Every finding on record at Autumn View Health Care Facility L L C

Based on interview and record review conducted a survey, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (1) (Resident #258) of four (4) residents reviewed. Specifically, when Resident #258 was readmitted to the facility with pressure ulcers there was a delay in obtaining a full assessment of the pressure ulcers, including measurements and staging. The finding is:The policy titled Documentation of Pressure Ulcer and Chronic Wounds, last revised 06/2023, documented pressure ulcers and chronic wounds were monitored closely to monitor effectiveness of treatment and change in risk factors. Risk factors would be identified, monitored and documented on the Skin Risk Data Collection Tool, upon admission and whenever there was a change in condition. The Assistant Director of Nursing (or skin nurse as designated by the Director of Nursing) would be the official baseline and subsequent reference point for all skin/wound assessments. All skin surfaces were inspected upon admission and results documented on the Nursing admission Evaluation. The Assistant Director of Nursing, or designee was responsible for initiating the weekly skin status evaluation when a pressure ulcer, stasis wound, or chronic wound was identified. The items to address on the template included but were not limited to the type of area (pressure, stasis, arterial, or diabetic), site, stage, size (length by width by depth in centimeters), description/characteristics, and treatment.The policy titled admission Nursing Evaluation, last revised 03/2026, documented each resident's physical, functional, and nutritional information was compiled initially upon admission to determine the need for care, the type of care provided and the need for further assessment. The form included the residents' skin status. Resident #258 had diagnoses including malignant neoplasm of cervix (cervical cancer), rheumatoid arthritis (chronic autoimmune disorder where the immune system attacks the joint lining, causing painful, symmetrical swelling, stiffness, and potential deformity, often in hands and feet), and vesicovaginal fistula (abnormal opening between the bladder and vagina causing continuous, involuntary urine leakage). The Minimum Data Set (a resident assessment tool) dated 05/14/2025 documented Resident #258 was cognitively intact, had two (2) unstageable pressure ulcers (full thickness tissue loss where the depth of the wound is hidden by eschar [dead tissue] and slough [yellow/white soft, stringy, thick substance]) and required a substantial/maximal assist from staff for bed mobility. The Minimum Data Set, dated [DATE] documented Resident #258 had one (1) stage three (3) (full thickness tissue loss) pressure ulcer, one stage four (4) (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer, and three (3) unstageable pressure ulcers; all were present upon admission/readmission.The comprehensive care plan dated 07/14/2025 documented Resident #258 had impaired skin integrity with interventions to administer preventative treatments per provider order, monitor skin for changes daily during care, protect skin from external devices by padding or securing pressure reduction device for bed and chair, evaluate and measure skin/wound sites at least weekly. Document outcome and treatment progress/changes and monitor sites for signs and symptoms of infection.Review of Nursing admission Evaluation dated 07/16/2025, Registered Nurse #2 documented Resident #258 was admitted to the facility via a wheelchair van. The skin assessment included Resident #258 had an ulcer to buttock stage to be determined, left inner thigh open area approximately one (1) centimeter by one (1) centimeter, right heel and ankle open wound, left heel sore, left outer calf open area approximately one (1) centimeter by one (1) centimeter, left calf red areas not open. There was no documented evidence of a complete pressure ulcer assessment including staging and measurements.Review of Medical Visit Note dated 07/17/2025, the Medical Director documented Resident #258 was readmitted to the facility after being hospitalized , had a chronic stage four (4) sacral ulcer. Refer to nursing notes for full skin assessments and wound measurements if any.Review of Resident #258s nursing Progress Notes, Weekly Skin Status Documentation, and Medical Visit Notes dated 07/16/2025 to 07/22/2025 revealed no documented evidence Resident #258 had a full assessment of their pressure ulcers including measurements and staging. Review of Wound Care Assessment/Consultation dated 07/23/2025, the Wound Care Consultant documented Resident #258 was admitted with a stage four (4) pressure ulcer to their sacrum (area above tailbone on right and left buttocks), coccyx (tailbone), and bilateral gluteal (buttock) folds. There were multiple areas clustered together that measured 26 centimeters long by 23 centimeters wide by 6.2 centimeters deep. Resident #258 had an unstageable pressure ulcer to their right lower extremity that measured 1.5 centimeters long by 2 centimeters wide with slough (layer of dead tissue) covering the surface, an unstageable pressure ulcer to their right heel that measured 2.5 centimeters long by 2.8 centimeters wide with slough covering the surface, an unstageable pressure ulcer to their right ankle that measured 1.5 centimeters long by 2 centimeters wide with slough covering the surface, and a stage three (3) pressure ulcer to their left medial thigh that measured 1 centimeters long by 2 centimeters wide 0.1 centimeters deep.During an interview on 03/13/2026 at 9:52 AM, Licensed Practical Nurse #3 stated the admitting nurse was responsible for completing a full skin assessment on a new admission/readmission, a Registered Nurse then was responsible for reviewing and signing off on the assessment. They stated a Licensed Practical Nurse could not stage pressure ulcers, a Registered Nurse was responsible for measurements and staging of pressure ulcers which needed to be completed within 24 hours after admission. Licensed Practical Nurse #3 reviewed Resident #258s Nursing admission Evaluations skin assessment dated [DATE] and stated there were no specific measurements or stages documented for Resident #258s pressure ulcers upon admission and there should have been. They reviewed Resident #258s progress notes, wound notes, and wound consultant notes and stated the first documented staging and measurements for Resident #258s pressure ulcers after admission were documented on 07/23/2025. Licensed Practical Nurse #3 stated it was important to have timely measurements and staging of pressure ulcers after admission to ensure accurate treatments were in place and to monitor for worsening of the wounds. During a telephone interview on 03/13/2026 at 10:54 AM, Registered Nurse #2 stated they completed the Nursing admission Evaluation for Resident #258 when they returned from the hospital in July. They did a full body assessment but did not document specific stages or measurements. They stated they were not trained in how to measure wounds or stage wounds. Registered Nurse #2 stated Licensed Practical Nurse #3 was responsible for completing wound assessments after the Wound Care Consultant saw the residents. They stated Resident #258 should have had measurements and staging completed sooner than 07/23/2025 because infection happened fast, wounds and pressure ulcers needed to be monitored for worsening or improvement.During an interview on 03/13/2026 at 11:19 AM, the Medical Director stated all residents should be examined within 24 hours of admission or readmission, all new and existing wounds needed to be documented. The Medical Director stated they would have expected nursing staff to have documented measurements, characteristics, and descriptions of wounds, new or existing, within 24 hours of admission for Resident #258; it was important for adequate documentation of progression, to monitor for improvement or worsening so that the wounds could be tracked accordingly.During an interview on 03/13/2026 at 11:34 AM, the Assistant Director of Nursing stated they would have expected a Registered Nurse to have completed a full assessment of Resident #258s pressure ulcers within 24 hours of admission, including staging and measurements. If Registered Nurse #2 did not feel comfortable staging or measuring a pressure ulcer, they should have reached out for guidance. During an interview on 03/13/2026 at 11:45 AM, the Director of Nursing stated they would have expected a full assessment of Resident #258s pressure ulcers, including staging and measurements, to have been completed, and documented upon admission, or within 24 hours after admission. The Director of Nursing stated if the admitting nurse, Registered Nurse #2, did not feel comfortable doing those things, they should have reached out to another unit coordinator, the Assistant Director of Nursing or the Director of Nursing so that they could guide them in the right direction. They stated it was important to have accurate timely assessments of wounds to determine whether a wound was improving or worsening, if different treatments were needed, and it could lead to further health issues.10NYCRR 415.12 (c)(2)

Based on observation, interview and record reviewed conducted during a survey, the facility did not ensure that all residents care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (1) (Resident #222) of two (2) resident's reviewed. Specifically, Resident #222 was observed with numerous cigarettes in their possession and they were care planned for all smoking materials to be kept at the nurse's station. The finding is: The policy titled Resident Smoking Policy dated 01/2025 documented the unit Social Worker will complete the Smoking Data Collection tool quarterly and with any significant change to determine whether a resident is deemed responsible or non-responsible and what restrictions if any needed to be placed on the resident's smoking privileges. All restrictions shall be noted on the smoking care plan so all personnel may be alert to smoking restrictions. The facility will receive consent from the resident or the resident's representative prior to completing a room search to determine if residents classified as non-responsible have any smoking articles that are in violation of the smoking regulations. The policy titled Interdisciplinary Care Planning dated 09/2025 documented a comprehensive resident-centered Care Plan is developed by the Interdisciplinary Team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay. The comprehensive Care Plan and Kardex (a guide used by staff to provide care) must always be current and accurately reflect the resident's status. The Care Plan/Kardex must always be reviewed by staff prior to initiating resident care. Resident #222 had diagnoses including disorder of the brain, dementia and hypertension. The Minimum Data Set (a resident assessment tool) dated 12/24/2025 documented Resident #222 understood, understands and had severe cognitive impairment. The Minimum Data Set documented Resident #222 was a smoker. The comprehensive Care Plan dated 03/03/2023 documented Resident #222 uses tobacco products. An intervention initiated on 05/23/2025 documented smoking materials were kept at the nurse's station. Review of the Kardex dated 03/13/2026 documented smoking materials were kept at the nurse's station - may go out on their own. Review of the nurse Progress Notes from 01/01/2026 to 03/13/2026 revealed on 01/02/2026 at 4:57 PM, Resident #222 was out of bed and self-propelled without difficulty. They continued to frequently go outside to smoke. Review of the Social Work Smoking Data Collection Tool dated 12/29/2025, revealed Social Worker #1 documented Resident #222 smokes during the day and was safe during smoking. There was a recommendation that Resident #222 required storage of smoking materials in staff possession. During an observation and interview on 03/12/2026 at 9:12 AM, Resident #222 was in their room. They stated they go outside to smoke. Resident #222 lifted a pouch that was beside them in their wheelchair and underneath the pouch was one (1) cigarette. Resident #222 opened their pouch and there were numerous cigarettes in the pouch. Resident #222 stated they did not have their lighter. During an interview on 03/13/2026 at 8:54 AM, Certified Nurse Aide #1 stated Resident #222 has been a smoker at the facility for years. They stated the only area that Resident #222 keeps their cigarettes and lighter was at the nurse's station. They stated that the nurses keep Resident #222's smoking materials so that other residents would not get ahold of them and get injured. They stated all staff were responsible for making sure Resident #222 remained safe. During an interview on 03/13/2026 at 9:12 AM, Certified Nurse Aide #3 stated Resident #222 kept their cigarettes and lighter with the nurse. They stated that they were responsible for Resident #222's care and knew that when Resident #222 went to go smoke because Resident #222 would go to the nurse. The nurse would give Resident #222 one (1) cigarette and their lighter before going outside. They stated the nurses and certified nurse aides were responsible for making sure Resident #222 stayed safe. During an interview on 03/13/2026 at 9:44 AM, Social Worker #1 stated they evaluated the smokers, who were grandfathered into smoking at the facility, every quarter. They stated during the smoking evaluations, they would sit with the resident who was smoking outside and make sure they were able to propel themselves to the designated area, light their cigarette, smoke their cigarette without ashes falling on them, extinguish their cigarette and return inside the facility safely. They stated that Resident #222 received a score of three (3) on their Brief Interview Mental Status evaluation, which was low, but Resident #222 would also refuse to respond to some of the questions saying, why do I need to know the month or day of the week?. They stated sometimes Resident #222 would respond better to another staff member when they were questioned and it depended on what kind of mood Resident #222 was in. Social Worker #1 stated that there have been times that Resident #222 appeared more confused than usual and that was the only reason why Resident #222 had an intervention on their care plan to keep their smoking material, including lighter and cigarettes, at the nurse's station. During an interview on 03/13/2026 at 10:02 AM Licensed Practical Nurse #1 stated Resident #222 would wheel themselves up to them whenever they wanted to go out to smoke. They would then give Resident #222 their lighter and one (1) or two (2) cigarettes. They stated that Resident #222 had a tendency of attempting to go smoke before eating their meal or taking their medications, so they made sure that Resident #222 had taken their medications and ate their meal before giving them their cigarettes and lighter. Licensed Practical Nurse #1 stated they would make sure that they received the lighter back when Resident #222 returned. Licensed Practical Nurse #1 stated they were not sure why it was care planned that Resident #222's cigarettes and lighter were to be stored at the nurse's station but they also did not want another resident to somehow get ahold of any smoking materials that Resident #222 had in their possession. They stated that Resident #222 was known to hoard items including cigarettes and it was possible that they would try to hold on to any extra cigarettes they had, but they always returned the lighter. During an observation and interview on 03/13/2026 at 10:12 AM, Resident #222 returned to the unit from outside. They stated they were returning from smoking and gave Licensed Practical Nurse #1 their lighter. With Licensed Practical Nurse #1 present, Resident #222 was observed to open their pouch that was next to them in the wheelchair. There were 22 cigarettes in the pouch. Licensed Practical Nurse #1 stated they were unaware Resident #222 had that many cigarettes with them and would lock them up. During an interview on 03/13/2026 at 10:21 AM, Licensed Practical Nurse #2 Unit Coordinator stated Social Worker #1 had completed an assessment on Resident #222 and determined they were safe to smoke outside but the smoking materials, including any lighters and cigarettes, were to be locked in the medication storage room. They stated they tried to keep up on it, but Resident #222 tended to be very sneaky. Licensed Practical Nurse #2 Unit Coordinator stated Resident #222 has only smoked in the designated area because Resident #222 knew that their smoking privileges would be taken away if they were caught smoking inside the facility. They stated all staff members were responsible for resident safety. They stated they were not sure if it would be considered a break in the care plan because Resident #222 was so sneaky, but they would not want them to have the smoking materials in their possession because they should not be there. During an interview on 03/13/2026 at 10:32 AM Nurse Practitioner #1 stated the facility had deemed Resident #222 safe to smoke. They stated smoking materials, including lighters and/or cigarettes, should be locked up because it just takes one (1) resident to smoke in their room and put their safety and other residents' safety at risk. During an interview on 03/13/2026 at 12:10 PM, the Director of Nursing stated they expected the staff to follow the care plan. They would not expect to find smoking materials, including lighters or cigarettes, in Resident #222's possession. They stated it was possible that Resident #222 would offer a cigarette to a resident who did not smoke. It was expected that the nurses would keep the cigarettes and lighter locked up until Resident #222 asked for them before going to smoke. The Director of Nursing stated Resident #222 could be deceptive and it was expected that the nurses would check Resident #222 when they returned from smoking for any lighters or cigarettes. The certified nurse aides and nurses who were responsible for Resident #222's care during the shift were responsible for making sure the care plan was followed for Resident #222's safety. During an interview on 03/13/2026 at 12:23 PM, the Administrator stated it was their expectation that staff read and followed the care plan for Resident #222's safety. 10NYCRR 415.11(c) (1)

Based on interview and record review conducted during a Complaint investigation (#NY00328230) during a Standard survey completed on 2/12/24, the facility did not ensure that a resident has the right to refuse treatment for one (Resident #137) of six residents reviewed for immunizations. Specifically, Resident #137's Health Care Proxy did not give consent for a COVID 19 vaccine, and the resident received it. The finding is: Review of the policy and procedure titled COVID 19 Vaccination dated 10/19/23 documented that residents or their representatives will be educated regarding the risks, benefits, contraindications, and potential side effects associated with the COVID 19 vaccine. Further review of the policy documented that residents or the residents' representatives must have verbal or written consent prior to receiving the vaccine. Resident #137 was admitted to the facility with cancer of the frontal lobe of the brain, dementia, and dysphagia (difficulty in swallowing food or drink). Review of the Minimum Data Set (a resident assessment tool) dated 9/15/23 documented that the resident was cognitively intact, understood by others, and understands others. Review of the Health Care Proxy dated 6/28/23 documented that the resident designated their spouse as their Health Care Proxy and that the Health Care Proxy would go into effect when the resident could not make their own health care decisions. Review of the Determination of Incapacity/Adult Without Capacity HCP (health care proxy) form for Resident #137 dated 6/29/23 documented that the cause of the resident's incapacity was dementia, and that the probable duration was permanent. Review of the COVID 19 Vaccination Consent/Declination form dated 11/1/23, documented that Registered Nurse Unit Coordinator #1 received a verbal consent from Resident #137's Health Care Proxy for a COVID 19 immunization. The consent form was signed by the Registered Nurse Unit Coordinator #1 and was not signed by the resident, their Health Care Proxy or any witnesses. The Medication Administration Record dated 11/1/23 - 11/30/23 documented that Resident #137 received the COVID 19 vaccination on 11/7/23 at 12:04 PM. The Medication Administration Record documented that Resident #137 was monitored for post COVID 19 immunization side effects every shift from 11/7/23 to 11/9/23. Review of Resident #137's care plan last updated 12/18/23, documented that the resident had a Health Care Proxy activated. The care plan documented that the resident had alterations in their decision-making ability and some difficulty making decisions in new situations. The care plan also documented that the COVID 19 vaccination was previously declined twice. Review of a Medication/Treatment Variance Report dated 11/8/23 documented that Resident #137 was given the COVID 19 vaccine without consent. The medication error report documented that Resident #137 had a slight fever and a reddened area on the injection site. The medication error report also documented a statement from Registered Nurse Unit Coordinator #1 that they gave Resident #137 the COVID 19 vaccine in error and to be more vigilant with consents. During an interview on 2/8/24 at 8:32 AM, Registered Nurse Unit Coordinator #1 stated that they received a verbal consent from Resident 137's Health Care Proxy by telephone. They stated that they gave the COVID 19 shot and the day after they administered the shot, the Health Care Proxy said they didn't want Resident #137 to receive the shot. The Registered Nurse Unit Coordinator #1 stated that they explained to the Health Care Proxy about monitoring Resident #137 after receiving the shot and that the Health Care Proxy was okay with the resident receiving the COVID 19 shot. During an interview on 2/9/24 at 9:02 AM, Resident #137's Health Care proxy stated that they did not receive a phone call from Registered Nurse Unit Coordinator #1 about consenting to a COVID 19 immunization for the resident. They stated that they found out Resident #137 received the shot the day after it was given to the resident when they came for a visit. The Health Care Proxy stated that they visited Resident #137 every day and that they could have signed the declination for the COVID 19 shot. The Health Care Proxy stated they did not sign a consent form or a declination for the COVID 19 shot. The Health Care Proxy stated that they did not receive any educational material concerning the COVID 19 immunization before or after Resident #137 received the vaccination. During an interview on 2/9/24 at 10:22 AM, the Registered Nurse Unit Coordinator #1 stated that they had 46 consents to obtain and was told they had to get them. They stated they made a phone call to Resident #137's Health Care Proxy and thought they obtained a verbal consent. The Registered Nurse Unit Coordinator #1 stated when they spoke to the Health Care Proxy after Resident #137 received the COVID 19 shot, they realized they made a mistake. The Registered Nurse Unit Coordinator #1 stated they reported to the Director of Nursing that they gave the COVID 19 immunization in error. During an interview on 2/9/24 at 10:40 AM, the Assistant Director of Nursing Registered Nurse Infection Preventionist stated the process was that we get an order for the vaccination from the resident's physician. They stated that they expected Unit Coordinators to get a verbal or written consent from the resident or the resident's representative or Health Care Proxy prior to administering the vaccination. They stated that the Unit Coordinators were told to obtain consents, verbal or written, for the flu, pneumonia, or COVID 19 shots. They stated they would not expect the Unit Coordinator to get all consents, verbal or written, in one day. They also stated that it would be difficult to obtain consents for an entire unit in one day. During an interview on 2/9/24 at 11:10 AM, the Director of Nursing stated they expected the nursing staff to obtain verbal or written consents prior to the administration of any immunization. They stated that if a resident had capacity to make healthcare decisions, the resident should sign the consent or declination. They stated that if the resident does not have capacity to make healthcare decisions, then the Health Care Proxy should sign the consent or declination. During an interview on 2/9/24 at 2:22 PM, Resident #137's Physician stated they expected nursing staff to get a consent, verbal or written, prior to giving an immunization to a resident. During an interview on 2/12/24 at 10:31 AM, the Administrator stated that at that time, the resident was cognitively intact and could have refused the COVID 19 shot. The Administrator stated that the Health Care Proxy likes to be involved with Resident #137's care and therefore nursing staff should have obtained the consent from the Health Care Proxy. During an interview on 2/12/24 at 10:56 AM, Registered Nurse Unit Coordinator #1 stated that Resident #137 could not sign a consent or a declination form because the resident had brain cancer and could not have capacity to consent, refuse, or decline any immunization. 10 NYCRR 415.3(f)(1)(ii)

Based on observation, interview, and record review completed during the Standard survey completed on 3/22/22, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #48) of two residents reviewed for feeding tubes. Specifically, the facility did not administer the tube feed formula at the flow rate as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: The facility policy and procedure (P&P) titled Gastrostomy Feeding Tubes revised 8/2017 documented that the purpose was to provide nourishment, hydration, and medication for residents requiring feeding through a gastric tube (g-tube) inserted into the stomach through the abdominal wall when the oral route is inaccessible and/or medically contraindicated. The procedure included that the nurse was to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For continuous feeding types (uninterrupted administration of enteral formula over extended periods of time), the nurse was to allow the contents of the feeding bag to flow into the stomach at the rate ordered by the physician and regulate the flow by adjusting the flow regulator or the infusion pump. 1. Resident #48 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 1/18/22 documented Resident #48 had moderately impaired cognition, sometimes understands, and was sometimes understood. Additionally, the MDS documented that the resident received 26-50% (percent) of total calories and 501 cc (cubic centimeter) per day or more fluid intake through [MEDICATION(S)] or tube feeding. The Comprehensive Care Plan (CCP) reviewed 1/25/22 documented Resident #48 required a percutaneous endoscopic gastrostomy tube (PEG tube- most common type of g-tube) related to dysphagia. Interventions included to administer the tube feed per MD orders. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional order dated 3/4/22 documented to record end total volume of enteral feed at 10 AM, shut off enteral feed when total volume mL's of ordered formula per 24 hours are infused (total feed=1100 mL's/24 hours, total calories=1650/24 hours). Intermittent observation of Resident #48 revealed the following: - 3/16/22 at 2:52 PM, Resident #48 was lying in bed with the head of the bed elevated and the continuous enteral feed was infusing via PEG tube at the set flow rate of 60 mL (milliliters) per hour; at 3:53 PM, the feeding was observed still infusing at 60 mL per hour. - 3/17/22 at 8:45 AM, the continuous feed initiated the day prior was still infusing at 60 mL per hour. The total volume infused (TVI) was 2158 mL; at 3:42 PM, a new bag of enteral feeding formal, signed with the last name of licensed practical nurse (LPN) #1, was infusing at set rate of 60 mL per hour. - 3/18/22 at 9:19 AM, the continuous feed initiated the day prior was still infusing at 60 mL per hour. The total volume infused (TVI) was 2114 mL; at 2:45 PM, a new bag of enteral feeding formal initialed by LPN #2 was infusing at set rate of 60 mL per hour. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document titled Weight and Vitals Summary dated 9/9/21 through 3/31/22 for Resident #48 documented the following weights: 9/9/21 174.6 lbs. (pounds), 10/1/21 178 lbs., 11/1/21 174.6 lbs., 12/1/21 175.6 lbs., 1/6/22 175 lbs., 2/1/22 174.9 lbs., 3/2/22 192.6 lbs., 3/9/22 190.6 lbs., 3/13/22 191 lbs. Review of Medication/Treatment Discrepancy/Error Report dated 3/18/22 revealed that Resident #48's PEG tube pump rate was set at 60 cc/hour instead of 55 cc/hour as per MD orders on 3/16/22, 3/17/22, and 3/18/22. During an interview on 3/18 at 2:56 PM, Licensed Practical Nurse (LPN) #1 stated that they were assigned to Resident #48 that shift, but LPN #2 administered the resident's enteral feeding because LPN #1 was unsure of the process for tube feeding. During an interview on 3/18/22 at 3:02 PM, LPN #2 stated that they administered Resident #48's enteral feeding during the shift. LPN #2 stated they checked the resident's paper chart to verify the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 observed the resident's enteral feeding and stated that it was currently infusing at 60 mL's per hour and that it was not set to infuse per the MD orders. LPN #2 stated that they set it at the wrong rate and were going to reset the pump to infuse at 55 mL per hour, as ordered. LPN #2 stated that they did not go check on the Resident #48 after starting the enteral feed to ensure it was properly infusing because the resident was assigned to LPN #1 that shift. During an interview on 3/18/22 at 3:02 PM, Registered Nurse (RN) #1, Unit Coordinator (UC) stated the expectation was for the bedside LPN to check their resident's infusion rate before administration and to monitor the enteral feeding infusion throughout shift the to ensure it was running at the correct flow rate. RN #1 stated that the enteral feeding orders for Resident #48 had recently changed due to weight gain. New orders began at the beginning of March to infuse the feeding at 55 mL's per hour and feed infusing at 60 mL's was a medication error. During an interview on 3/18/22 at 3:55 PM, the Registered Dietician (RD) stated that the nursing staff were responsible to set up and ensure that a Resident #48's enteral feeding was running as order. The RD stated that they decreased Resident #48's flow rate from 60 mL per hour to 55 mL's per hour to address weight gain, with goal of the resident not gaining anymore weight and possibly losing weight. The RD stated that it would not be following current orders if the feed was being administered at 60 mL per hour. The RD further stated that Resident #48 could continue to gain weight or maintain current weight and not lose weight if being administered enteral feed at higher infusion rate. During an interview on 3/18/22 at 4:08 PM, the Director of Nursing (DON) stated that they would have expected the nurse to set Resident #48's enteral feed per orders and to monitor the feed throughout their shift. The DON stated that having more enteral feed infused than ordered would be a medication error which could result in weight gain or fluid issues for the resident. During a follow-up telephone interview on 3/22/22 at 9:13 AM, LPN #1 stated that they should have verified the flow rate on 3/18/22 after LPN #2 started the enteral feed and throughout the shift since Resident #48 was assigned to LPN #1 and did not. LPN #1 further stated that they should have looked at the flow rate prior to taking the feed down and signing it off on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 3/22/22 at 10:30 AM, the Physician stated that they would have expected the tube feed formula to be running at 55mL per hour as ordered. 415.12(g)(2)

Based on interview, observation, and record review conducted during a Complaint investigation (Complaint #NY 755) completed during the Standard survey on 3/22/22, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for two residents (#298 and #184) of four residents reviewed for indwelling catheters (tubing put into a patient's urethra to collect urine from their bladder). Specifically, the lack of adhering to professional standards of practice and infection prevention and control practices. This included the lack proper hand hygiene and glove change during catheter care (#298) and a catheter drainage bag and tubing that were observed directly on the floor during multiple observations (#184). Both residents had urinary tract infections. The findings are: The facility policy and procedure (P&P) titled Policy on Hand Washing dated 11/2019 documented that all personnel who are working in the long-term care facility are required to wash their hands before and after direct resident contact, before and after assisting a resident with toileting, before and after assisting a resident with personal care like bathing, and after handling soiled or used linens, dressing, bedpans, catheters and urinals. The facility P&P titled Incontinent Care dated 3/2022 documented that a staff member should clean the genital area first, the perineal area (the area between the genitals and the anus) second, and the anal area last; after cleansing the resident's genital area, staff are to remove their gloves and wash their hands. The facility P&P titled Catheter Drainage Bag Care documented that care should be taken to make sure the tubing does not touch or drag on the floor. Staff should wash hands before and after any manipulation of the urinary drainage apparatus. 1. Resident #298 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 3/9/22 documented Resident #298 was cognitively intact, understands and was understood. The MDS documented Resident #298 was taking an antibiotic for an infection. The Nursing Admission Evaluation dated 3/2/22 documented that Resident #298 had a urinary catheter upon admission to the facility. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented that the antibiotic was to be taken until 3/23/22. Resident #298's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #298's care plan dated 3/2/22 documented the resident had an alteration of bladder function due to a surgical procedure, and had a urinary catheter related to [CONDITION(S)]. Documented interventions included that catheter care was to be completed every shift. The Visual/Bedside Kardex Report (guide used by staff to provide care) dated 3/2/22 documented that the CNA was to perform urinary catheter care every shift. During an observation of urinary catheter care in the presence of Licensed Practical Nurse (LPN) Clinical Educator #3 on 3/21/22 at 3:30 PM, CNA #1 was wearing gloves and un-tabbed Resident #298's incontinence brief and asked the resident to roll onto their right side. CNA #1 proceeded to tuck the brief outside in under the hip of the resident. Resident #298 was incontinent of stool. CNA #1 completed fecal incontinence care using a basin of water and a spray cleanser. Once fecal incontinence care was completed, and without removing their gloves or washing their hands CNA #1 assisted Resident #298 onto their left side, by touching the resident's hip and bed linens. CNA #1 then removed the soiled brief completely and positioned Resident #298 onto their back. Without washing their hands and wearing the same gloves used to complete fecal incontinent care, CNA #1 then cleaned Resident 298's urinary catheter, genital area, inner thigh area, and applied a clean brief on the resident. During an interview on 3/21/22 at 3:45 PM, CNA #1 stated they should have washed their hands and changed gloves after completing fecal incontinent care. CNA #1 stated that by not washing their hands or changing gloves it could lead to an infection. During an interview on 3/21/22 at 3:46 PM, LPN #3 stated CNA #1 should have washed their hands and changed her gloves after performing fecal incontinent care, as the CNA could have caused cross contamination. During an interview on 3/21/22 at 3:50 PM, Registered Nurse (RN) Unit Coordinator #2 stated the expectation was for staff to wash their hands and change their gloves after touching a resident especially after performing fecal incontinent care. RN #1 stated the CNA should have cleaned the resident's genital area first then performed fecal incontinent care as there could be a cross contamination. During an interview on 3/21/22 at 4:10 PM, the Director of Nursing (DON) stated the expectation was for staff to wash their hands and change their gloves when performing incontinent care. The DON also stated that there was possibility of cross contamination by going from a dirty area to a clean area. They stated that staff are taught to go from front to back (from genital area to anal area) when cleaning a resident after incontinent care. 2. Resident #184 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #184 was cognitively intact, usually understood, and usually understands. The MDS documented Resident #184 had an indwelling urinary catheter. The undated Comprehensive Care Plan (CCP) documented Resident #184 had alteration in their bladder function related to the use of an indwelling urinary catheter and a [CONDITION(S)]. Documented interventions included that a leg bag (holds urine that drains from catheter and fits under clothing) was to be worn during daytime hours and that Resident #184 required total care for toileting tasks. The Telephone/Verbal Order Signature Details documented that Resident #184 had the following antibiotic medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 300mg every 12 hours for [CONDITION(S)] with started date of 2/24/22 until 3/1/22. -[MEDICATION(S)] was discontinued on 2/28/22 and [MEDICATION(S)] 600 mg every 12 hours for [CONDITION(S)] was ordered from 2/26/22 until 3/7/22. -[MEDICATION(S)] 200mg every 12 hours for [CONDITION(S)] with started date of 3/16/22 until 3/19/22. Review of the Lab Results Report documented: -2/25/22 Clean catch urine culture results were positive for [MEDICATION(S)] resistant enterococcus (VRE- a bacterial strain). -3/14/22 Clean catch urine culture results were positive for [CONDITION(S)] oxytoca (a gram-negative bacterial strain). Intermittent observations of Resident #184 during survey from 3/16/22 through 3/22/22 revealed the following: -3/16/22 at 9:20 AM, Resident #184 was seated in their wheelchair (w/c) across from the nursing station, the urinary drainage bag was attached beneath the w/c seat and the foley tubing was on the floor. -3/16/22 at 11:49 AM, Resident #184 was seated in their w/c in their room the urinary drainage bag was attached beneath the w/c seat and the foley tubing was touching on the floor. -3/16/22 at 2:54 PM, Resident #184 was in bed, the bed was in a low position and the urinary drainage bag was attached to bed frame. The drainage bag was touching the floor, and there was no barrier between the bag and the floor. -3/17/22 at 4:04 PM, Resident #184 was in bed, the bed was in a low position and the urinary drainage bag was attached to the bed frame. The drainage bag was touching the floor, and there was no barrier between the bag and the floor. -3/18/22 at 9:55 AM, Resident #184 was seated in their w/c in their room, the foley drainage bag was attached beneath the w/c seat and the foley tubing was on the floor. -3/18/22 at 11:45 AM, Resident #184 was seated in their w/c in their room, after returning from therapy, the foley bag was attached beneath the w/c seat and the foley tubing on the floor During an observation on 3/18/22 at 12:26 PM Resident #184 was observed seated in their w/c in their room. The resident's foley drainage bag was hanging beneath the w/c seat and the foley tubing was on the floor. CNA #3 took a blue privacy bag from windowsill and placed the blue privacy bag around the foley bag. CNA #3 washed their hands and exited the resident's room. The foley tubing remained directly on the floor. During an interview on 3/18/22 at the time of the observation CNA #3 stated that they do not usually put a leg bag on Resident #184 because they are usually in their room. CNA #3 stated there is a slit in the bottom of the blue privacy bags and the extra foley tubing falls out of the bottom of the bag. During an observation in the presence of the DON on 3/18/22 at 12:34 PM, LPN #4 fixed the placement of the privacy bag, urinary drainage bag and tubing, so the tubing was no longer on the floor. The DON stated Resident #184 had a shorter w/c and the foley tubing was touching the floor. The DON stated that residents, if tolerated, should be wearing foley leg bags. During an interview on 3/18/22 at 12:45 PM, LPN #4 stated that there was an opening in the bottom of the privacy bag that makes the foley bag fall through to the ground. LPN #4 stated that Resident #184 could be wearing a foley leg bag if they were to leave their room. In a further interview on 3/18/22 at 12:52 PM, the DON stated the foley tubing touching the ground could possibly result in a [CONDITION(S)]. During an interview on 3/22/22 at 9:52 AM, RN #4 Infection Control Preventist stated that a foley leg bag should be utilized anytime a resident gets out bed that has a foley catheter. If a resident refused to wear a leg bag, the tubing should run down the resident's pant leg and if there was extra tubing then that should be placed into the privacy bag. RN #4 stated the foley bag or foley tubing touching the ground could result in cross contamination. 415.12(d)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 3/22/22, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for two (Residents #119 and 92) of five residents reviewed for ADLs. Specifically, Resident (#119) was not provided with complete AM ADL care including washing of their underarms, hands and perineal area and Resident (#92) was not provided timely incontinence care. Additionally, barrier cream was not applied following incontinence care (#119) and staff did not complete hand hygiene in-between glove change after incontinence care (#92). The findings are: The facility policy and procedure (P&P) titled Bathing and Grooming revised 2/2019 documented a partial bed bath (AM Care) included washing the resident's face, neck, underarms and under breasts. Also, to wash the resident's genitals, buttocks, and apply A&D ointment (skin protectant). The facility P&P titled Policy on Hand Washing with revised date 11/2019 documented that proper handwashing technique is used for the prevention of transmission of infectious diseases. The P&P documented that all personnel working the long-term care facility are required to wash their hands before and after assisting a resident with personal care and after removing gloves. 1. Resident #119 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented Resident #119 had moderate cognitive impairment, required extensive two person assist for bed mobility and was totally dependent on staff for toileting and hygiene. The Visual Bedside Kardex Report (used by Certified Nurse Aides (CNA) to guide care) dated 3/18/22 documented Resident #119 required two assist for side-to-side bed mobility, total care for bathing and personal hygiene, and a moisture barrier following incontinence care. During observation of morning (AM) care on 3/18/22 at 8:31 AM, Resident #119 was lying in bed, wearing the same shirt they had been wearing the day before. There were linens on the overbed table including washcloths, a towel, and an incontinence brief. There was no basin of water. CNA #2 removed the pillow that was under Resident 119's legs then removed the resident's shirt and started to put a different shirt on the resident. Resident #119 stated No, CNA #2 asked the resident if they wanted a different shirt, and Resident #119 stated, yes. CNA #2 obtained a different shirt from the resident's closet, Resident #119 approved the shirt, and the CNA put the clean shirt on the resident. CNA #2 did not wash Resident 119's underarms, chest, hands, or apply deodorant before putting on the clean shirt. CNA #2 went to the sink, applied water and soap to the washcloth and placed the washcloth directly on the resident's bed. CNA #2 unfastened Resident 119's brief and folded it down between their thighs. Resident #119 was incontinent of urine. CNA #2 turned Resident #119 onto their left side, using 1 assist and washed the resident's buttocks, gluteal folds, wiped once between the resident's thighs, placed a new brief under the resident, and positioned the resident on their back. CNA #2 did not wash Resident 119's genital and groin area or apply moisture barrier cream to the resident's buttocks. The resident said No, the CNA asked the resident if they wanted a larger brief, the resident stated yes. CNA #2 left the room to obtain a new brief and the Registered Nurse Unit Coordinator (RN UC) #1 returned to the room with CNA #2. CNA #2 and RN UC #1 turned Resident #119 to their left side and applied the new brief. CNA #2 put pants on the resident, and the two staff members transferred Resident #119 into a chair using a mechanical lift. During an interview on 3/18/22 at 10:10 AM, CNA #2 stated Resident 119 required two assist for bed mobility and they should have asked for assistance to turn the resident. The CNA stated the resident was a two assist because they required a mechanical lift and the resident sometimes had pain in their legs. The CNA stated washing underarms, chest, and hands were a normal part of morning care and didn't do it. CNA #2 stated they do look at the Kardex but didn't look at all the details and missed that they were to apply the barrier cream, they have tubes of A&D ointment that should be used. During an interview on 3/18/22 at 10:34 AM, the RN UC #1 stated they expected that the CNA would use 2 assist to turn Resident #119 per the Kardex. RN #1 stated morning care was supposed to include washing the resident's underarms, hands, and peri area and should be completed daily to keep the residents clean. During an interview on 3/22/22 at 11:01 AM, the Director of Nursing (DON) stated they expected the CNAs to follow the care plan to ensure resident safety and comfort. The CNA should have applied barrier cream to prevent skin breakdown. The DON stated washing underarms, hands, and peri area was part of basic morning care. 2. Resident #92 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #92 had severe cognitive impairments, was sometimes understood, sometimes understands. The MDS documented Resident #92 required total assist for toileting, was always incontinent of bladder and bowel and was at risk for developing pressure ulcers. The visual/bedside Kardex report dated 3/21/22 documented Resident #92 was incontinent and required total care for toileting. Interventions included to provided incontinent care every 2-3 hours and as needed. During a continuous observation on 3/21/22 from 8:41 AM through 12:31 PM Resident #92 was observed to be seated in their Geri-chair (specialized reclining chair) in an upright seated position. The resident was not checked for incontinence, provided with incontinence care or with assisted with positional changes during this time. During an observation of incontinence care in the presence of RN #5 on 3/21/22 at 1:08 PM, Resident #92 was in bed on their back with CNA #3 at bedside. The room smelled of urine. CNA #3 and CNA #5 performed hand hygiene and donned (put on) clean gloves. The CNAs positioned Resident #92 onto their left side, and removed the resident's incontinence brief. The brief was saturated with urine and a small amount of stool. CNA #3 provided urinary and bowel incontinence care. CNA #3 removed their gloves, donned new gloves and washed Resident #92 face and hands. CNA #3 did not complete hand hygiene in-between the glove change. Upon pulling up Resident #92's pants it was noted that their pants were also wet. CNA #3 changed the resident's pants. During an interview on 3/21/22 at 1:45 PM, CNA #3 stated they had gotten Resident #92 out of bed around 7:30 AM. CNA #3 stated they were floated to another unit about 8:15 AM and returned to the unit about 9:30 AM. CNA #3 stated that Resident #92 should have been put back to bed every 2-4 hours and provided with incontinence care before lunch around 11:00 AM. During an additional interview on 3/22/22 at 10:06 AM, CNA #3 stated that they did not check or provided incontinence care to Resident #92 until after lunch on 3/21/22 (1:08 PM). During an interview on 3/21/22 at 1:57 PM, CNA #5 stated Resident #92 was on their assignment while CNA #3 floated to another unit. CNA #5 stated they did not provide any ADL or incontinence care to Resident #92 during that time. During an interview on 3/21/22 at 2:00 PM, LPN #5 stated that Resident #92 should be turn and positioned every 2 hours and have incontinence care provided every three hours and did not know if that took place. During an interview on 3/21/22 at 3:04 PM, RN #5 Director of Education/Director of Quality stated that during observation of incontinence care for Resident #92, CNA #3 did not wash their hands in-between glove change and they should have. RN #5 stated the expectation was for residents to be provided with incontinence care every two hours and as needed. During an interview on 3/22/22 at 9:58 AM, RN #4 Assistant Director of Nurses /Infection Control Preventist stated that staff should wash their hands after taking off gloves and applying new gloves to prevent cross-contamination of germs and infection. During an interview on 3/22/22 at 10:52 AM, the DON stated that their expectation was a resident should be toileted per their care plan to prevent skin breakdown. 415.12(a)(3)

Based on record review and interview conducted during the Standard survey completed on 3/22/22, the facility did not ensure that New York SCREEN Forms DOH (Department of Health) - 695 were completed as required. One (Resident #119) of one resident reviewed with mental [CONDITION(S)]/developmental disabilities (MR/DD) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: Resident #119 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment and was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability. The facility policy Pre-Admission Screening & Resident Review (PASRR) dated 11/18 documented a resident who was identified as having mental [CONDITION(S)]/developmental disability on their admission screen Level I Review and met the criteria for Categorical Determination, requires a stay longer than the appropriate physician documented number of days, a screen and Level II evaluation must be completed. Review of the Hospital and Community Patient Review Instrument (HC/PRI) dated 12/10/20 revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the SCREEN Form (DOH-695) dated 12/10/20 revealed the Level I review answered Items # 24-26 no; which determined the resident had no documented history of MR/DD and no Level II referral was made. Review of the SCREEN Form (DOH-695) dated 1/13/2021 revealed the Level I review answered Items # 24-26 yes; which determined the resident had a documented history of MR/DD. Items #27-30 were answered no and the document directed screener to complete item #33 (Level II Referrals), which was blank. Review of social work Progress Notes dated 12/14/20-3/18/22 revealed no evidence a Level II referral was made to OPWDD. During an interview on 3/18/22 at 10:22 AM, the Social Worker (SW) #1 stated the resident had some developmental disability and that residents who require a Level II are usually checked prior to admission to the facility. SW #1 stated they check the SCREENs to ensure they had a valid screener number and that was it, they don't check that it was accurate. SW #1 stated they didn't know why a Level II would be done or wouldn't be done and didn't know the qualifications needed for a resident to be referred for a Level II review. During further interview on 3/18/22 at 10:55 AM, SW #1 stated they went through all the resident's screens in the chart and the screener (at the hospital) did not indicate a Level II referral was needed. The SW #1 stated the resident was initially admitted for short term rehab and that nothing changes once someone goes long term care in regard to a Level II referral. SW #1 stated the group home couldn't meet the resident's needs anymore and the resident transitioned to long term care. During an interview on 3/21/22 at 11:24 AM, SW #1 stated the resident did have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . SW #1 reviewed the facility policy, stated it was revised 11/2018 and said if the resident was initially here for a brief stay, but exceeded 30 days, they must make a referral for a Level II, then the Level II should be completed within 40 days from the referral. During an interview on 3/22/22 at 10:27 AM, SW #2 stated they were the resident's social worker upon the January 2021 admission and that they reviewed SCREEN forms only to make sure there was a valid screener number. SW #2 stated they would make a Level II referral if the resident had a developmental disability and was expected to remain in the facility longer than 30 days. SW #2 stated the resident was switched to another SW's case once the resident transitioned to long term care prior to the 30 days, so they did not make a Level II referral. During an interview on 3/22/22 at 11:07 AM, the Director of Nursing (DON) stated a referral to OPWDD was to be made once someone with intellectual disabilities transitioned to long term care and it was the social worker's responsibility to make the referral. 415.11 (e)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/2/19, the facility did not ensure that the facility establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One (Resident #206) of three residents reviewed for infection control during care had issues with the lack of proper infection control practices. Specifically, the Certified Nurse Aide (CNA) did not change gloves and wash hands after cleaning feces prior to washing another area on the resident. In addition, touched environmental surfaces with contaminated gloves. The finding is: The facility policies and procedures (P&P) titled Hand Washing dated 7/09 documented proper handwashing technique is used for the prevention of transmission of infectious disease. All personnel working in the long-term care facility are required to wash their hands before and after assisting a resident with toileting needs: After handling soiled bedpans and urinals: After handling soiled equipment. The facility P&P titled Perineal Care dated 10/17 documented wash perineal area from front to back to prevent contamination. The facility P&P titled Bedpans/Urinals dated 8/05 documented a bedpan or urinal is used when a resident is unable to use the bathroom. Gloves are worn when contact with body fluids and secretions are expected. Dispose of urine or stool in toilet. Rinse urinal or bedpan with water. Return to bottom shelf of bedside stand. 1. Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 6/11/19 documented the resident was severely cognitively impaired, sometimes understands, sometimes understood, and required an extensive assist of two people for bed mobility and toileting needs. The current Visual/Bedside Kardex Report (guide used by staff to provide care) documented the resident required total assist of one person for personal hygiene. The Hospital Discharge Summary dated 5/23/19 documented UTI as a secondary diagnosis. During observation on 7/1/19 at 9:27 AM, CNA #1 donned gloves and removed a soiled bedpan from under the resident containing a small amount of brown stool and washed the resident's rectal area with a soapy wash cloth. On the washcloth was a small amount of brown smeared debris and placed the soiled washcloth onto a barrier cloth. She positioned the resident onto his back, removed an empty urinal from between the resident's legs and proceeded to wash the perineal area with a clean washcloth without removing her gloves and washing hands. CNA#1 then emptied and rinsed the bedpan and with the same gloves, touched the handle on the door of the bedside stand and placed the bedpan onto the bottom shelf and shut the door. She then removed the glove on her right hand, gathered soiled linens with her gloved hand and disposed the linens in the soiled utility room receptacle down the hall. Interview on 7/1/19 at 9:35 AM with CNA #1 revealed that she normally washes from front to back and would remove her gloves and wash her hands in between. CNA #1 stated, I removed the bedpan and washed the resident not thinking to change my gloves and wash my hands prior to washing the front. I was nervous. Interview on 7/1/19 at 9:38 AM with Registered Nurse (RN) #1 revealed CNA #1 should have removed her gloves and washed her hands before doing perineal care to reduce risk of infection. CNA #1 should have removed the bedpan, wiped the resident with toilet tissue then wash the perineal area then proceed to the back and wash the rectal area. Gloves are removed, and handwashing is done prior to touching and surfaces in the room to prevent cross contamination. Interview on 7/1/19 at 10:55 AM with the Director of Nursing (DON) revealed she expected her staff to perform hand hygiene after handling a resident's soiled bedpan and before touching any of the resident's care equipment. The DON stated she would expect her staff to wash from front to back when performing perineal care. 415.19(b)(4)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint # NY 333) completed on 5/17/18, the facility did not ensure the resident's right to be free from abuse of any type by anyone, including verbal abuse. One (Resident #1) of four residents reviewed for verbal abuse was the recipient of unwanted verbal abuse by nursing home staff. Specifically, on 1/4/18, a certified nurse aide (CNA #1) verbally and mentally abused the resident and used an obscene gesture toward the resident. The incident was witnessed by another CNA who did not did not immediately report the abuse to facility staff. The finding is: Review of a facility policy and procedure entitled Abuse Prohibition dated 10/2016 revealed that residents have the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, involuntary seclusion, misappropriation of property and exploitation. This includes freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat medical symptoms. 1. Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/1/17 revealed the resident has moderate cognitive impairment. Review of the Visual/ Bedside/ Kardex Report printed on 4/13/18 revealed the resident uses a hearing aid in both ears; communication is to be in writing and staff are to utilize a dry erase board as needed. Review of the facility's Internal Investigation dated 1/8/18 revealed a verbal abuse incident occurred involving Resident #1 on 1/8/18 (the date of the incident on the investigation is incorrect. The incident date is 1/4/18) at approximately 10:50 PM. The investigation documented that the resident was ringing his call bell for assistance and had rung for assistance several times prior to the incident. CNA #1 was at the desk (Nurses' Station) prior to the incident. CNA #1 asked CNA #2 to accompany her to the resident's room. While in the room, it was alleged that CNA #1 became upset with the resident, mimicking him and his questions. The resident became increasingly confused, and in response yelled out I don't understand. In response, CNA #1 said Do you understand this you dumb M . F ., extending her middle finger. The investigation conclusion stated that the resident was interviewed by the social worker and acknowledged that the incident did occur; however, given the resident's hearing impediment it was unclear if he heard the derogatory statement. The resident was able to confirm that CNA #1 mimicked him with the use of the white/dry erase board, according to the social worker's interview of the resident. CNA #1 was terminated for verbal and mental abuse. Review of CNA #2's written statement dated 1/8/18 revealed that at 10:50 PM on 1/4/18, he and CNA #1 entered Resident #1's room. The resident had rung multiple times because he gets confused about his days and nights. CNA #2 had already told the resident that he should stay in bed. When CNA #2 and CNA #1 entered the room, the resident asked to get up thinking that it was morning. CNA #1 told him no. CNA #1 then grabbed the resident's whiteboard and wrote, No it's 11 PM. Resident said he didn't understand. CNA #1 wrote, I don't understand. Resident read it and said, What, I'm confused. CNA #1 took the board from him and wrote, What, I'm confused. The resident said, you're crazy. CNA #1 wrote, you're crazy. Finally, the resident yelled I don't understand. CNA #1 leaned over the bed, flipped the resident off and said, do you understand this you dumb M . F . and stormed out of the room. Review of a written statement by CNA #1 dated 1/9/18 revealed that on 1/5/18 at 10:55 PM, the resident rang and CNA #2 went to check on him. CNA #2 came back and said the resident wanted to get up. The resident called again at 10:57 PM and CNA #1 and CNA #2 went in the room, the resident said that he wanted to call his daughter and wanted to get up. CNA #1 asked, why do you want to call your daughter. The resident said, I don't understand you. CNA #1 wrote on the dry erase board, What would you like? The resident kept repeating, I don't understand you. CNA #1 stated that she was getting a little edgy, so she told CNA #2 to talk to the resident and if we needed to get him up we would. CNA #1 stated that she excused herself, went to the nurse's desk, and CNA #2 was behind her. CNA #1 stated that the resident did not call for the rest of the shift. Review of employee files revealed that CNA #1 completed an On-the Unit Inservice regarding Verbal Abuse, Identifying Abuse, Abuse Prohibition, and Abuse Reporting on 7/26/17. Review of CNA #2's employee file revealed that he completed Mandatory In-services including Abuse Reporting and Abuse Prohibition on 9/18/17 during General Orientation. During an interview on 4/13/18 at approximately 9:15 AM, the resident was wearing hearing aids but was still hard of hearing and used a communication board. The resident was asked if people are nice to him here and he stated, they don't pay attention to me. The resident was asked if anyone has yelled at him or mocked him, he stated they don't pay attention to me. The resident was asked if anyone had abused him, he stated, no. The resident then stated that he wanted to go back to bed and lay down since he got up early today. During an interview on 4/18/18 at approximately 10:00 AM, the Director of Nursing (DON) stated that the incident (verbal abuse) occurred on 1/4/18 and CNA #2 reported the incident to the RN supervisor on 1/7/18 in the evening. The DON stated that the RN supervisor immediately called her to report the incident to her. The DON told the RN supervisor to make sure CNA #1 was not on the schedule, which she was not. Statements were obtained on 1/8/18, CNA #2 was disciplined for not reporting the incident in a timely manner and CNA #1 was terminated for the incident. During a telephone interview on 4/18/18 at approximately 3:00 PM, CNA #2 stated that the incident occurred on 1/4/18. CNA #2 stated that he worked the 3:00 PM to 11:00 PM shift and CNA #1 worked the 11:00 PM to 7:00 AM shift and came in a few minutes early. CNA #2 stated that the resident was not on his assignment but the resident had been ringing his bell and he had gone to the room a few times to check on the resident. CNA #2 stated that the resident thought it was morning. CNA #2 stated that at approximately 10:50 PM, he was at the Nurses' Station and the resident rang his bell again. CNA #1 was there and said that she would come with him and show CNA #2 how to handle the resident. Upon entering the room, the resident stated that he wanted to get up. CNA #1 told the resident that he could not get up. CNA #1 picked up the white dry erase board and kept re-writing everything the resident said to her. The resident kept saying I don't understand and was getting very agitated because CNA #1 was messing with him. CNA #2 stated that CNA #1 gave the resident the middle finger right in his face and said, do you understand this you dumb M . F . and the resident said, ouch. CNA #2 stated that he knew it was wrong but by the time he left his shift at 11:15 PM, his supervisors were gone. CNA #2 reported the incident to the evening shift RN supervisor a few days later. He spoke with the administrator and DON about the incident on 1/8/18 and wrote a signed statement. CNA #2 stated that he was disciplined by the facility for failure to report the incident right away. During a telephone interview on 4/23/18 at approximately 9:45 AM, the 3:00 PM to 11:00 PM shift RN Supervisor stated that CNA #2 reported the incident to her on 1/7/18 between 9:30 PM and 10:30 PM. The RN Supervisor stated that she immediately called the DON to report the incident to her. The DON told her to check to make sure that CNA #1 was not on the schedule. CNA #1 was not. She stated that they handled the issue on 1/8/18. The RN Supervisor stated that CNA #2 told her that he wasn't sure what to do about the situation. During a telephone interview on 5/17/18 at approximately 11:00 AM, CNA #1 stated that on 1/4/18 she worked the 11:00 PM to 7:00 AM shift. She stated that the resident kept ringing his call bell and she and CNA #2 went to the resident's room at approximately 10:55 PM. Upon entering the room, the resident stated that his back hurt. CNA #1 stated that she asked the resident if he wanted her to report the back pain. The resident kept saying I don't understand, I don't understand. CNA #1 said that she asked the resident if he wanted pain medication and the resident stated, yes. The resident then said, I don't want nothing. CNA #1 stated that she told the resident, we'll be back in a few minutes. CNA #1 stated that she reported the back pain to the nurse. CNA #1 denied mimicking the resident with the dry erase board. She denied gesturing to the resident with her middle finger and denied being verbally abusive to the resident. 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during the Standard survey completed on 4/16/18, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. One (Resident #25) of four residents reviewed for unnecessary medications did not receive a gradual dose reduction (GDR) of [MEDICATION NAME] (antipsychotic medication) and there was a lack of supporting documentation for the continued use of the antipsychotic. The finding is: Review of a facility policy and procedure (P&P) entitled [MEDICAL CONDITION] Medication Use - Initiation and Gradual Dose Reduction dated 8/17 revealed that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions and behavioral interventions unless contraindicated. Periodic re-evaluation of [MEDICAL CONDITION] medication is necessary to determine whether prolonged or indefinite use of a medication is indicated. The clinical rationale for continued use of medication should be documented in the clinical record. 1. Resident #25 was admitted to the facility on [DATE] with diagnose that include dementia, anxiety and diabetes mellitus. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/12/18 revealed the resident has moderate cognitive impairment, is usually understood, usually understands, has no behaviors and receives an antipsychotic medication daily. The MDS documented that no GDR was attempted and there was documentation by the physician on 12/26/17 supporting the medication use. Review of a facility In-House Consultation Report completed by a psychiatrist dated 5/6/16, revealed a recommendation for [MEDICATION NAME] 25 mg (milligrams) twice a day with a notation that the dose may be increased to three times per day if the benefits are unsustained. Review of Medication Administration Records (MARs) dated 5/2016 to 4/17/18 revealed the resident received [MEDICATION NAME] 25 mg twice daily. Review of the Comprehensive Care Plan (CCP) dated 1/23/18 revealed a Focus area for Psychosocial Well-Being documented that the resident has the potential for alteration in mood and behavior patterns related to dementia with behaviors, agitation, and neurocognitive disorder with behavior disturbances. The CCP documented that the resident calls out and refuses care routines at times. No alteration in psychosocial well-being. CCP interventions include: Psychiatric consult per MD order; preserve familiarity and build relationships; social activities; monitor mood/behavior for changes; respond to behaviors with diversions such as redirect thoughts, provide one to one in short term intervals; and administer [MEDICAL CONDITION] medication per MD order. The CCP documented [MEDICAL CONDITION] medication - GDR clinically contraindicated for [MEDICATION NAME]. Review of Social Work [MEDICAL CONDITION] Medication Reviews dated 4/3/17 through 4/4/18 revealed Behaviors were not exhibited. Review of Behavior Monitoring Records, located in a binder containing CNA (certified nurse aide) documentation dated 12/2017 through 4/2018 revealed the resident displayed behaviors including Disruptive Sounds, i.e. yelling during the day shift on 3/11/18, 3/16/18, 3/17/18 and Refused Care during the day shift on 3/22/18. Review of a Physician's Progress Note dated 2/26/18 revealed the Patient has been stable, but continues with periods of calling out in a disruptive non-stop manner. She is calm and quiet today. The patient has good days and bad days, adequately controlled, but unable to consider GDR of medication because she still has episodes of calling out, which is disruptive to others. Review of Nursing Progress Notes from 3/1/18 through 4/11/18 revealed there was no documentation of behaviors. Review of a History and Physical, completed by the Physician, dated 3/26/18 revealed no new problems were noted by staff, although the resident still has occasional episodes of calling out in a loud voice. The Physician documented the resident has advanced dementia with behaviors that are disruptive at times and she is unaware that her verbal outbursts and yelling disrupts the nursing unit. Patient needs [MEDICATION NAME], with no GDR, because of these episodes. Review of a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Observation on 4/9/18 at 11:13 AM revealed the resident was sitting in her wheel chair in front of the Unit C Nurses' Station quietly calling help, help, help. The Licensed Practical Nurse (LPN #3) Unit Coordinator (UC) approached the resident, who asked if it was time to eat. The LPN UC offered the resident to attend the activity, and transported the resident to activities. Observation 4/10/18 at 11:22 AM revealed the resident was sitting in front of the Unit C Nurses' Station and called out help, help. A Certified Nurse Aide (CNA #5) approached the resident, asked her if she was hungry, and offered her a drink. On 4/13/18 at 10:39 AM, the resident was observed in the Unit C lounge watching a television game show and quietly called out help two times. CNA #5 offered the resident a shower and transported the resident into the shower. During an interview on 4/12/18 at 10:15 AM, CNA #5 stated the resident is known to call out occasionally and she is usually easily redirected by offering activities, taking her for a stroll around the units or doing one on one for a short time. During an interview on 4/12/18 at 10:48 AM, CNA #4 stated the resident typically calls out after lunch when she wants to lie down or needs to be changed. The CNA stated as long as her needs are met, She's fine. During an interview on 4/12/18 at 1:57 PM, the LPN (#3) UC stated the resident has a short attention span and does not stay in activities for long periods of time. I believe the calling out is Attention Seeking. The LPN UC stated the resident has good days and some bad days. Medications are reviewed with the Interdisciplinary Team (IDT) monthly. The LPN UC then stated the resident has been stable and the Physician was hesitant to decrease the [MEDICATION NAME] because it took so long to get her stable on the medication. During interview on 4/12/18 at 2:16 PM, the Physician stated the resident was a patient of his when she was in the community. When patients are started on an antipsychotic, he typically will wait 6 months before he revaluates the medication and will determine if a GDR is desired. The Physician stated in this case, The resident calls out. The staff are not charting on things that become the norm and do not document her inappropriate behaviors. The Physician stated when he's on Unit C, the resident will repetitively call his name and It's disrupting to me. Her calling out is disruptive to others and can potentially be harmful to her. During an interview on 4/13/18 at 3:03 PM, the Social Worker stated the resident typically calls out until her needs are met, she will start to call out as soon as you help someone else, and referred to the resident's behaviors as attention seeking. The Social Worker then stated the resident's behaviors have been well controlled and did not think it was necessary to do a GDR, as long as the Physician documents the benefits versus the risks. During a telephone interview on 4/14/18 at 8:52 AM, the Pharmacy Consultant stated she requested a GDR for the [MEDICATION NAME] in (MONTH) of (YEAR) because she identified that the resident had been stable for some time. The Physician disagreed with her, stating it was difficult to control her behaviors and was against making medication changes. The Pharmacy Consultant stated that she reviews the medical record, electronic health record, labs (laboratory tests), and nurse's notes for behaviors. The Pharmacy Consultant was unaware of the CNA behavior documentation kept in a binder on the nursing units. She'll make recommendations based on her review and one copy will go into the chart, one copy to the Nursing Supervisor and the Supervisor will give it to the Unit Coordinator. The Pharmacy Consultant stated that when a Physician disagrees with her recommendations, she will just leave it alone. It's self-defeating. 415.12(l)(2)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed on 4/16/18, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in the choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, two (Residents #109, 206) of five residents reviewed for activities had issues involving the lack of available activities on the Subacute Unit and lack of staff assistance to attend activities off the unit. The findings are: Review of a facility policy and procedure (P&P) entitled Activity Department Philosophy dated 11/2016 revealed The Activities Department is to maintain an effective recreation service, which will provide the incentive and opportunity for the resident to utilize fully his mental and physical ability, and to make his leisure time both productive and enjoyable. It is also our responsibility to assist the resident in making an adjustment to a changing environment. The facility P&P entitled Activity Attendance Record dated 11/2009 revealed that the Attendance Record is used to monitor resident participation in activity programming as indicated on the resident's care plan and measurable goals. 1. Resident #109 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS - a resident assessment tool) dated 3/6/18 revealed that the resident was cognitively intact and section F- Preferences for Customary Routine and Activities documented that the resident stated it is very important to do their favorite activities. Review of a physician's orders [REDACTED].>The facility Activities Personal Preference Interview dated 3/5/18 documented that the resident answered, very important when asked how important is it to you to do things with groups of people? and How important is it to you to do your favorite activities? The Interview revealed the resident preferred pet visits, Catholic religious activities, and keeping up with the news. The resident's current undated Comprehensive Care Plan (CCP) for Leisure Time Activities documented a plan for the resident to participate in religious services one to two times a week; one on one visits four to five times a week; leisure time activities four to five times a week on the unit; and be involved in large group leisure time activities one to two times a week through the next review. Further review revealed the resident was admitted for Subacute care and was independent with wheel chair mobility and within hands reach ambulation in the corridor. The current undated Certified Nurse Aide (CNA) Bedside Kardex Report revealed the section for Leisure Time Activities documented that staff will provide transport assistance/verbal direction to LTA's (leisure time activities) of interest. During an interview on 4/9/18 at 1:03 PM, the resident stated there were no activities on the Subacute unit and that you have to wheel yourself to the other units to do activities. On 4/11/18 at 11:02 AM, the Activities Director was heard to state They (the residents) have therapy in rehab so they don't really have activities. Review of the Activities Attended by sheet dated (MONTH) 27, (YEAR) to (MONTH) 13, (YEAR) revealed that Resident #109 attended 17 activities and there were no activities noted on six weekends. Further interviews with the resident on 4/12/18 at 10:35 AM and 4/13/18 at 8:57 AM revealed there were no activities for residents on the weekends and no one has invited her to go to activities. She also stated that the print is so small on the activity calendar that she couldn't read what activities were there. The resident stated that sometimes staff come by to tell her about activities, but it's hard to roll there (other units). Observation on 4/12/18 at 1:15PM revealed there was a Communion activity with the facility pastor. Resident #109 did not attend this activity. Interview with the Activities Director on 4/13/18 at 9:31 AM revealed that she believes that the Activities Department should put more programs on the Subacute unit. She stated that we used to do activities down there and only one or two people would show up. She then stated that she was surprised people complained about the lack of activities. We will try to get more activities down there. 2. Resident #206 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed that the resident was cognitively intact and section F- Preference for Customary Routine and Activities documented that the resident stated that it was somewhat important for them to do their favorite activities. During an interview on 4/10/18 at 10:18 AM, the resident stated there were no activities on the Subacute Unit and that if you wanted to participate, you had to go to the other units. Review of a physician's orders [REDACTED]. An Activities Personal Preference Interview dated 2/21/18 revealed that it was very important for the resident to attend activities with groups of people, keep up with the news, have books and newspapers to read, and to do their favorite activities. The current undated CCP for Leisure Time Activities documented a goal for the resident to attend large group activities one to two times a week; be involved with unit activities four to five times a week; and participate in religious services/communion one to two times a week through the next CCP review. Review of the current undated CNA Kardex Bedside Report revealed that the section for Leisure Time Activities documented that staff will provide transport assistance/verbal directions to activities of interest to the resident. The Activities Attended by sheet for the resident dated 2/20/18 to 4/16/18 revealed that the resident attended 17 activities and there were no activities noted for eight weekends. Interview with the Unit Clerk on 4/11/18 at 12:35 PM revealed that they do have DVD players on the unit that the resident can use, but the residents have to ask for them. Interview with the resident on 4/11/18 at 1:35 PM revealed that most mornings she is in therapy and can't attend morning activities. She also stated that there is nothing to do here on the weekends and they don't even have movies to watch. She stated the only activity they have in the evening was Bingo and that is only for old people and I ain't old. The resident stated that she didn't know that they have DVD's to watch. 415.5(f)(1)(i,ii)

Based on observation, interview, and record review conducted during the Standard survey completed on 4/16/18, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. One (Resident #32) of five residents observed for implementation of care related to saftey lacked the planned intervention for Dycem (non-slip, self-adhesive mat) in the -wheelchair. The finding is: The facility policy and procedure entitled Interdisciplinary Care Planning revised 5/2017 revealed the comprehensive resident-centered care plan is developed by the interdisciplinary team upon admission and reviewed/ updated on a regular basis. 1. Resident #32 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS - a resident assessment tool) dated 1/19/18 documented the resident had severe cognitive impairment, usually understands, is usually understood. Additionally, the MDS documented the resident required the assistance of two people for bed mobility, and transfers. The MDS documented the resident had one fall. Review of the Continuous Quality Improvement Report dated 12/22/17 revealed the resident bent over in the wheelchair and slid onto floor. Dycem was added to the wheelchair cushion to prevent further re-occurrence. Review of the Comprehensive Care Plan (CCP) dated 1/30/18 revealed the resident has had falls. Interventions included, Dycem (non-slip, self-adhesive mat) to wheelchair; not to be left alone in bathroom; remind to call for assist; low bed; nonskid shoes/ slippers; falls risk tool. Review of the Bedside Kardex Report (a guide used by staff to provide care) dated 4/12/18 revealed the following safety interventions: Arm protectors and or long sleeves at all times; Dycem to wheelchair; House lotion to both upper and lower extremities; Long pants on at all times; Monitor skin for changes; Nonskid shoes/ slippers; Not to be left alone in the bathroom. During an observation on 4/12/18 at 9:14 AM, Certified Nurse Aide (CNA #5) reviewed the bedside Kardex report for the resident. CNA #4 & CNA #5 then transferred the resident into the wheel chair with a pressure reducing cushion. There was no Dycem in the wheel chair. During interview on 4/12/18 at 9:30 AM CNA #5 stated she reviewed the Kardex but did not realize the Dycem was not in the wheel chair. CNA #5 then stated Dycem is typically used to prevent sliding out of wheel chairs and stated she would go to Occupational Therapy to get another Dycem because she was unable to locate the Dycem in the room. During additional observation on 4/12/18 at 11:38 AM CNA #4 & CNA #5 assisted the resident to a standing position from her wheel chair and placed a new piece of Dycem onto the pressure reducing cushion in the wheel chair. During interview on 4/13/18 at 11:06 AM the Director of Rehab stated the Nursing Supervisor implemented the Dycem after the fall. During interview on 4/13/18 at 11:19 AM the Registered Nurse (RN #2) stated the Dycem was implemented secondary to a fall out of the wheel chair and stated she obtained the Dycem from Occupational Therapy on a weekend and personally added it to the Care Plan and the wheel chair to prevent reoccurrence. During interview on 4/13/18 at 11:28 AM the Licensed Practical Nurse (LPN #3) stated the Dycem should have been in place. The CNA's are expected to read the entire Kardex prior to starting care to make sure safety devices were in place. If the Dycem was not in place, the CNA should have notified the Unit Coordinator prior to transferring the resident into the wheel chair. The LPN stated she was unaware the Dycem was missing. During interview on 4/16/18 at 9:15 AM the Director of Nurses (DON) stated, Dycem to a wheel chair is utilized typically to prevent falls. The expectation was for the CNA's to thoroughly review the Kardex prior to care to ensure all safety devices are in place. 415.11(c)(3)(ii)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/22/16, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Four (Units A, B, C, D) of five resident units observed for a safe environment had an issue involving electric heaters in resident rooms with metal surfaces that were extremely hot to the touch and not shielded from resident access. Residents #130, 201, and 261 were involved. The findings are: 1. Observations on Units A, B, C, and D on 12/21/16 from approximately 11:35 AM until 1:15 PM revealed resident rooms had electric baseboard heaters installed. The electric baseboard heaters measured six to eight feet long by approximately five inches high by three inches deep and were installed so the bottom of the unit was approximately three inches above the floor. Continued observations during this time revealed the electric baseboard heaters in ten of 29 resident sleeping rooms (seven resident rooms had two separate electric baseboard heaters that were each measured) had metal surfaces that were extremely hot to the touch. Additionally, all of the heaters were easily accessible to residents, families and staff and had no shielding from the metal. During this time period, the following surface temperatures of electric baseboard heaters were measured by the Environmental Services Manager using the facility's laser type infra-red thermometer in the following rooms: Unit A - Resident Room # 201 R - 159 F (degrees Fahrenheit) Resident Room # 202 R - 156 F Resident Room # 204 L - 150 F Resident Room # 205 R - 165 F Resident Room # 206 L - 153 F Resident Room # 36 P - 164 F Unit B - Resident Room # 20 P - 140 F Unit C - Resident Room # 100 P - 164 F Unit D - Resident Room # 91 P - 151 F Resident Room # 88 P - 141 F Continued observation during this time revealed the electric baseboard heaters in the Bump-out Units (new rooms added to the unit) were controlled by a dial-type thermostat on the heater and the electric baseboard heaters in the main part of the facility were controlled by a wall-mounted dial-type thermostat, both types were accessible to residents. Interview with the Environmental Services Manager on 12/21/16 at approximately 11:40 AM revealed the main source of heat for the building is a rooftop electric heating units and the electric baseboard heaters in Units A, B, C, and D provide supplemental heat. 2. a. Resident #130 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- resident assessment tool) dated 11/1/16 revealed that the resident is cognitively intact and sometimes understands and is usually understood. Review of a Visual/Bedside Kardex Report (guide used by staff to deliver care) dated 12/21/16 revealed the resident requires a total mechanical lift with the assistance of two people for transfers, is non - ambulatory and requires contact assist of two staff members for bed mobility. During an interview on 12/20/16 at approximately 1:04 PM, the resident stated she was afraid that she would fall out of her bed onto either the floor (on one side) or the heater (the other side). During an observation at the time of the interview the resident's bed was positioned approximately six to eight inches from the heater. Upon touching the heater, the metal casing was found to be extremely hot to the touch. During an additional interview on 12/21/16 at approximately 11:45 AM, the resident stated the heater had burned a large plastic tote of hers last year. Observation of Resident #130's room, a semi-private room located on the A Unit Bump-out, on 12/21/16 at approximately 12:12 PM revealed the top guard of the electric baseboard heater's metal casing was hot to touch and measured 156 degrees Fahrenheit. During an interview at the time of the observation, the Environmental Services Manager stated that's hot. b. Resident #201 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment sometimes understands and is sometimes understood. Review of a Fall Risk Assessment Tool dated 11/29/16 revealed that the resident has confusion, poor safety awareness, forgets to ask for assistance, ambulates with a device, has gait balance issues, has agitation/behavior issues and is non-compliant with care plans. Review of the Comprehensive Care Plan dated 11/3/16 revealed that the resident attempts to self-transfer and uses a rolling walker and wheelchair for transport and is planned for ambulation assistance of two staff members. The Care Plan also documented that the resident is a fall risk and requires reminders to call for assistance. Observation of Resident #201's room, a private room located on the B Unit, on 12/21/16 at 1:01 PM revealed the wall-mounted dial-type thermostat was set for 65 degrees Fahrenheit and the top guard of the electric baseboard heater's metal casing was hot to touch and the temperature was 140 degrees Fahrenheit. The surveyor needed to remove her hand after two to three seconds due to excessive heat from the top of the heater casing. c. Resident #261 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment and usually understands and is usually understood. Review of a Fall Risk Assessment Tool dated 9/27/16 revealed that the resident has poor safety awareness and forgets to ask for assistance. Review of the Comprehensive Care Plan dated 11/8/16 revealed that the resident transfers with a rolling walker, and has planned intervention to ambulate in her room and corridor with the assistance of two staff. The Care Plan also documented that the resident is a fall risk and requires reminders to call for assistance. Observation of Resident #261's room, a semi-private room located on the A Unit Bump-out, on 12/21/16 at approximately 12:25 PM revealed the top guard of the electric baseboard heater's metal casing was hot to touch and temperature was159 degrees Fahrenheit. 415.12(h)(1)

Based on interview and record review conducted during the Standard survey completed on 12/22/16, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Two (Residents #348, 361) of five residents reviewed for unnecessary medications had issues involving the lack of documented non-pharmaceutical interventions prior to the administration of injectable antipsychotic medication and an anti-anxiety medication. The findings are: 1. Resident #348 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (minimum data set-assessment tool) dated 7/11/16 revealed the resident was cognitively intact and had verbal behaviors directed toward others occurring one to three days during the assessment period. Review of the physician's orders [REDACTED]. - 7/10/16 - [MEDICATION NAME] (antipsychotic medication) 0.5 mg (milligrams) IM (intramuscular-in the muscle) every eight hours prn (as needed) - 7/23/16 - Discontinued [MEDICATION NAME] - 7/26/16 - Start [MEDICATION NAME] 0.5 mg IM every eight hours prn Review of the Medication Administration Record [REDACTED] - 7/13/16 at 1:53 AM and 10:25 PM - 7/20/16 at 5:27 PM - 7/27/16 at 8:46 PM - 7/30/16 at 8:45 PM - 7/31/16 at 8:11 PM Review of the physician's progress notes revealed the following: - 7/11/16 revealed the resident had uncontrollable aggressive behavior, controlled with [MEDICATION NAME] on 7/10/16. Condition has been the same. - 7/19/16 the residents pain is controlled, attending physical and occupational therapy, reports of associated sun downing. - 7/23/16 started [MEDICATION NAME] on 7/20/16 for behavioral problems, evaluated by Psychiatry on 7/21/16, recommended discontinuing [MEDICATION NAME] and cautioned about [MEDICATION NAME] use. The resident's condition has been the same since last visit. No medication side effects noted, pain is controlled. - 7/27/16 [MEDICATION NAME] was restarted on 7/26/16, condition has been uncontrolled, no medication side effects noted, has been remittent since last visit. Review of the 24 Hour Nursing Services Supervisor Report dated 7/12/16 11-7 shift revealed resident had behavior issues, [MEDICATION NAME] 0.1 ml IM given. There are no documented non - pharmacological interventions prior to administering the medication. Review of a Progress Note dated 7/13/16 at 7:35 AM written by the night shift LPN (Licensed Practical Nurse) revealed, Resident alert with confusion, able to makes needs known. Administered [MEDICATION NAME] 0.1 ml IM for agitated, restlessness, yelling out, and positive effect. There are no documented non - pharmacological interventions prior to administering the medication. Review of a Progress Note dated 7/27/16 at 10:59 PM written by the GN (graduate nurse) revealed, the resident was noted to have increased agitation, was striking out at staff at hs (hour of sleep). PRN [MEDICATION NAME] given with positive effect. Resident sleeping in bed at this time. There are no documented non - pharmacological interventions prior to administering the medication. During an interview on 12/21/16 at 2:22 PM, the Registered Nurse (RN#3) Unit Coordinator stated the staff should document what else they tried to do before the [MEDICATION NAME] and what other interventions you did before you think they needed the medication. During an interview on 12/22/16 at 9:15 AM, the Director of Nursing (DON) stated that she expects staff to document interventions before giving the prn medication. The DON further stated they have a BMAR (behavior monitoring flowsheet) where they document interventions. review of the resident's medical record revealed [REDACTED]. During an interview on 12/22/16 at 11:40 AM, the Administrator stated they cannot find the BMAR documentation for July and August for this resident. Review of the policy entitled Psychopharmacological Initiation and Gradual Dose Reduction revised 2/09 revealed non - pharmacological approaches are trialed prior to psychological medication initiation, including but not limited to: providing a quiet environment; predictable routine; identifying and removing precipitants to agitation, activity participation, psychiatrist/ psychologist consultation, social services consultation. Documentation on the Behavior Monitoring record is completed for at least two weeks after initiation of pharmacological medication. 2. Resident #361 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired. The MDS further documented the resident experiences inattention and disorganized thinking which fluctuates. Review of the current comprehensive care plan revealed the resident has a potential for alteration in mood and behavior pattern related to dementia with behaviors, anxiety, agitation, and a neurocognitive disorder with behavior disturbances. Interventions included Respond to behaviors with the following diversions/ approaches: redirect thoughts, provide one to one in short term intervals. Review of the physician's orders [REDACTED]. - 5/1/16 - [MEDICATION NAME] ([MEDICATION NAME], antianxiety medication) 0.25 mg (milligrams) twice a day PRN for anxiety - 5/2/16 - [MEDICATION NAME] 0.25 mg three times a day PRN for anxiety - 5/7/16 - [MEDICATION NAME] 0.25 mg (milligrams) every 12 hours PRN for anxiety Review of the MARs (medication administration record) from 5/1/16 through 12/21/16 revealed the resident received PRN [MEDICATION NAME] on the following dates: - May 1st x 2, 2nd , 3rd x 2, 13th , 15th , 20th , 23rd and 31st - June 3rd, 6th and 21st - July 2nd, 10th, 24th, 27th, 28th x 2 and 31st - August 26th - September 24th - November 15th and 25th - December 18th, 20th and 21st Review of the Progress Notes dated 5/6/16 through 12/21/16 revealed no documentation that non-pharmacological interventions were attempted prior to administering [MEDICATION NAME]. Review of Unit D Behavior Monitoring Book revealed there were no behavior monitoring records for resident #361. During an interview on 12/22/16 at 7:49 AM, RN #3 Unit Coordinator stated, if the resident becomes anxious the resident is checked for pain, toileted, and given snack, etc. She further stated that behaviors are to be documented on the behavior monitoring sheets. She reviewed the Behavior Monitoring Book and the resident's medical record in the presence of the surveyor and stated that there were no behavior monitoring sheets for the resident. 415.12 (l)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/22/16, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. Three (Residents #143, 216, and 363) of thirty nine residents medical records reviewed for accuracy had issues involving the lack of documented evidence of: a Registered Nurse (RN) assessment, Physician and family notifications, psychosocial and physical monitoring after an incident of non-consensual physical contact (#363). In addition, the lack of documented evidence the facility provided health education (#143); and the lack of documented evidence that meal and fluid intakes were monitored for three days (#216). The findings are: 1. Resident #363 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/26/16 revealed the resident is severely cognitively impaired, usually understands, and is usually understood. Review of the facility reported complaint (Complaint #NY 206) revealed Resident #363 was observed by staff, in non - consensual physical contact with another resident on 11/10/16. Both of the residents lacked capacity to be consenting adults. Review of Progress Notes dated 11/8/16 through 11/18/16 revealed there was no documented evidence of the incident. Review of the Progress Notes and Evaluations dated 11/8/16 through 11/18/16 revealed there was no documented evidence that a RN assessment of the resident was completed upon the discovery of the incident. Review of the Progress Notes dated 11/8/16 through 11/18/16 revealed there was no documented evidence the residents Physician or responsible party was notified was notified of the incident. Additional review of the Progress Notes dated 11/8/16 through 11/18/16 revealed there was no documented evidence of ongoing monitoring of the resident's psychosocial and physical well-being. Interview with the Director of Nursing (DON) on 12/22/16 at approximately 7:26 AM revealed the expectation is that a description of the incident and a physical head to toe RN assessment of the resident to be documented in the electronic medical record (EMR). Interview with the Medical Director on 12/22/16 at approximately 9:01 AM revealed, he was notified of the incident either the night of the incident or first thing in the morning. There were no reported injuries to the resident and there did not appear to be any adverse effects from the incident. Interview with the residents responsible party on 12/22/16 at approximately 9:10 AM revealed, the responsible party was notified of the incident and came to the facility for a meeting with the staff. Review of facility policy titled Abuse Reporting and Facility Incident Reporting revision date 11/2016, included the following: - Sexual Abuse. Resident to resident. Non-consensual sexual intrusion or penetration. - Upon receiving reports of abuse, the supervisor immediately [MEDICATION NAME] the resident. Findings of the examination are recorded in the resident's medical record. 2. Resident #143 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understood, and usually understands. The resident was observed on multiple occasions on 12/16/16 and 12/19/16 between 8:00 AM and 3:00 PM ambulating independently throughout the facility with a rolled walker and approximately one foot of the Foley catheter (tube inserted into the bladder to drain urine) tubing dragging on the ground. Interview with the Assistant Director of Nursing (ADON) on 12/16/16 at approximately 12:45 PM revealed, We have spoken with the resident on multiple occasions but she refuses a leg bag and insists on allowing the tubing to drag on the ground. Interview with the RN #1 Unit Coordinator (UC) on 12/20/16 at approximately 10:22 AM revealed, We have attempted to use a leg bag but the resident refuses. She has requested the Foley be worn the way it is and refuses any intervention. The interview further revealed, We have provided education to the resident on the risk for infection to travel up the catheter tubing from dragging on the ground, and we also have educated the resident on the tripping hazard, but she still insists on having the tubing drag on the ground. Review of Progress Notes 1/1/16 through 12/15/16 revealed no documented evidence of any education provided to the resident regarding the infection control risks and accident risks associated with Foley catheter tubing dragging on the ground. 3. Resident #216 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Review of the Nutritional Screen/ assessment dated [DATE] revealed the resident received a regular consistency house diet. The resident's is height is 4' (feet) 11 (inches) and current weight is 85.6 pounds. Laboratory (lab) results (obtained from hospital) were documented as BUN (blood urea nitrogen - blood test to determine kidney function and hydration status) was 15 (normal 5-31) and creatinine was 0.73 (blood test to determine kidney function) (normal 0.40-1.60). The resident's estimated fluid needs based on actual body weight is [PHONE NUMBER] ml (milliliters) per day. The dietary assessment also documented the resident was at risk for dehydration secondary to diuretic use. Fluids to be provided at a minimum of 1800 mls daily with meals plus additional fluids offered between meals and with medication pass. Review of a dietary note dated 8/22/16 revealed laboratory data was obtained on 8/19/16, and the results were positive for [MEDICAL CONDITION] ([MEDICAL CONDITION], infectious diarrhea). A physician's orders [REDACTED]. The resident is at risk for dehydration due to; antibiotic therapy. Fluids are provided at a minimum of 1800 ml daily with meals, plus a water pitcher in room. Hydration protocol is up to the MD's (medical doctor) discretion. Review of a Hematology report (laboratory results of the blood) dated 8/23/16 revealed the resident's BUN was 87 and creatinine was 1.83. Review of the Documentation Survey Report dated August 2016 revealed the nutrition/ meal consumption section was blank for all meals from 8/21/16 - 8/23/16. Review of the untitled document dated 7/16/16 - 7/31/16 revealed fluid intakes with medication pass and nourishments were documented by each shift. There is no documentation of fluid intakes with med passes and nourishments for August 2016. Review of a Progress Note dated 8/23/16 at 10:59 PM revealed the MD was updated on the lab results and vital signs with new orders to infuse IV (intravenous) bolus fluids, recheck vital signs and lung sounds. The bolus was given and the MD was updated on blood pressure, new order to send to hospital. Review of a physician's orders [REDACTED]. During an interview on 12/22/16 at 9:58 AM, the RD (Registered Dietician) stated nursing puts in (documents) the I and O's (intakes and outputs). This residents intakes varied but were stable. Her weights were monitored weekly and they were stable. She was provided more than enough fluids compared to her estimated needs and they can't force a resident to drink them. The RD further stated we are very careful about what we ask for here, some doctors don't like residents to be encouraged to drink fluids if they are on diuretics and some do, so it's up to the doctor about starting the hydration protocol. During an interview on 12/22/16 at 9:39 AM, the LPN #2 Unit Coordinator stated that they had an I and O sheet at that time. I don't think we had (computer software name), we used a sheet that was kept with the MAR (medication administration record). When showed the meal consumption record from August 2016 (from their electronic medical record-EMR) LPN #2 stated that looks like something dietary should fill out, I've never seen this before. When told it was from the EMR, the LPN stated the nurses or the aides put the meal intakes into the computer. When showed the untitled fluid intake and med pass and nourishment flowsheet dated for July 16-31, the LPN stated that the nurses fill that out. During an interview on 12/22/16 at 10:10 AM, the LPN Clinical Instructor stated I don't know why there are no intakes documented for the last couple days of her admission, there are nurse's notes on those days, so the resident was still here at that time. The LPN Clinical Instructor further stated they reviewed the 24 hour reports for this resident and there is nothing documented about intakes. During an interview on 12/22/16 at 10:48 AM, the Director of Nursing (DON) stated the nurses are supposed to make sure the resident's intakes are documented. 415.22 (a) (1,2)

Based on observation, interview and record review conducted during the Standard survey completed 10/8/14, the facility did not ensure that it is free of medication error rates of five percent or greater. There were two errors (Residents #73, 222) for 28 residents observed for medication errors due to medications not administered per Physician Orders. This resulted in a medication error rate of 7.1428% (percent). The issue involved the administration of the wrong dose of medication (Resident #222) and a medication administered at the wrong time (Resident #73). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #73 had [DIAGNOSES REDACTED]. During an observation on 10/6/14 at approximately 9:33 AM the Licensed Practical Nurse (LPN) was observed to administer medications to Resident #73. The LPN administered one scoopful of Cholestyram powder (a drug used for reducing cholesterol levels in the blood) in cranberry juice, [MEDICATION NAME] (medication used to treat hypertension) 5 milligrams (mg) one tablet, [MEDICATION NAME] (iron supplement) 325 mg one tablet, [MEDICATION NAME] (multivitamin) one tablet, [MEDICATION NAME]/hctz (water pill used to treat hypertension and swelling) 75 mg / 50 mg one half tablet, Vitamin C 500 mg one tablet, [MEDICATION NAME] (Tylenol-pain/fever) 325 mg two tablets, [MEDICATION NAME] (Klonopin - [MEDICAL CONDITION] medication used to treat anxiety and panic attacks) 0.5 mg one tablet, and [MEDICATION NAME] (medication used to treat hypertension) 100 mg one half tablet. Review of a Physician order [REDACTED]. Give other medications one hour before or four hours after dose. Review of the medication administration record (MAR) dated 10/1/14 through 10/31/14 revealed the Cholestyram powder was timed to be given at 9:00 AM, along with [MEDICATION NAME], [MEDICATION NAME]/hctz, Vitamin C, [MEDICATION NAME], and [MEDICATION NAME]. During an interview on 10/6/14 at approximately 9:58 AM the LPN reviewed the MAR and stated "I always give them together". The LPN also stated that all of the medications are timed for 9:00 AM on the MAR and that "the Cholestyram should be given separately". 2. Resident #222 has a [DIAGNOSES REDACTED]. During a medication administration observation on 10/6/14 at approximately 8:37 AM the LPN was observed to administer [MEDICATION NAME]-S (medication to treat constipation) 8.6 mg one tablet. Review of the Physician order [REDACTED]. Review of the MAR dated 10/1/14 through 10/31/14 revealed the resident was to receive [MEDICATION NAME]- S two tablets. During an interview at approximately 9:00 AM the LPN said "Oh, I will go give another one right now." Review of a facility policy and procedure entitled General Information About Drug Administration dated 9/2014 revealed using the MAR, check it against the prescription label identities: name, room number, name of the mediation, dosage, and time of administration. Administer all the medication for the administration time to the resident. 415.12 (m)(1)

Based on interview and record review conducted during the Standard survey completed 10/8/14, the facility did not provide the necessary care and services to maintain a resident's highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #253) of one Hospice resident reviewed for quality of care did not have blood work obtained per the Physician's Order. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is; 1. Resident #253 has a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 9/17/14 revealed the resident is severely cognitively impaired, is usually understood and sometimes understands. Review of a Physician Order dated 6/18/14 revealed the resident had a decrease in [MEDICATION NAME] (cardiac medication to treat an irregular heart rate) to 62.5 mcg (micrograms) po (by mouth) every day. Review of a Physician Order dated 9/23/14 revealed an order for [REDACTED]. Review of the laboratory (lab) results dated 10/2/14 revealed results for the BMP but not for the [MEDICATION NAME] Level. Review of the unit's lab log book revealed no [MEDICATION NAME] Level had been drawn on 10/2/14 or was scheduled to be drawn. Review of the resident Comprehensive Care Plan dated 9/23/14 revealed Problem - cardiac conditions A-Fib with Approach - laboratory tests per Physician's Orders. During an interview on 10/3/14 at approximately 2:38 PM the Registered Nurse (RN) Unit Manager reviewed the Physician's Orders and the unit lab log book. The RN stated the [MEDICATION NAME] Level was missed and not drawn. The process is that when the Physician orders a lab, the nurse transcribing the order would write the lab to be drawn on the calendar and a unit secretary would complete the lab requisition form. The RN reviewed the calendar and said the BMP was documented but not the [MEDICATION NAME] Level. The RN stated she would call the lab and have the [MEDICATION NAME] Level drawn "right away". Review of the facility policy entitled Laboratory Services dated 6/2006 revealed the lab slip is logged into the unit phlebotomy (lab) book and the lab work orders are double checked by the Nursing Supervisor. 415.12

Based on interview and record review conducted during the Standard survey completed 10/8/14, the facility did not ensure that Notices of Medicare Non-Coverage forms were signed by the beneficiary or the beneficiary's representative when Medicare coverage for skilled services were terminated. Two (Residents #97, 98) of three residents reviewed for notification of Medicare Non-Coverage and Liability Notice had issues involving the lack of the resident's or the resident's representative signature on the form and lack of documented evidence that the form was mailed to the representative following telephone notification. This was a pattern of no actual harm with potential for minimal harm. The finding is: 1. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 6/6/14 revealed the resident is cognitively intact. Review of a Notice of Medicare Non-Coverage form for Resident #97 revealed a determination that "Current Skilled Services" would end on July 11, 2014. The "Additional Information" section of the form documented that the resident's spouse was notifed by telephone on July 11,2014 that July 11,2014 was the "last covered day" and she was given appeal information during the call. The form also documented that on 7/11/14, the resident requested to be discharged on [DATE]. The signature of the resident or resident's representative (spouse)was not on the form and there was no documentation that the form was mailed to the representative. 2. Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had moderately impaired cognition. Review of a Notice of Medicare Non-Coverage form for Resident #98 revealed a determination that "Current Skilled Services" would end on July 10, 2014. The "Additional Information" section of the form documented that the resident's caregiver was notifed by telephone on July 8,2014 that July 10,2014 was the "last covered day" and the caregiver was given appeal information during the call. The form also documented that the resident was due to be discharged home on[DATE]. The signature of the resident's representative was not on the form and there was no documentation that the form was mailed to the representative following the 7/8/14 telephone call. During an interview on 10/7/14 at 2:00 PM, the Business Office Manager stated that they were told as long as the people are notified in some way, they don't really have to sign the forms. The Business Office manager stated she doesn't complete the Notice of Medicare Non-Coverage forms, she thinks the Social Workers do them. During an interview on 10/7/14 at 2:15 PM, the Social Worker on the E Unit stated that they get the signature when the resident stays in the building and they have Medicare days remaining. The Social Worker also stated that the people who get the Notice of Medicare Non-Coverage forms are in agreement with their discharge, so they don't have them signed. Review of the "Form Instructions for the Notice of Medicare Non Coverage" (NOMNC) CMS- dated 12/31/11 revealed for the signature line: "The beneficiary or representative must sign this line". 415.3(g)(2)(iii)

Based on observation and interview during the Standard survey completed 8/14/13, the facility did not ensure it is free of medication error rates of five percent or greater. There were two errors for 30 observed medication opportunities resulting in a medication error rate of 6.66% (percent). Issues involved not following the physician's orders [REDACTED]. In addition, a Licensed Practical Nurse prepared to crush and administer an extended release anti-hypertensive medication labeled "Do Not Crush". Residents #32 and 126 were involved. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. During medication administration observation on 8/8/13 at 10:14 AM, the Unit C Licensed Practical Nurse (LPN) Medication Nurse was observed to pour the following medications for Resident #32: - [MEDICATION NAME] (used to treat [MEDICAL CONDITION] bloating) chewable 80 milligrams (mg) 1 tab po (by mouth) before meals at 7:30 AM - [MEDICATION NAME] ([MEDICATION NAME]) 10 mg 1 tab by mouth (po) for hypertension at 9:00 AM - Aspirin (prevention of clot formation) 81 mg chewable one tablet for [MEDICATION NAME] at 9:00 AM - [MEDICATION NAME] 40 mg tab one tablet for hypertension at 9:00 AM - [MEDICATION NAME] 1 tablet po for allergies [REDACTED]. - [MEDICATION NAME] 10 mg one tablet BID (twice a day) at 9:00 AM and 9:00 PM - Nateglinide (used to treat type 2 diabetes) 60 mg one tablet BID at 9:00 AM and 5:00 PM - Vitamin B 12 (used to treat [MEDICAL CONDITION]) 1000 mg po at 9:00 AM - Senna S (used to treat constipation) 8.6-50 mg 1 tablet po bid at 9:00 AM and 5:00 PM - Isosorb [MEDICATION NAME] (medication used to treat high blood pressure) 20 mg 1 tablet 12:00 AM, 8;00 AM, 4:00 PM (Yellow sticker on blister pack Do Not Crush) [MEDICATION NAME] 100 mg ER 1/2 tablet (50 mg) by mouth BID for hypertension at 9:00 AM and 5:00 PM (Yellow sticker on blister pack Do Not Crush) The LPN Medication Nurse added applesauce to the medication cup and proceeded to the resident's room at approximately 10:28 AM, took the resident's blood pressure and stated "Your BP is 122/72". When the Medication Nurse handed the resident the medication cup with the medication and applesauce, the resident was observed to look in the medication cup and stated "They crush my pills". The Medication Nurse explained it says you take your pills whole in apple sauce. The resident refused to take the pills in apple sauce unless they were crushed. At 10:35 AM, the Medication Nurse stated that the sheet says she (the resident) gets the pills whole in apple sauce. At this time, the Medication Nurse discarded the medications in the trash on the medication cart. On 8/8/13 at 10:44 AM, the Medication Nurse was observed to repour the above medication into a medication cup, place it in a small plastic bag, and start to place the bag of pills in the pill crusher. The surveyor asked the Medication Nurse if she was going to crush the medications and give them to the resident and she said "Yes". The surveyor stopped the Medication Nurse from crushing the medications and asked the Medication Nurse to remove the blister packs (carded plastic packaging used to dispense individual doses of medication) from the medication drawer. The Medication Nurse removed the blister packs from the medication cart and observed the "Do not crush stickers on the packs". The Medication Nurse stated "I wonder how they have been giving these pills". She then was observed to remove the Senna S, Isosorb [MEDICATION NAME] and the [MEDICATION NAME] 100 mg ER 1/2 tablet (50 mg) and place them in a medication cup. She stated there are three pills I cannot crush and proceeded to crush the remainder of the medication and place them in apple sauce. The Medication Nurse stated the resident said she cannot take the pills whole and then said "I wonder if it is a preference that the resident does not take the pills whole". On 8/8/13 at 10:50 AM, the Medication Nurse reentered the resident's room and gave the uncrushed pills in applesauce to the resident. The resident again stated "I do not take them whole" and refused to take the pills. At 10:50 AM, the Medication Nurse was observed to administer the crushed pills in applesauce. When interviewed on 8/8/13 at 10:53 AM, the Medication Nurse stated she will document that the resident refused the uncrushed pills and she will tell the Charge Nurse. When interviewed on 8/8/13 at 1:55 PM, the Medication Nurse revealed pharmacy puts the yellow "Do not crush" sticker on the medication packs. She explained when the medication pack is labeled "Do not crush" the medication should not be crushed. When interviewed on 8/14/13 at 9:41 AM, the Dispensing Pharmacist revealed pharmacy put the yellow sticker "Do not crush" on the medication packs. He stated most Isosorb [MEDICATION NAME] cannot be crushed. He revealed this is the only one that can be crushed and the pharmacy tech must have automatically put the sticker on the package. The Dispensing Pharmacist stated the [MEDICATION NAME] tab 100 mg ER can be split but not crushed. He revealed the expectation would be when the medication blister pack is marked "Do not crush" the nurse should not crush it. He stated if the nurse crushes this medication you may see a drop in BP more than expected. After review of the other medications administered during the observed medication pass, the Pharmacist revealed there is a possibility that with the other hypertensive medications the resident is receiving at 9:00 AM that crushing this medication would theoretically enhance the reaction of lowering the resident's BP. When interviewed on 8/14/13 at 10:27 AM, the resident stated she remembered the surveyor from 8/8/13 and stated they have always crushed all her medication prior to that morning. She explained that is why she refused the pills that were not crushed. 2. Resident #126 has [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Observation on 8/13/13 at 10:30 AM revealed an LPN Medication Nurse administered [MEDICATION NAME] 2.5-500 to the resident. Interview with the LPN Medication Nurse on 8/13/13 at 10:44 AM revealed the resident usually eats breakfast in the dining room; however, she ate breakfast in her bedroom today and she missed giving the medication at the scheduled time. 415.12(m)(1)

Based on interview and record review conducted during the Standard survey completed on 8/14/13, the facility did not develop a comprehensive care plan to include measurable objectives to meet a resident's medical, nursing and psychosocial needs. One (Resident #408) of 23 residents reviewed for Care Plans did not have a care plan developed with parameters or alternatives for the use of an as needed medication for anxiety. Additionally there was no care plan to address the resident's antipsychotic medication. There was no actual harm with potential for more than minimum harm that is not immediate jeopardy. The finding is: 1. Resident #408 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 7/1/13 revealed the resident is cognitively intact. Review of a Hospital Discharge Summary dated 6/20/13 revealed recommendations for [MEDICATION NAME] (antipsychotic medication) 5 milligram (mg) ? tab daily at bedtime. Review of the History and Physical dated 6/21/13 revealed the resident denied any significant symptoms of current depression or anxiety. "Affect is calm. Memory and judgment appear to be grossly intact." Review of the physician's orders [REDACTED]. Review of the Physicians Progress Notes dated 6/27/13, 7/8/13, 7/20/13 and 8/3/13 does not address the resident's orders for [MEDICATION NAME] or [MEDICATION NAME]. Review of the "Sub Acute Plan of Care Inside Unit E" dated 6/20/13 revealed the resident had no cognitive impairment with approaches to monitor mood and behavior for changes and provide medication(s) per MD order. Review of the facility's untitled Medication Record dated 6/20/13 through 8/11/13 revealed [MEDICATION NAME] 2.5 mg q hs was administered daily from 6/20/13 to 8/11/13 and [MEDICATION NAME] 1 mg q 8 hours prn was administered on 7/2/13, 7/4/13, 7/5/13, 7/25/13, 7/26/13, 7/31/13 and 8/10/13. The Pharmacy Summary dated July 2013 revealed "no recommendations at this time." When interviewed on 8/13/13 at 1:02 PM, the Registered Nurse (RN) Sub Acute Manager stated the care plan for [MEDICATION NAME] and [MEDICATION NAME] should be under Social Work. After review of the Social Work care plan, she revealed [MEDICATION NAME] and [MEDICATION NAME] were not addressed on the care plan. The RN Sub Acute Manager stated the resident was getting the [MEDICATION NAME] PRN and [MEDICATION NAME] daily at bedtime. After review of the resident's medical record, the RN Sub Acute Manager stated there was a physician's orders [REDACTED]. The RN stated the resident received [MEDICATION NAME] in July and August and explained that the resident requests [MEDICATION NAME] when he gets anxious. The RN Sub Acute Manager stated "Yes" when asked if the resident should have a care plan for [MEDICATION NAME] and [MEDICATION NAME]. When interviewed on 8/13/13 at 2:22 PM, the Unit E Social Worker (SW) stated she would address cognition, [MEDICAL CONDITION] medications, advanced directives and smoking on the resident care plan. After review of the "Sub Acute Plan of Care Inside Unit E" dated 6/20/13, the SW stated she documented medication per MD order on the care plan. The SW stated there was no care plan for [MEDICATION NAME] and [MEDICATION NAME], but it was in her assessment. When interviewed on 8/14/13 at 2:42 PM, the Director of Nursing (DON) provided the Sub Acute Care Plan Review and Update and the Sub Acute Plan of Care Inside Unit E dated 6/20/13. Review of the documents did not reveal a care plan to address [MEDICATION NAME] or the prn [MEDICATION NAME] with parameters for administration or alternatives for use. 415.11(c)(1)