Every finding on record at Bayberry Nursing Home

Based on observation, record review and interview during the recertification survey from 07/15/2025 to 07/18/2025, the facility did not ensure each resident received necessary respiratory care in accordance with professional standards of practice for 1 of 2 residents (Resident # 35) reviewed for respiratory care. Specifically, Resident # 35 had a physician order dated 5/17/25 which documented oxygen via nasal cannula at 1 Liter per minute continuous and was observed receiving 4.5 liters of oxygen via nasal cannula. The findings include:An undated policy titled Oxygen Administration via Concentrator documented oxygen given via nasal cannula on concentrator may be performed by any qualified healthcare professional who has demonstrated the proper knowledge, skill and competency related to the use of the medical equipment and procedures involved. The procedure documented set the flow rate exactly as prescribed by the healthcare provider. Never change the rate without medical guidance. Concentrator use: set the oxygen flow rate as ordered by the physician. Resident # 35 was admitted with diagnoses including but not limited to systolic congestive heart failure, acute respiratory failure with hypoxia, and shortness of breath.The 2/11/24 Care Plan documented alteration in respiratory status related to congestive heart failure, respiratory failure, hypoxemia, systolic heart failure. Oxygen continuous via nasal prongs per physician order. The 5/17/2025 Physician order documented oxygen via nasal cannula at 1 Liter per minute continuous. The Annual Minimum Data Set (assessment tool) with reference date of 05/22/2025 documented Resident #35 had moderately cognitive impairment and received oxygen therapy.The Medication Administration Record dated July 2025 documented from 7/1/25 to 7/17/25 oxygen via nasal cannula at 1 Liter per minute continuous.On 7/15/2025 at 1:48 PM Resident #35 was observed in bed with oxygen via nasal cannula. The oxygen concentrator was on the floor next to their bed. The flow meter dial was observed at 4.5 Liters. The humidifier bottle was empty.On 07/16/2025 at 8:54 AM Resident #35 was observed in bed with oxygen via nasal cannula. The oxygen concentrator was next to their bed with the flow meter dial at 4.5 Liters. The humidifier bottle was full dated 7/16/2025. On 07/16/2025 at 1:16 PM Resident was observed in bed with oxygen via nasal cannula. The oxygen concentrator flow meter dial was at 4.5 Liters. During an interview on 7/16/2025 at 5:36 PM Certified Nurse Aide #1 stated they did not touch the oxygen concentrator flow meter at all. The nurses were responsible for oxygen as they knew how much the resident was supposed to have.During an interview on 07/16/2025 at 5:38 PM Licensed Practical Nurse #2 stated they were responsible for checking the oxygen to make sure the correct amount was administered based on the doctor's order. They stated they did not check the flow rate of the oxygen. Licensed Practical Nurse #2 stated although they documented in the Medication Administration Record for 1 Liter per minute of oxygen, they did not check the flow meter dial of the oxygen concentrator. During an interview on 07/17/2025 at 8:43 AM Licensed Practical Nurse/ Unit Manager #3 stated as the unit manager, they were ultimately responsible for making sure residents on oxygen therapy were receiving the correct amount of oxygen based on the physician's order. They stated they did not check the oxygen concentrator for Resident #35 and stated the resident was not receiving the correct amount of oxygen based on the doctor's order.NYCRR415.12 (k) (6)

Based on observation, record review and interviews during the recertification survey from 7/15/2025 to 7/18/2025, the facility did not ensure that food was stored in accordance with professional standards for food safety practice. Specifically, 1) Opened food that did not have expiration dates were observed in freezer #1 and 2) Expired marshmallows were observed in the dry storage room. The findings include:The Policy and Procedure titled Food Safety and Labeling last reviewed April 2025, documented food items with expiration dates or best by or use by dates should be discarded once the date has passed. Frozen foods must be labeled and dated and not stored for more than 6 months.During initial tour of the kitchen conducted with the Food Service Manager on 7/15/2025 at 9:26 AM the following were observed: The walk-in freezer #1 contained cheesecake which was opened and undated without an expiration date. A bag of jumbo stuffed shells did not contain an expiration date.The dry storage room contained a bag of Jet-Puffed mini marshmallows with a 5/17/2025 expiration date.During an interview on 7/15/25 at 10:05AM the Food Service Manager stated they were responsible for receiving and checking expiration dates of food. They stated once they received food, they put a label on the food which contained a receive date and checked every day for expiration dates. They stated they overlooked the expiration date for the bag of marshmallows and did not know the expiration date of the cheesecake.10NYCRR 415.14 (h)

Based on record review and interview during the recertification survey conducted from 7/15/25-7/18/25, the facility did not ensure an ongoing review of antibiotic use protocols and a system to monitor antibiotic use were completed for 1 of 1 resident reviewed for antibiotic stewardship. Specifically, for Resident #27 the facility was unable to provide an infection/antibiotic tracking report that ensured their antibiotic program was implemented to monitor antibiotic use protocols when an antibiotic was prescribed to a resident. The findings include:The policy titled Antibiotic Stewardship Program revised 4/2025 documented the facility shall work to ensure safe use of antibiotics and shall actively seek to minimize the appropriate use of antibiotics through ongoing assessment, education and leadership activities. Resident #27 had diagnoses including Type II Diabetes Mellitus, Depression and Seizures. The Physician Order dated 7/10/23 documented Bactrim DS oral tablet 800-160mg one tab by mouth at bedtime Mon, Wed Fri for urinary tract infection.There was no documentation on an antibiotic line list for Resident#27 who had been on long standing Bactrim antibiotic for the reviewed months of May, June and July 2025. During an interview on 07/17/2025 at 1:37 PM the Director of Nursing/Infection Preventionist stated the nurses wrote down the names of the residents who were on antibiotic/s. They stated they did not refer to the list for accuracy. When asked why Resident #27 was not on the May, June, July antibiotic list they stated they had not been checking the antibiotic list and was counting on the unit nurses to keep the record. They stated this was not a good system and they needed to be more involved with tracking of antibiotics.During an interview on 07/17/2025 5:35 PM the Administrator stated they were not aware of the antibiotic stewardship problem. They stated it needed to be addressed.10 NYCRR 415.19

Based on observations, interviews, and record review during the recertification survey from 5/22/2023 to 5/30/23, the facility did not ensure residents had a right to a dignified existence for one of 2 residents screened for dignity. Specifically, Resident #20 had a sign above the bed, on the wall, which contained instructions for staff about the resident's wounds and incontinence pads, which was visible from the roommate's side of the room. The findings are: The facility policy Resident Rights, revised 12/2022, documented the resident had the right to be treated with dignity, respect and consideration at all times and have a right to privacy in the treatment and care of personal needs. Resident #20 was admitted with diagnoses including dementia, pressure ulcers, anxiety, and weakness. The admission Minimum Data Set (MDS, an assessment tool), dated 05/16/2023, revealed the resident was cognitively impaired and needed extensive assistance of one person with bed mobility and dressing. The resident was dependent on staff for toileting and was incontinent of bowel and bladder. Resident #20 was observed on 5/24/2023 at 9:30 AM and 5/26/2023 at 10:16 AM, in bed with an 8-inch by10 inch hand written sign that noted Do not put dressing on her hips. Do not close her diaper while in bed. These wounds must be left open to air to heal- The Wound Team. The sign was visible from the resident's side of the room and the roommate's side including families, visitors, and staff. During an interview on 05/26/2023 at 10:23 AM, the Registered Nurse Unit Manager (RNUM) #1 stated they did not know how long, or who, put the sign on the wall at the top of Resident #20's bed. RNUM #1 stated it provided too much personal information and was a privacy issue. During an interview on 05/26/2023 at 1:41 PM, the MDS Coordinator #1 stated they made rounds with the wound Physician Assistant and was unaware of the sign above Resident #20's bed. The MDS Coordinator stated they would never put a sign up over a resident's bed as it contained private confidential information.

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion for 1 of 3 residents (Resident #9) reviewed for range of motion/position mobility. Specifically, Resident #9 was observed without the use of physician ordered hand splints. The findings are: The Policy and Procedure titled Assistive Devices effective 2008 documented all assistive devices including positioning devices, skin protection items and feeding supports were listed on the daily assignment sheet. Every shift assigned aide was to check that devices were in place as ordered. Resident #9 was admitted to facility 5/27/08 with diagnoses including but not limited to Aphasia, Non-Alzheimer's Dementia, and Spastic Quadriplegia. The 5/10/21 Physician Order documented right-hand and left-hand splints on at the beginning of day shift and removed at 11 PM by the evening shift. The 5/11/23 Quarterly Minimum Data Set (MDS) Assessment documented Resident #9 had severe cognitive impairment and had functional limitation in range of motion of the bilateral upper and lower extremities. There was no documented evidence in the April 2023 and May 2023 Treatment Administration Record (TAR) to address the application and removal of the right and left hand splints. There was no documented evidence in the May 2023 Certified Nurse Assistant Care Card Instructions to address the application and removal of the right and left hand splints. The 10/26/17 Care Plan titled Activities of Daily Living (ADL) Self-Care Performance Deficit with a 5/20/21 revision date documented apply left and right hand splints in the beginning of the day shift (by staff who has been in serviced) and removed at the end of the day shift. The 4/5/23 Occupational Therapy (OT) discharge note documented Resident #9 continues to have limitations in the bilateral upper extremities, requiring splinting. During observation on 5/23/23 at 11:59 AM, 5/25/23 at 2:27 PM and 5/26/23 at 11:22 AM Resident # 9 was observed without the left hand resting splint in place and a hand roll in the right hand. During an interview on 5/26/23 at 11:07 AM Certified Nurse Assistant (CNA) #1 stated Resident #9 had splints that should be worn for contractures. CNA #1 stated the resident is supposed to wear the splint every day and they are removed at night. CNA #1 stated there are 2 splints, but they do not appear to be the same. CNA #1 stated they did not have to document for the application of the splints. CNA #1 had no explanation as to why the splint was not being worn. During an interview on 5/26/23 at 11:22AM Licensed Practical Nurse (LPN) #1 stated that Resident #9 used a hand roll but was not aware of any other devices that Resident #9 required. LPN #1 looked in the electronic medical record (EMR) and stated there was a physician order for bilateral hand splints. LPN #1 stated they were not aware that Resident #9 had an order for the splints and when they checked the Treatment Administration Record (TAR) there was no indication for the application of and removal of the left and right hand splints. During an interview on 5/26/23 at 11:44 AM the Director of Nursing (DON) stated they did not know why the order for left and right-hand splints for Resident #9 were missing from the Treatment Administration Record (TAR) and the Certified Nurse Assistant (CNA) Care Card Instructions. The DON stated they have not been made aware of issues regarding physician's orders being populated into the TAR. 415.12(e)(1)

Based on record review and interview conducted during a recertification survey, the facility did not properly establish and / or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) the facility did not have a site-specific water management plan for legionella, (2) the facility did not have an annual facility risk assessment for legionella, and (3) the facility did not have an annual legionella culture sampling and analysis. The findings are: Review of the facility Policy on Healthcare Associated Legionnaire's Disease initiated on 04/2018 and revised on 04/2019, 04/2020 and 09/09/2020 documented that the facility shall conduct surveillance to identify cases to ensure that [CONDITION(S)] is considered in the differential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There is not documented evidence of a water management plan that would describe the facility water distribution system, control measures, and actions to be taken if control measures are not met. There is no documented evidence that a facility risk assessment for legionella was completed annually. Review of Weschester County Department of Laboratories and Research Microbiological Services Laboratory Report dated 07/23/2018 (collected 07/10/2018) and 05/01/2017 (collected 04/20/2017) revealed negative test results for legionella. There is no documented evidence that a legionella culture sampling and analysis was completed after the water sampling that was done in 07/10/2018. There is no documented evidence of a facility contract with a vendor for water sampling. Review of an email between the facility and Special Pathogens laboratory revealed a communication dated 09/09/2020 at 1:26 PM. Review of the facility infection / antibiotic line listing from 07/2018 to 09/14/2020 revealed there were no residents in the facility that has presented symptoms consistent with legionella and there were no residents in the facility who was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Infection Control QAPI Study for Legionella Pneumonia 2019 dated 09/14/2020 documented by the Medical Director revealed that in 2019 the facility had seven cases of Pneumonia, but the seven residents had no symptoms consistent with legionella disease. The MD also documented that there is no reason to suspect Legionella pneumonia was an etiology for the seven cases that they had. An interview conducted with the Administrator on 09/09/2020 at 02:30 PM revealed that he oversees the legionella requirements and not his director of maintenance. He stated that the facility did not have testing in 2020 but he made some calls and a vendor will be coming to do water sampling on 09/10/2020. He stated he does not have a contract with any vendor but that it would be arranged as soon as they come in the following day. A follow up interview conducted with the Administrator on 09/11/2020 at 11:30 AM revealed that there were no changes to all the policies that he submitted since 04/2018. A follow up interview conducted with the Administrator on 09/14/20 at 11:19 AM revealed that he made a mistake because he thought that his brother had the Legionella Testing done in July 2019. He stated that he finally was able to contact Weschester County and they stated there are no records that any testing was done in 2019 for the facility. He stated that the last time water sampling was done was 07/23/2018. He stated that the Medical Director documented for their QAPI study that there was no resident that had symptoms consistent with Legionella disease since 2019. An interview conducted with the Director of Nursing on 09/14/20 at 11:54 AM revealed that they had no residents that displayed symptoms of any Legionnaires diseases from July 2018 to present. She stated that they have been doing infections surveillance regularly and they never had any cases of legionnaires disease or any legionella associated symptoms. 415.19(b)(4)

Based on observation and staff interview during the Life Safety Recertification survey, the facility did not ensure all applicable state codes were met. Specifically, the facility did not install a carbon monoxide detector in the kitchen in accordance with section 915 of the 2015 edition of the International Fire Code, as adopted by New York State and contained in the NYS Uniform Code Supplement Section 915.3, which requires carbon monoxide detection in buildings with fuel-burning appliances. The findings are On 09/10/2020 at 12:20 p.m. a tour of the First Floor revealed the facility's main kitchen had a gas range/oven and a carbon monoxide detector was not installed in the kitchen or throughout the entire First Floor. Furthermore, the First Floor contained one resident-use physical therapy room and the main dining room. In an interview on 09/11/2020 at approximately 3:30 p.m., the Administrator stated carbon monoxide detection was not installed in the skilled nursing facility. 10 NYCRR: 415.29 (a)(2), 711.2 (a)(1); 42 CFR: 483.70 (b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9

Based on record review and staff interview conducted during a recertification survey the facility did not develop a person-centered care plan that included measurable objectives, time frames and interventions based on the comprehensive assessment to address [MEDICAL CONDITION] for 1 of 2 residents (#37) reviewed for nutrition and pressure ulcers. The finding is: Resident #37 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment tool) of 6/18/18 documented that the Care Area Assessment Summary (the section of the MDS that indicates the care areas triggered for further assessment and evaluation) documented that nutritional status and feeding tube were triggered. The laboratory reports on the following dates were reviewed and revealed a progressive decrease in the levels of red blood cells (RBC), hemoglobin (Hgb) and hematocrit (Hct) as follows: - 6/14/18 - RBC 4.37mcL (normal range is 4.7 - 6.1), Hgb 11.9g/dL (normal range is 13.5 - 17.5) , and Hct 37% (normal range is 45-52%); - 7/9/18 - RBC - 3.52, Hgb - 9.4, and Hct - 32; and on - 7/26/18 - RBC - 3.21, Hgb - 8.8, and Hct - 27. The resident was subsequently assessed on the Significant Change in Status (SCS) MDS of 9/13/18 which indicated a [DIAGNOSES REDACTED]. The comprehensive person-centered care plan revealed no documented evidence that a plan of care with measurable objectives, time frames and interventions was developed to address the care of this resident with [DIAGNOSES REDACTED]. The unit Registered Nurse (RN #2) was interviewed on 10/31/18 at 3:00 PM and was asked regarding whether a care plan was initiated to address [MEDICAL CONDITION]. RN #2 responded there was none and that the missing care plan would be developed at that time. 415.11(c)(1)

Based on observation, record review and staff interview the facility did not provide the treatment services to address the care of a resident with [DIAGNOSES REDACTED]. The finding is: Resident #37 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment tool) of 6/18/18 documented that the Care Area Assessment summary (the section of the MDS that indicates the care areas triggered for further assessment and evaluation) documented that nutritional status and feeding tube were triggered. The laboratory reports on the following dates were reviewed and revealed a progressive decrease in the levels of red blood cells (RBC), hemoglobin (Hgb) and hematocrit (Hct): - 6/14/18 - RBC 4.37mcL (normal range is 4.7 - 6.1), Hgb 11.9g/dL (normal range is 13.5 - 17.5) , and Hct 37% (normal range is 45-52%); - 7/9/18 - RBC - 3.52, Hgb - 9.4, and Hct - 32; and on - 7/26/18 - RBC - 3.21, Hgb - 8.8, and Hct - 27. There were no clinical progress notes to address these decreasing laboratory values. The resident was subsequently assessed on the Significant Change in status (SCS) MDS of 9/13/18 which indicated a [DIAGNOSES REDACTED]. The comprehensive person-centered care plan revealed no documented evidence of a plan of care with measurable objectives, time frames and interventions was developed to address [MEDICAL CONDITION]. The attending physician (MD) was interviewed on 10/31/18 at 10:00 AM and stated that the resident was not exhibiting symptoms of [MEDICAL CONDITION]. He stated further that he will closely monitor the resident. The attending MD stated that the hemoglobin and hematocrit were going down because the resident had been properly hydrated and that he will order blood work the next day. Following this interview, the physician documented in his progress that the resident has progressive [MEDICAL CONDITION] on the last blood blood count report and there were no signs and symptoms of [MEDICAL CONDITION]; there was no chest pain, shortness of breath or palpitations; and will recheck CBC (complete blood count), stool for guaiac (to determine presence of blood in the stool) iron, Vitamin B12 and folate levels. The unit Registered Nurse (RN #2) was interviewed on 10/31/18 at 3:00 PM and was asked regarding whether a care plan was initiated to address [MEDICAL CONDITION] which was identified during the above SCS assessment. RN #2 responded that the missing care plan would be developed at that time. The Registered Dietitian (RD) was also interviewed at that time and stated that the resident is taking vitamin supplements daily. ([MEDICATION NAME] multivitamins with minerals liquid- the iron content of this supplement contains only 9 mg of iron). The RD had no response when asked as to what other interventions were in place to address the resident's nutrition in light of the abnormal or low blood count. 415.12

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. This was evident for 2 of 6 residents (#1 and #47) observed during a medication pass for a total of 2 out of 29 opportunities for error resulting in an error rate of 6.9%. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. A medication observation was conducted on 10/26/18 at 10:09 AM on the 3rd floor unit. The Licensed Practical Nurse (LPN #1) administered one multivitamin with minerals tablet from a stock bottle. The physician's orders [REDACTED]. The mineral ingredient of the medication that was administered was not part of the physician's orders [REDACTED].>LPN #1 was interviewed on 10/26/18 at 1:13 PM following review of physician's orders [REDACTED]. 2. Resident # 47 has [DIAGNOSES REDACTED]. A medication observation was conducted on 10/26/18 10:36 AM on the 3rd floor unit. LPN #1 administered Vitamin B-12 1,000 mcg tablet from a stock bottle. The physician's orders [REDACTED]. The current (MONTH) (YEAR) Medication Administration Record [REDACTED]. The medication cart revealed that the ordered Vitamin B Complex medication was available in the cart, along with the resident's other medications. LPN #1 was interviewed on 10/26/18 at 12:45 PM following review of the physician's orders [REDACTED]. LPN #1 stated she had administered the ordered Vitamin B Complex medication, the day prior, from the dispensed package, but did not realize that the medication was available on the day of the medication observation. She stated that she was unsure if the medication that she administered was the same as what the physician ordered. 415.12(m)(1)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that residents' environment were free from accident hazards as possible. Specifically, free standing closets in 18 of 37 resident rooms were not secured to the wall to prevent them from falling over. The findings are: During room observations on 5/19/17 free standing closets were located in 18 out of 37 rooms observed. Upon inspection, the free standing closets were not secured to the wall to prevent them from falling over. The residents who lived in the rooms of concern were either alert and oriented or unable to go to the closets independently. The administrator was interviewed in the afternoon of 5/19/17 regarding the free standing closets and stated they have been doing a lot of renovations and electrical work and things have been moved around. He stated those closets should have been secured to the wall. 415.12(h)(1)

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 2 of 5 residents (#50 and #63), observed for medication pass, for a total of 29 opportunities for error. This resulted in a medication error rate of 6.8%. The findings are: 1. Resident #63 has [DIAGNOSES REDACTED]. A medication observation was conducted on 5/22/17 at 10:04 AM on the 2nd floor unit. The Registered Nurse (RN) administered [MEDICATION NAME] (65 mg Iron) 325 mg tablet oral to Resident #63 from a stock bottle. The Physician order [REDACTED]. Review of the 4/12/17 and 5/11/17 Medication Administration Record [REDACTED]. The medication label revealed that the medication did contain the [MEDICATION NAME] coated preparation ordered by the physician. The RN was interviewed on 5/22/17 at 12:03 PM and stated that he was not sure if the regular [MEDICATION NAME] sulfate medication that he administered, as indicated above, was the same as the [MEDICATION NAME] coated one that was ordered by the physician. The RN reviewed the medication label and stated that it did not state [MEDICATION NAME] coated on the bottle. 2. Resident # 50 has [DIAGNOSES REDACTED]. A medication observation was conducted on 5/22/17 at 10:14 AM on the 2nd floor unit. The RN administered Vitamin B 12 1,000 mcg tablet orally to Resident #50 from a stock bottle. Following the above medication observation, the Physician Orders, dated 5/18/17 was reviewed and revealed that the resident should receive a lower dose of Vitamin B 12 100 mcg orally daily for Vitamin B deficiency. The 4/21/17 and 5/19/17 MAR indicated [REDACTED]. The RN was interviewed on 5/22/17 at 12:04 PM and stated that he thought that the doctor's order was for Vitamin B-12 1,000 mcg because the resident was receiving it before. The RN was unable to provide a doctor's order to indicate that the order was for 1,000 mcg of Vitamin B 12. The primary physician was interviewed via telephone on 5/23/17 at 12:17 PM and stated that he was aware of the error, and there was no significant change to the resident. The physician stated that he wanted the resident on his ordered medication of Vitamin B 12 100 mcg tablet oral daily. 415.12(m) (1)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that the contact information for the Abuse Hotline and Ombudsman Program were prominently displayed in a location that were easily accessible and known to the residents without asking a facility staff person. The findings are: The president of the resident council was interviewed on 5/23/17 at 10:00 AM and was asked if the residents were aware of their rights to complain to the state agency about the care they are receiving and if they knew where to find the telephone number or contact information. The president of the resident council stated that she did not know about the number nor was she aware of the right to complain. When asked if residents knew about the Ombudsman Program and their right to contact the ombudsman regarding issues they might have in the facility, she stated they were not aware of the Ombudsman Program. Review of the resident council meeting minutes for the last year revealed that the minutes included a paragraph at the end of all the meeting minutes that states the social worker covered information about abuse, mistreatment and neglect and where to find the poster with the hotline number as well as the ombudsman poster. The social worker was interviewed on 5/24/17 at 9:45 AM and was asked about reviewing the information about the Ombudsman Program and the Abuse Hot Line with the residents. The social worker stated she does but they must not remember what she said. On 5/24/17 between 12:30 PM and 1:30 PM seven members of the resident council were interviewed about the whereabouts of the telephone numbers. Five of the members stated they did not know where the numbers were located and it wasn't discussed during the meetings. One member stated she has a memory problem and one member stated this was her first meeting and she doesn't remember if the numbers had been discussed. 415.3(c)(2)(i)(b)

Based on observation and interviews conducted during a recertification survey, the facility did not ensure that the result of the most recent survey was accessible and available for review by residents without having to ask a facility staff member. Specifically, the residents were not aware of the location of the survey results. The findings are: The president of the resident council was interviewed on 5/23/17 at 10:00 AM and was asked if the residents were informed of where the most recent survey results were located. The president of the resident council stated that she had no idea where they were. Observation of the survey results on 5/23/17 revealed they were located in a wall holder next to the elevator. The label on the holder read Plan of Correction. Review of the Resident Council meeting minutes for the past year, included a paragraph that stated where the survey results could be found. The social worker was interviewed on 5/24/17 at 9:45 AM and was asked about reviewing the information about the survey results with the residents. The social worker stated she does but they must not remember what she said. On 5/24/17 between 12:30 PM and 1:30 PM seven members of the resident council were interviewed about the whereabouts of the most recent survey results. Five of the members stated they did not know where the survey results were and it wasn't discussed during the meetings. One member stated she has a memory problem and one member stated this was her first meeting and she doesn't remember if the survey results had been discussed. 415.3(1)(c)(1)(v)

Based on observation, interview and record review, the facility did not ensure that recommendations by the Physical Therapist to improve ambulation for residents, who had been discharged from physical therapy, were implemented as required. This was evident for 2 of 3 residents reviewed for community discharge (Residents #17 and 66). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 (Minimum Data Set - an assessment tool) dated 4/11/11 revealed that the resident has no discharge plan. She was admitted for long term placement. Review of the Physical Therapy Evaluation and Care Plan revealed that the resident could benefit from short term rehabilitation for improvement of range of motion, strengthening and gait. She received Physical Therapy from 4/6/11 - 4/15/11. Review of the Physical Therapy Progress Note / Discharge Note dated 4/15/11 revealed that the resident was discharged from physical therapy due to improved strength, balance and endurance. The Physical Therapist discharged the resident with the following recommendations: Discontinue use of the wheelchair but continue to use a walker with 1 person assist for ambulation. Nursing rehabilitation was recommended 7x/week for transfers and hand held ambulation to improve safety in transfers and balance in ambulation. Review of Restorative Nursing Program documentation for the month of August revealed that the resident was supposed to ambulate for at least 15 minutes or more each day as tolerated. This resident was ambulated an average of 9 minutes per day during August on the 8AM - 4PM shift. On 8/24/11 at 12:00PM the CNA who cares for the resident and who is responsible for ambulating her was interviewed. The CNA stated that the resident wants to sit down before the 15 minutes is up due to hip pain. In an interview with the LPN Charge Nurse on 8/24/11 at 12:15PM, she stated that this is the first she is hearing that this resident is not walking for the full 15 minutes. The CNA is supposed to report to her if there are any issues and she would report to the Physical Therapist for possible evaluation. Observation of the resident on 8/24/11 at 12:20PM revealed she was sitting in a wheelchair in the day room. Review of the physician's orders [REDACTED]." There was no order for the use of a wheelchair. In an interview with the Physical Therapist she stated that she was unaware of the fact that this resident had not been walking for the recommended 15 minutes and she was also unaware that the resident was now using a wheelchair that she had discontinued in April. 2. Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 dated 6/7/11revealed that there was no discharge plan in place. "Discharge to the community not feasible." Additionally the resident was receiving Physical Therapy 2 days per week. Review of the care plan for ADL - Ambulation dated 6/1/11 revealed an intervention for the resident to participate in Physical Therapy 3x per week "focusing on gait training and resident education." Review of the Physical Therapy Progress Note dated 6/14/11 revealed the goal of therapy was to "improve safety in transfers and ambulation. Plan: continue with physical therapy 3x/wk for 2 wks." The 7/1/11 Physical Therapy Progress Note / Discharge Note revealed the resident was to continue ambulation without a device with assist of one - nursing. Review of the physician's orders [REDACTED]." In an interview with the Physical Therapist on 8/23/11 at 1:45PM, she stated that the resident was discharged from physical therapy because her gait was very unsteady and not improving and she has retropulsion (falling backwards) that continuing with physical therapy would not improve. She further stated that the resident was discharged from physical therapy with the recommendation that she was to be ambulated with an assist of one whenever possible. The reason the resident was not on a specific floor ambulation program was because she wanted her to be ambulated more than once per day. Review of the Nursing Rehabilitation book revealed that there is no documentation for nonspecific ambulation, while there is a place for documentation when a Restorative Nursing Program for ambulation. Review of the ambulation instructions on the CNA Assignement Record for Aug / Sept revealed, Ltd. (limited) assist of 1 - hand held." It does not specifiy how often or how far. In an interview with the resident at 1:30PM on 8/23/11, she stated that she enjoyed walking during her Physical Therapy sessions. She further stated that her backside is getting sore from sitting in her wheelchair so much. In an interview with the CNA who cares for the resident on 8/23/11at 2:00PM she stated that she is not the usual CNA that cares for the resident during the day. She is the 4PM-12AM CNA. She stated that she walks the resident from her wheelchair to the bathroom in her room. In an interview with the Director of Nursing on 8/23/11at 2:30PM she stated that sometimes the resident is difficult to ambulate because she is insecure with the CNAs walking her. She further stated that she does better in physical therapy because she is more secure with the therapist. She stated that she thought that the nursing rehabilitation aides might be a better option for ambulating this resident. There is no documented evidence that any of this information was ever communicated to the Physical Therapist. 415.12(a)(2)

Based on interview and record review, the facility did not ensure that food consumption data necessary to assess the adequacy of the protein caloric intake of a resident experiencing weight loss was obtained when requested. This was evident for 1 of 3 residents (Resident #77) reviewed for weight loss. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's weight chart showed that the residents admission weight obtained 4/5/11 was 160#. The admission nutritional assessment and nutritional care plan showed that the resident's appetite was poor. A 3-day calorie count to determine the resident's actual protein and caloric intake was initiated by the Registered Dietitian (RD) on 4/15/11. (Adequate protein and calories is necessary to maintain acceptable parameters of one's nutritional status.) A review of the report of the resident's intake showed that 2 of the 3 days were incomplete. On 4/15/11 one meal was missing and on 4/17/11 two meals were missing. The RD used the data for one day to assess the adequacy of the resident's protein and caloric intake. There is no documented evidence that the RD requested that the 3-day calorie count be repeated. Interview with the RD on 8/23/11 in the afternoon revealed that the nursing staff is responsible for documenting the resident's actual food/fluid intake for the calorie count. She offered no explanation why this was not done as requested. 415.12 (i)(1)

Based on observation, record review and interview, the facility did not ensure that a resident's drug regimen was monitored through aprropriate laboratory testing. Specifically, a resident who was receiving a cholesterol lowering medication did not have Liver Function Tests done as ordered by the physician. (Resident #66). This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #66 has [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Included on the order form were monitoring orders that originated on 5/31/11, which included Basic Metabolic Profile (BMP), Liver Function Tests (LFT) and Lipid Profile for June and December. The Liver Function Tests and Lipid Profile are test used to monitor the [MEDICATION NAME]. A further review of the record revealed results from lab tests for June 2011 included the BMP and Lipid Profile. There were no LFT results. The Daily Specimen Log dated 6/2/11 was reviewed and revealed that on that date a complete blood count, lipid profile and BMP were drawn. Liver function tests which were ordered by the physician had not been done. In an interview with the Licensed Practical Nurse/Supervisor (LPN) on 8/23/11 at 11:15 AM, she stated that she thought the test had been ordered but was never sent from the lab. She then called the lab to have them send a copy of the results. Review of the copy from the lab revealed that it was a duplicate and did not include the Liver Function Test. Following surveyor intervention, the Liver Funtion Test for this resident was done and the results were available on 8/24/11. 415.12(I)(1)

Based on interview and record review, the facility did not ensure that an irregularity in a resident's drug regimen review was identified by the consultant pharmacist. This was evident for 1 of 8 residents who medication regimen was reviewed (Resident #66). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #66 has [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Included on the order form were monitoring orders that originated on 5/31/11, that included Basic Metabolic Profile (BMP), Liver Function Tests (LFT) and Lipid Profile for June and December. The LFTs and the Lipid Profile are tests used to monitor the Crestor. A further review of the record revealed results from lab tests for the month of June 2011 including results for the BMP and Lipid Profile. There were no LFT results. The Daily Specimen Log dated 6/2/11 was reviewed and revealed that on that date a complete blood count, lipid profile and BMP were drawn. The Liver FunctionTests that were ordered by the physician had not been ordered and therefore not done. In an interview with the Licensed Practical Nurse/Supervisor (LPN) on 8/23/11 at 11:15 AM, she stated that she thought the test had been ordered but was never sent from the lab. She then called the lab to have them send a copy of the results. Review of the copy from the lab revealed that it was a duplicate and did not include the Liver Function Test. Review of the Consultant Pharmacist Plan of Care dated 6/8/11, 6/28/11 and 7/27/11 revealed that the Pharmacy Consultant did not identify the missing Liver Function Test. The pharmacy consultant was interviewed on 8/23/11 at 11:20AM regarding the missing LFT. She reviewed the chart and stated that she had focused on the Lipid Profile and the BMP and had missed the LFT. 415.18(c)(2)