could recall was couple months ago, the resident was not able to reach her grandson and became tearful. The CNA stated that since he had been caring for the resident there was no attempt by the resident to leave the building or any agitation with care. An interview was conducted on 5/24/17 at 11:30 AM with the day shift CNA. The CNA stated that the resident is pleasant and has no aggressive behavior. The CNA stated that she has not observe the resident with behaviors that would harm herself or others. The CNA stated that the resident does not lash out at others or get into altercation with other residents. The CNA stated at times the resident gets emotional, stating she misses her son and grandson and at times becomes tearful. The CNA stated that the resident frequently speaks about her grandson and thinks he needed her help. The CNA stated that the resident has once mentioned she wanted to go home but has never made an attempt. An interview was conducted on 5/24/17 at 9:34 AM with the Registered Nurse (RN) Unit Manager. The RN stated that she has spoken with the Psychiatrist regarding a Gradual Dose Reduction (GDR) of the [MEDICATION NAME] in March of 2017. The RN stated in April 2017 that she made out a second consult requesting the resident be evaluated for GDR when she saw that it was not reduced in the month of March. When the RN was asked about behavior symptoms exhibited by the resident, the RN stated that the resident at times is tearful and stated that she was going home no matter what and at times refuses care. However, there was no behaviors symptoms exhibited by the resident that was a threat to herself or others. An interview was conducted on 5/24/17 at 9:50 AM with the Psychiatrist. The Psychiatrist stated that he knew the resident for about 6 to 7 years. The Psychiatrist stated based on his clinical judgement after discontinuing the [MEDICATION NAME] he increased the [MEDICATION NAME] to 5 milligram (mg) as he felt 2.5 mg was not adequate enough to stabilize the resident. The Psychiatrist stated he did not make any attempt to reduce the [MEDICATION NAME] because he felt the resident had high risk behavior and would destabilize. When the Psychiatrist was asked about the high risk behavior that the resident was exhibiting he stated that the resident was agitated and making threats to leave the facility. The Psychiatrist stated that this was documented in the Nursing Progress Notes. The Psychiatrist further stated that the indication for the use of [MEDICATION NAME] was Major [MEDICAL CONDITION] and not [MEDICAL CONDITION]. An interview was conducted on 5/24/17 at 11:55 AM with the the Attending Physician. The Physician stated that the staff does discuss GDR and any behaviors exhibited by the resident. The Physician stated that the resident is delusional as she states she wanted to go home while she no longer has a home in the community. The Physician stated that the Psychiatrist would be better able to say why a GDR was not attempted. 415.12(l)(1)

Based on record review and staff interview during the Recertification survey, the facility did not ensure that each residents Minimum Data Set (MDS) assessment accurately reflected the resident's status. This was evident for one of three residents reviewed for Pressure Ulcers (PU) in a total of twenty two Stage 2 sampled residents. Specifically, Resident #1 was incorrectly assessed as having a Stage III PU on admission. The finding is: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission assessment dated [DATE] documented that the resident had a large Scar on the left buttock area. A Body Check Tool dated 12/9/16 documented a large scar to the left buttock. An Admission Minimum Data Set (MDS) assessment dated [DATE] and a 14-day MDS assessment dated [DATE] documented the resident was at risk for pressure ulcer development and had one unhealed Stage III pressure ulcer that was present on admission. A Nurse's Note dated 12/21/16 documented that the resident was noted with an open area to his Left buttock approximately 2 cm x 2 cm. The open area was noted at the center of a large significant scar. The resident stated that he had previously sustained a large pressure ulcer which had healed. A CCP dated 12/19/16 documented the resident had scar tissue to left buttocks. In the evaluation section of the CCP it was documented on 12/21/16 that the resident was seen by the Wound Care Team for a Left buttocks Stage III PU measuring 2 centimeter (cm) x 2 cm x 0.3 cm. An interview was conducted on 5/23/17 at 9:34 AM with the Registered Nurse (RN) Unit Manager (UM). The RN stated that when he had assessed the area on 12/9/16 the resident had a large scar to the left buttock area. An interview was conducted on 5/23/17 at 9:59 AM with the RN/MDS Coordinator. The RN stated that she made a mistake in documenting that the resident had a PU on admission. The RN stated that it should not have been documented on the 5 Day or 14-Day MDS Assessment that the resident was admitted with the Stage III PU. 415.11(b)

Based on,record review and staff interviews during a recertification and abbreviated survey the facility did not provide services that met professional standards of practice. Specifically, the licensed nursing staff failed to provide newly admitted and readmitted residents their Physician ordered and scheduled significant and non significant medications on the evening of their admission/readmission. This affected 15 of 15 sampled newly admitted /readmitted residents from 7/3/13 to 7/22/13. (Resident's #77, #145, #270, #271, #274, #275, #276, #277, #278, #279, #280, #281, #282, #283, and #284). This resulted in no actual harm that is Immediate Jeopardy to residents' health and safety. Reference from Centers for Medicare and Medicaid Services dated 12/30/2004 :That nursing facility personnel administer medications pursuant to the prescription order. Nursing facility regulations specify that the facility must develop and implement appropriate policies and procedures for accurate acquiring, receiving and administering of all medications. The findings include but are not limited to: 1)Resident #274 was admitted to the facility on [DATE] at 5:15 PM. The resident had [DIAGNOSES REDACTED]. A Hospital Final Medication Form (undated) documented that the next dose of [MEDICATION NAME] 15 units was due on 7/17/13 at 10:00 PM, [MEDICATION NAME] 25 mg was due on 7/17/13 at 10:00 PM, [MEDICATION NAME] was due 7/17/13 at 10:00 PM and [MEDICATION NAME] 7.5 mg was due on 7/17/13 at 10:00 PM A Admission/Re-Admission Physician order [REDACTED]. A Medication Administration Record (MAR) dated 7/17/13 documented [MEDICATION NAME] 0.1 mg 9:00 PM, [MEDICATION NAME] 25 mg 9:00 PM, [MEDICATION NAME] 15 units, [MEDICATION NAME] 20 mg at 9:00 PM, [MEDICATION NAME] 0.8 mg at 9:00 PM. The MAR documented an arrow in the nurses signature box for all the Physician ordered 9:00 PM medications for 7/17/13. A Nurses Note (NN) dated 7/18/13 6:00 AM documented the resident's blood sugar level (BSL) was 549 (normal 60-120). The NN also documented that the resident's Physician was notified and ordered [MEDICATION NAME] Regular Insulin 10 units to be given. The NN further documented that the Insulin was administered. A Physician's Interim Order Form (PIOF) dated 7/18/13 at 6:00 AM documented to administrator [MEDICATION NAME] R 10 units as coverage for BSL of 549 one time now. A MAR dated 7/18/13 documented that the resident received 5 units of insulin at 11:30 AM for the BSL of 400. A NN dated 7/18/13 at 1:00 PM documented that the resident ate his lunch and that he had a second episode of brown colored emesis today. BSL was rechecked and was 398. The Physician was notified and had no new orders, staff to monitor. A Patient Transfer Form (PTF) dated 7/18/13 (not timed) documented that the resident was being transferred to the hospital for [MEDICAL CONDITIONS] and Diabetic Control. A Physician Communication Progress Note (PCPN) dated 7/18/13 at 6:30 PM under the title : Situation: documented poor diabetic control , [MEDICAL CONDITION] and [MEDICAL CONDITION]. The PCPN also documented that this has become worse on 7/18/13 and to transfer to the hospital. A NN dated 7/18/13 at 5:30 PM documented that the Physician was in to see the resident and ordered to send the resident to the hospital emergency room (ER). A NN dated 7/18/13 at 11:00 PM documented that the resident was admitted to the hospital with [REDACTED]. There is no documented evidence in the medical record that the newly admitted Resident #274 received the Physician ordered scheduled medications on 7/17/13 at 9:00 PM or that the Physician was notified that the medications were not administered. An interview was held on 7/24/13 at 11:00 AM with the Pharmacist. The Pharmacist stated that the pharmacy received a faxed copy of the resident's admission medication orders on 7/17/13 at 8:21 PM. The Pharmacist also stated that the facility signed that they received the medications at 10:33 PM on 7/17/13. An interview was held on 7/24/13 at 11:45 AM with the 3:00 PM - 11:00 PM shift (unit E) Licensed Practical Nurse (LPN)#1 medication nurse that worked on 7/17/13 .The LPN stated that she did not administer the medications [MEDICATION NAME],[MEDICATION NAME],[MEDICATION NAME] or [MEDICATION NAME] to Resident #274 on 7/17/13 at 9:00 PM. The LPN stated that arrows in the nurses signature boxes (on the MAR) means that the medication is not available and that it will be given the next day. The LPN also stated that the Physician should be called if the medications are not available and it should be documented in the medical record. She did not recall calling the Physician or informing the supervisor that the resident's medications were not available. An interview was held on 7/25/13 at 10:00 AM with the 3:00 PM - 11:00 PM shift Registered Nurse (RN) Charge Nurse of Unit E. The RN stated that he receives the residents medications from the RN supervisor and that he gives them to the LPN medication nurse to administer. The RN also stated that the facility usually receives delivery from the pharmacy 2 times on the 3 PM - 11 PM shift and that the last delivery is usually about 10:00 PM to 10:30 PM. The RN stated that he was not aware that the newly admitted /readmitted residents were not receiving their medications. The RN also stated that the LPN medication nurse would be responsible to let him know so he could call the Physician. 2) Resident #282 was readmitted to the facility on [DATE] at 2:20 PM to Unit B. The resident had [DIAGNOSES REDACTED]. The A/RPOF dated 7/16/13 documented [MEDICATION NAME] 10 mg at 9:00 PM (Dementia), [MEDICATION NAME] 20 mg a 9:00 PM (Depression),[MEDICATION NAME] caplet at 9:00 PM (to prevent diarrhea from use of antibiotic ), [MEDICATION NAME] 10 mg 9:00 PM (Dementia), [MEDICATION NAME] 150 mg at 9:00 PM (GERD), [MEDICATION NAME] 200 mg at 9:00 PM (constipation), and Keflex 500 mg at 9:00 PM ([MEDICAL CONDITION]). A MAR dated 7/16/13 documented [MEDICATION NAME] 10 mg at 9:00 PM , [MEDICATION NAME] 20 mg a 9:00 PM,[MEDICATION NAME] caplet at 9:00 PM, [MEDICATION NAME] 10 mg 9:00 PM , [MEDICATION NAME] 150 mg at 9:00 PM , [MEDICATION NAME] 200 mg at 9:00 PM , and Keflex 500 mg at 9:00 PM. The MAR documented an arrow in the nurses signature box for the 9:00 PM medications. A Pharmacy Delivery Acquisition dated 7/16/13 documented that the resident's medications were delivered to the facility at 10:41 PM on 7/16/13. There is no documented evidence in the medical record that the newly readmitted resident received the Physician ordered scheduled medication on 7/16/13 at 9:00 PM or that the Physician was notified that the medications were not administered. An interview was held with LPN #5 on 7/25/13 at 9:30 AM. The LPN stated that she was the medication nurse that was on duty on 7/16/13 (unit B) on the 3:00 PM to 11:00 PM shift. The LPN reviewed the MAR and stated that the arrow in the medication boxes on 7/16/13 at 9:00 PM meant that the medication was not available. The LPN also stated that if the medications were not available she should call the Physician for further instructions and document it in the NN. The LPN also stated that she could not recall if they were available or if she told the Supervisor that the medications were not available. The LPN further stated that she did not administer any of the residents scheduled medications. 3) Resident #145 was readmitted to the facility to (Unit C) on 7/5/13 at 2:35 PM. The resident had [DIAGNOSES REDACTED]. A NN written by an RN dated 7/5/13 (no time) documented that the resident was readmitted to the facility at 2:35 PM and that the nurse was to discuss orders with the Physician. An A/RPOF dated 7/5/13 documented [MEDICATION NAME] 25 mg at 9:00 PM (Depression), [MEDICATION NAME] (Dementia) 50 mg at 9:00 PM, Acidophiles (prevents diarrhea from antibiotic use) 1 caplet at 9:00 PM, [MEDICATION NAME] eye drops ([MEDICAL CONDITION]) and [MEDICATION NAME] 250 mg (URI) at 9:00 PM. There is no documented evidence of a MAR dated 7/5/13 for the Physician ordered 9:00 PM medications. A Pharmacy Delivery Acquisition dated 7/5/13 documented that the resident's medications were delivered to the facility at 10:41 PM on 7/5/13. There is no documented evidence in the medical record that the resident who was readmitted to the facility at 2:35 PM on 7/5/13 received the Physician ordered scheduled medication on 7/5/13 at 9:00 PM or that the Physician was notified that the medications were not administered. An interview was held on 7/25/13 at 4:05 PM with LPN # 3, the medication nurse that was on duty on (unit C) on 7/5/13 on the 3:00 PM to 11:00 PM shift. The LPN reviewed the MAR and stated he could not recall why the medications were not administered on 7/5/13 at 9:00 PM. The LPN also stated that if the medications were not available he would call the Physician and document it in the resident's chart, that the arrow in the medication boxes on 7/5/13 at 9:00 PM meant that the medication was not available. The LPN also stated that he could not recall if they were available or if he told the Supervisor that the medications were not available. The LPN further stated that he could not explain why there was not an MAR for 7/5/13 when the resident was admitted at 2:35 PM on 7/5/13 or why the resident did not receive his medication until 7/6/13. Additionally, there is no documented evidence in the medical record that LPN #1, LPN #2, LPN #3, LPN #4 and LPN #5 administered scheduled Physician ordered medications to the newly admitted /readmitted residents as follows: LPN #1: Residents #281 (7/15/13) ,#283 (7/16/13) and #284 (7/22/13) (unit E). LPN #2: Resident #279 (7/11/13) (unit E). LPN #3: Residents # 270 (7/16/13), # 271(7/12/13) (unit C) #277 (7/3/13) (unit E). LPN #4: Residents #275 (7/17/13), #276 (7/15/13), #278 (7/11/13), #280 (7/13/13) (unit E). LPN #5: Residents #77 (7/17/13), #282 (7/16/13) (unit B). An interview was held on 7/25/13 at 1:30 PM with the Director of Nursing Services (DNS). The DNS stated that she was not aware that the newly admitted /readmitted residents were not receiving their scheduled medication on the night of admission/readmission. The DNS also stated that the LPNs should have called the Physician and ordered the medication stat from the pharmacy. The practice for the medication nurses would be to call the Physician if the medication is not available for the documented 9:00 PM medication administration. The DNS further stated that if the medication was in the facility and it was an hour after the documented 9:00 PM scheduled time the LPN would not give the medications, but should inform the Physician. An interview was held on 7/25/13 at 2:00 PM with the 3:00 PM - 11:00 PM RN Supervisor responsible for all nursing units. The RN stated that when the pharmacy delivered the medications to the facility that he signs that he received them and then delivers the medications to the medication nurses. The RN also stated that the approximate delivery times from the pharmacy are 7:00 PM and 10:00 PM. If the medication is not available for administration the medication nurse should call the Physician for further instruction and document in the medical record. The RN further stated that he can not recall any requests for medications that were not available for newly admitted /readmitted residents. The RN also stated that he was not aware that the newly admitted /readmitted residents were not receiving their medications. An interview was held on 7/26/13 at 8:30 AM with the Medical Director. The Medical Director stated that he was not aware that the newly admitted /readmitted residents were not receiving their scheduled medications on the 3:00 PM- 11:00 PM shift. The Medical Director also stated that if the medications are ordered by the Physician they should be administered as ordered and if there is a problem that the medication can not be administered, the medication nurse should call the Physician for further instructions. An interview was held with the RN Inservice Coordinator on 7/26/13 at 11:45 AM. The RN stated that there is not a written policy or education/lesson plan for the licensed nurses on what procedure to follow if the newly admitted /readmitted residents' physician ordered medication is not available by 9:00 PM. The RN also stated that the licensed nurses should call the Physician if the medications are not available. 415.11(c)(3)(i)

Based on observation, record review and staff interviews during a recertification and abbreviated survey, the facility failed to ensure that residents were free from significant medication errors. Specifically, the facility failed to have systems in place to ensure that newly admitted and readmitted residents received their Physician ordered scheduled significant and non significant medications on the evening of their admission/readmission. This affected a sample of 15 of 15 newly admitted / readmitted residents in the past 3 weeks (7/3/13 - 7/22/13). All 15 residents were noted with delays in their medication administration.(#77, #145, #270, #271, #274, #275, #276, #277, #278, #279, #280, #281, #282, #283, and #284).This was evident on 3 of 4 nursing units (units B, C and E). Resident 274 was not given his physician ordered significant medication on the day of admission. Subsequently the residents blood glucose elevated and the resident was admitted to the hospital. This resulted in a pattern of Immediate Jeopardy and is Substandard Quality of Care for the health and safety of the residents and actual harm for Resident #274. The findings are : 1) Resident #274 was admitted to the facility on [DATE] at 5:15 PM. The resident had [DIAGNOSES REDACTED]. A Hospital Final Medication Form (not dated) documented that the next dose of [MEDICATION NAME] 15 units was due on 7/17/13 at 10:00 PM, [MEDICATION NAME] 25 mg was due on 7/17/13 at 10:00 PM, [MEDICATION NAME] was due 7/17/13 at 10:00 PM and [MEDICATION NAME] 7.5 mg was due on 7/17/13 at 10:00 PM. An Admission/Re-Admission Physician order [REDACTED]. A Medication Administration Record (MAR) dated 7/17/13 documented [MEDICATION NAME] 0.1 mg 9:00 PM, [MEDICATION NAME] 25 mg 9:00 PM,[MEDICATION NAME] 15 units , [MEDICATION NAME] 20 mg at 9:00 PM , [MEDICATION NAME] 0.8 mg at 9:00 PM. The MAR documented an arrow in the nurses signature box for all the above Physician ordered 9:00 PM medications for 7/17/13. A Nurses Note (NN) dated 7/18/13 6:00 AM documented the resident's blood sugar level (BSL) was 549 mg/dl (normal 60-120). The NN also documented that the resident's Physician was notified and ordered [MEDICATION NAME] Regular Insulin 10 units to be given. The NN further documented that the Insulin was administered and to monitor the resident closely. A Physician's Interim Order Form (PIOF) dated 7/18/13 at 6:00 AM documented to administrator [MEDICATION NAME] R 10 units as coverage for BSL of 549 mg/dl one time now. A MAR dated 7/18/13 documented that the resident received the [MEDICATION NAME] R 10 units at 6:30 AM. A NN dated 7/18/13 at 8:00 AM documented that the resident had a small amount of emesis in the morning, refused breakfast and that the staff will monitor. A NN dated 7/18/13 at 9:00 AM documented that the resident had a BSL of 549 mg/dl and staff was to monitor the resident. A NN dated 7/18/13 at 11:30 AM documented that the residents BSL was 400 mg/dl and that the insulin was administered as ordered and that the staff are to monitor. A MAR dated 7/18/13 documented that the resident received 5 units of insulin at 11:30 AM for the BSL of 400 mg/dl. A NN dated 7/18/13 at 1:00 PM documented that the resident ate his lunch and that the resident had a second episode of brown colored emesis, that the BSL was re checked and was 398 mg/dl. The Physician was notified and had no new orders, but that staff was to monitor. The NN dated 7/18/13 at 4:30 PM documented that the Physician will be in to see the resident. A Patient Transfer Form (PTF) dated 7/18/13 not timed documented that the resident was being transferred to the hospital for [MEDICAL CONDITIONS] and Diabetic Control. A Physician Communication Progress Note (PCPN) dated 7/18/13 at 6:30 PM documented under the title Situation: poor diabetic control , [MEDICAL CONDITION] and [MEDICAL CONDITION]. The PCPN also documented that this has become worse on 7/18/13 and to transfer to the hospital. A PIOF dated 7/18/13 (no time) documented to send the resident to the ER via ambulance. A NN dated 7/18/13 at 5:30 PM documented that the Physician was in to see the resident and ordered to send the resident to the hospital emergency room (ER). A NN dated 7/18/13 at 6:30 PM documented that the resident was out of the facility at the ER. A NN dated 7/18/13 at 11:00 PM documented that the resident was admitted to the hospital with [REDACTED]. There is no documented evidence in the medical record that the newly admitted resident received the Physician ordered scheduled medications on 7/17/13 at 9:00 PM or that the Physician was notified that the medications were not administered. During a medication pass observation on 7/18/13 at 9:00 AM, the resident appeared lethargic. Additionally, the resident took a long time, with effort, to take his medication. The Certified Nursing Assistant was in the resident's room and reported that the resident had vomited earlier in the morning. An interview was held with the resident's daughter on 7/24/13 at 9:45 AM. The resident's daughter stated that the resident did not receive the proper care at the facility and that he did not receive the correct medications. The daughter also stated that the resident was in the Medical Intensive Care Unit (MICU) for 3 days , that when he got to the hospital he was dehydrated, his kidneys were failing, and his mental status had deteriorated. An interview was held on 7/24/13 at 11:00 AM with the Pharmacist. The Pharmacist stated that for Resident # 274's medication, the pharmacy received a faxed copy of the resident's admission medication orders on 7/17/13 at 8:21 PM. The Pharmacist stated that the facility signed that they received the medications at 10:33 PM on 7/17/13. An interview was held on 7/24/13 at 11:45 AM with the 3:00 PM - 11:00 PM shift Licensed Practical (LPN) medication nurse that worked on 7/17/13 (unit E). The LPN stated that she took care of Resident #274 and that she did not administer the medications as follows: [MEDICATION NAME] 0.1 mg 9:00 PM, [MEDICATION NAME] 25 mg 9:00 PM, [MEDICATION NAME] 15 units, [MEDICATION NAME] 20 mg at 9:00 PM, [MEDICATION NAME] 0.8 mg at 9:00 PM. The LPN stated that an arrow in the nurses' signature boxes on the MAR means that the medication is not available and that it will be given the next day. The LPN also stated that the Physician should be called if the medications are not available and it should be documented in the medical record. She did not recall calling the Physician or informing the supervisor that the resident's medications were not available. An interview was held with the Resident # 274's Physician on 7/24/13 at 1:00 PM. The Physician stated that he was told by a nurse on 7/18/13 some time in the afternoon that the resident did not receive the scheduled [MEDICATION NAME] on 7/17/13. The Physician also stated that the resident's BSL sometimes run into the 300's mg/dl range but that 549 mg/dl is abnormal for the resident. The Physician further stated that he was called by a nurse about the 549 mg/dl BSL and ordered 10 units of [MEDICATION NAME] Insulin to be administered to the resident. The Physician also stated that he would expect that the nurses should administer the Physician ordered medication as scheduled. Additionally, the Physician stated that he was in the facility to examine the resident and ordered to send the resident back to the hospital on [DATE] at the family's request. An interview was held on 7/25/13 at 10:00 AM with the 3:00 PM - 11:00 PM Registered Nurse (RN) Charge Nurse that worked on 7/17/13 on unit E. The RN stated that when he receives the residents' medications from the RN supervisor, he gives them to the LPN medication nurse to administer. The RN stated that the facility usually receives deliveries from the pharmacy 2 times on the 3 PM- 11 PM shift and that the last delivery is usually about 10:00 PM to 10:30 PM. The RN stated that he was not aware that the newly admitted /readmitted residents were not receiving their medication and that if there was a problem with the medication, the LPN medication nurse would be responsible to let him know so he could call the Physician. He was not aware that Resident #274 did not receive his 9:00 PM medications and that the LPN should have reported it and then he would have called the Physician. 2) Resident # 282 was readmitted to the facility on [DATE] at 2:20 PM to Unit B. The resident had [DIAGNOSES REDACTED]. The A/RPOF dated 7/16/13 documented [MEDICATION NAME] 10 mg at 9:00 PM (Dementia), [MEDICATION NAME] 20 mg a 9:00 PM (Depression),[MEDICATION NAME] caplet at 9:00 PM (to prevent diarrhea from use of antibiotic ), [MEDICATION NAME] 10 mg 9:00 PM (Dementia), [MEDICATION NAME] 150 mg at 9:00 PM (GERD), [MEDICATION NAME] 200 mg at 9:00 PM (constipation), and Keflex 500 mg at 9:00 PM ([MEDICAL CONDITION]). A MAR dated 7/16/13 documented [MEDICATION NAME] 10 mg at 9:00 PM , [MEDICATION NAME] 20 mg a 9:00 PM,[MEDICATION NAME] caplet at 9:00 PM, [MEDICATION NAME] 10 mg 9:00 PM , [MEDICATION NAME] 150 mg at 9:00 PM , [MEDICATION NAME] 200 mg at 9:00 PM , and Keflex 500 mg at 9:00 PM. The MAR documented an arrow in the nurses signature box for the 9:00 PM medications on 7/16/13. A Pharmacy Delivery Acquisition dated 7/16/13 documented that the resident's medications were delivered to the facility at 10:41 PM on 7/16/13. There is no documented evidence in the medical record that the newly re admitted resident received the Physician ordered scheduled medication on 7/16/13 at 9:00 PM or that the Physician was notified that the medications were not administered. An interview was held with the Licensed Practical Nurse (LPN) # 5 Medication Nurse on 7/25/13 at 9:30 AM, that was on duty on 7/16/13 (unit B) on the 3:00 PM to 11:00 PM shift. The LPN reviewed the MAR and stated that the arrow in the medication boxes on 7/16/13 at 9:00 PM meant that the medication was not available. The LPN also stated that if the medications were not available she should call the Physician for further instructions and document it in the Nurses Notes (NN). The LPN also stated that she could not recall if they were available or if she told the Supervisor that the medications were not available. 3) Resident #145 was readmitted to the facility to Unit C on 7/5/13 at 2:35 PM. The resident had [DIAGNOSES REDACTED]. A NN written by an RN dated 7/5/13 (no time) documented that the resident was re admitted to the facility at 2:35 PM and that the nurse was to discuss orders with the Physician. An A/RPOF dated 7/5/13 documented [MEDICATION NAME] 25 mg at 9:00 PM (Depression), [MEDICATION NAME] (Dementia) 50 mg at 9:00 PM, Acidophiles (prevent diarrhea from antibiotic use) 1 caplet at 9:00 PM, [MEDICATION NAME] eye drops ([MEDICAL CONDITION]) and [MEDICATION NAME] 250 mg (antibiotic) at 9:00 PM. There is no documented evidence of a MAR dated 7/5/13 for the Physician ordered 9:00 PM medications. A Pharmacy Delivery Acquisition dated 7/5/13 documented that the resident's medications were delivered to the facility at 10:41 PM on 7/5/13. There is no documented evidence in the medical record that the newly readmitted resident who was readmitted to the facility at 2:35 PM on 7/5/13 received the Physician ordered scheduled medication on 7/5/13 at 9:00 PM or that the Physician was notified that the medications were not administered. An interview was held on 7/25/13 at 4:05 PM with the LPN #3 medication nurse that was on duty on (unit C) on 7/5/13 on the 3:00 PM to 11:00 PM shift. The LPN reviewed the MAR and stated he could not recall why the medications were not administered on 7/5/13 at 9:00 PM. The LPN also stated that if the medications were not available he would call the Physician and document it in the resident's chart. The arrow in the medication boxes on 7/5/13 at 9:00 PM meant that the medication was not available. The LPN also stated that he could not recall if they were unavailable or if he told the Supervisor that the medications were not available. The LPN could not explain why there was not an MAR for 7/5/13 if the resident was admitted at 2:35 PM on that day or why the resident did not receive his medications until 7/6/13. Additionally, there is no documented evidence in the medical record that LPN #1, LPN #2, LPN #3, LPN #4 and LPN #5 administered scheduled Physician ordered medications to the newly admitted /readmitted residents as follows: LPN #1: Residents #281 (7/15/13) ,#283 (7/16/13) and #284 (7/22/13) (unit E) LPN #2: Resident #279 (7/11/13) (unit E) LPN #3: Residents # 270 (7/16/13), # 271(7/12/13) (unit C) #277 (7/3/13) (unit E) LPN #4: Residents #275 (7/17/13), #276 (7/15/13), #278 (7/11/13), #280 (7/13/13) (unit E) LPN #5: Residents #77 (7/17/13), #282 (7/16/13) (unit B) An interview was held on 7/25/13 at 1:30 PM with the Director of Nursing Services (DNS). The DNS stated that she was not aware that the newly admitted /readmitted residents were not receiving their scheduled medication on the 3:00 PM- 11:00 PM shift. The DNS also reviewed the MAR for Resident #274 and stated that the resident should have received 15 units of the [MEDICATION NAME] and the [MEDICATION NAME], 7.5 mg at 9:00 PM as ordered by the Physician and that if it was not available the LPN should have called the Physician and ordered the medication stat from the pharmacy. The practice for the medication nurses would be to call the Physician if the medication is not available for the documented 9:00 PM medication administration. An interview was held on 7/25/13 at 2:00 PM with the 3:00 PM - 11:00 PM RN Supervisor that was on duty on 7/17/13. The RN stated that when the pharmacy delivers the medications to the facility, he signs that he received them and then delivers the medications to the medication nurses. The RN also stated that the approximate delivery times from the pharmacy are 7:00 PM and 10:00 PM. If the medication is not available for administration the medication nurse should call the Physician for further instruction and document in the medical record. The RN further stated that he can not recall any requests for medications that were not available for newly admitted /readmitted residents. An interview was held on 7/26/13 at 8:30 AM with the Medical Director. The Medical Director stated that he was not aware that the newly admitted /readmitted residents were not receiving their scheduled medications on the evening of the residents' admission/re-admission to the facility. The Medical Director also stated that if the medications are ordered by the Physician they should be administered as ordered and if there is a problem that the medication can not be administered, the medication nurse should call the Physician for further instructions. The Medical Director also stated that it would be a medication error if the medications are not administered. An interview was held with the RN Inservice Coordinator on 7/26/13 at 11:45 AM. The RN stated that there is not a written policy or education/lesson plan for the licensed nurses on what procedure to follow if the newly admitted /readmitted residents' physician ordered medications are not available by 9:00 PM. The RN also stated that the licensed nurses should call the Physician if the medications are not available. 415.12(m)(2)

Based on record review and staff interviews conducted during an abbreviated and recertification survey, it was determined that the Administration of the facility failed to ensure that there was a system in place to assure that each newly admitted /readmitted resident reached and maintained the highest practicable level of physical and psychosocial well being. Specifically, the Administrator failed to ensure that there were policies and procedures in place to ensure that each newly admitted /readmitted resident was administered their Physician ordered evening medications on the night of their admission. This was evident for 15 of 15 newly admitted /readmitted residents from 7/5/13 - 7/22/13, with the potential to affect all newly admitted /readmitted residents. This resulted in a pattern of Immediate Jeopardy to the health and safety of the residents. Refer to F333 Significant Medication Errors : Scope and Severity of K. The finding is: There was no documented evidence in the medical records from 7/3/13 to 7/22/13, that 15 of 15 newly admitted /readmitted residents received their Physician prescribed medications during the 3:00 PM to 11:00 PM shift on the day of admission. An interview was held with the Director of Nursing Services (DNS) on 7/26/12 at 12:00 PM. The DNS stated that the facility does not have a written policy/procedure for the Licensed nursing staff regarding directions of what to do if the newly admitted /readmitted resident's Physician prescribed medication is not available or comes into the facility after the scheduled dose time. An interview was held with the Administrator on 7/26/13 at 3:45 PM. The Administrator stated that she was not aware of the problem and that she did not become aware until the surveyor brought it to her attention. The Administrator also stated that she will work with the DNS to clarify the policy for the administration of medication on admission and to inservice the licensed staff on the policy. An interview was held on 7/26/13 at 8:30 AM with the Medical Director. The Medical Director stated that he was not aware that the newly admitted /readmitted residents were not receiving their scheduled medications on the evening of the residents' admission/re-admission to the facility. The Medical Director also stated that if the medications are ordered by the Physician, they should be administered as ordered and if there is a problem that the medication can not be administered, the medication nurse should call the Physician for further instructions. The Medical Director also stated that it would be a medication error if the medications are not administered. An interview was held with the RN Inservice Coordinator on 7/26/13 at 11:45 AM. The RN stated that there is not a written policy or education for the licensed nurses on what procedure to follow if the newly admitted /readmitted resident's physician ordered medication is not available at the scheduled time. 415.26