Every finding on record at Boro Park Center for Rehabilitation and Healthcare

Based on observations, record review, and staff interviews conducted during the Recertification survey from 04/20/2024 to 05/06/2024, the facility did not ensure that the survey results were posted in a place readily accessible to residents, visitors, or legal representatives where individuals wishing to examine survey results do not have to ask to see them. In addition, notices of the availability of such reports were not posted in areas of the facility that are prominent and accessible to the public. Specifically, the survey results were located inside a binder placed behind the Security desk, and there were only two notices posted about the availability of the survey results, and the notices which were not in conspicuous locations. The finding is: The facility policy and procedure titled Survey Results revised on 10/2015 stated that copies of all survey reports along with approved plans of correction are on file in the administrative office, and that survey results must be readily accessible for viewing. The policy also documented that residents, visitors etc. should not be required to ask to see the results. During multiple observations from 04/29/2024 to 05/06/2024, survey results could not be located throughout the facility. On 05/01/24 at 10:58 AM, during the Resident Council meeting, five of six residents present stated that they did not know where to locate the survey results. Resident #34 stated that if someone asked at the security desk the results would be given to them. On 05/01/24 at 01:09 PM, a notice which stated that the Annual Department of Health survey results are located at the security desk was observed posted on a wall around the corner from the elevator bank. In addition, a copy of the notice was also observed posted in a bulletin board opposite the employee time clock. During multiple observations from 05/01/2024 at 1:10 PM to 05/06/2024 at 12:15 PM, the survey results were not visible at the security desk. On 05/06/24 at 12:16 PM, an interview was conducted with Security Guard #1 who stated that the survey results are located in a binder that is located at the Security desk, right behind where the officers sit. Security Guard #1 also stated that residents or family members would have to ask the security officers for the survey results and they would hand the binder to them. Security Guard #1 further stated that previously the results were displayed behind fiberglass at the front desk, and the fiberglass has been broken for a few months now. Security Guard #1 was asked for the survey results and they proceeded to take a black binder, with a label that stated Department of Health survey, from a metal bin behind the Security desk. In the bin were 4 other colored binders. The black binder did not have a label on the spine indicating that it contained the survey results. On 05/06/24 at 01:19 PM, an interview was conducted with the Administrator who stated survey results signage is located in the lobby after the elevators. The Administrator stated that signage was always placed there and they considered this a conspicuous place because residents going to therapy can see it and residents congregate in that area on occasion. The Administrator further stated that they did not know that signage should be posted in more than one location. The Administrator stated that survey results are considered accessible because they are available at the Security desk and could be received once requested by residents or family members. The Administrator also stated that they were not aware that results should be available without being asked for. 10 NYCRR 415.3(d)(1)(v)

Based on observation, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure medications and biologicals were stored in accordance with currently accepted professional principles and expiration date, if applicable. This was evident for 2 of 16 medication storage areas (2 East medication room and 2 [NAME] Unit medical supply room). Specifically, 13 bags of expired intravenous fluids were observed in the medication room on unit 2 East, and 12 bags of expired intravenous fluids were observed in the medical supply closet on 2 West. This was evident for the Medication Storage task. The findings are: The facility policy titled Medication Storage revised [DATE] documented the facility will store medications in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with state and federal regulations. Expired, discontinued and or contaminated medications will be removed from the medication storage areas and disposed of in accordance with the facility policy. On [DATE] between 04:38 PM & 04:58 PM, the medication room on unit 2 East was observed with Licensed Practical Nurse #8. The following was observed in the drawer below the counter level: 1 bag of 0.9% sodium chloride 250 milliliter bag with an expiration date of [DATE] bags of 5% dextrose 50 milliliters with an expiration date of [DATE] bag of 5% dextrose and 0.45% sodium chloride 500 milliliters with an expiration date of [DATE]. In addition, there were 7 bags of 5% Dextrose and 0.9% sodium chloride injection USP 1000ml with an expiration date of [DATE]. On [DATE] at 12:13 PM, the medication supply/intravenous fluid storage room on 2 [NAME] was observed with the Central Supply Clerk and 12 bags of 5% Dextrose injection 50 milliliter bags were observed with an expiration date of [DATE]. On [DATE] at 04:49 PM, Licensed Practical Nurse #8 located on unit 2 East was interviewed and stated that the bags of intravenous solution in the drawer are to be used to start antibiotics for residents. If there is an emergency, the 50 milliliter, 250 milliliter or 500 milliliter intravenous fluid bags may be used depending on the antibiotic to be administered. Licensed Practical Nurse #8 also stated that they check the medication room weekly as part of their normal duties and the intravenous fluids should be checked, and thrown out if expired. On [DATE] at 05:08 PM, Registered Nurse #5 (the Unit Manager for 2 East) was interviewed and stated that they check the medication room daily for neatness and the expiration dates of items in the room. Registered Nurse #5 also stated that central supply also checks and stocks the intravenous medications. Registered Nurse #5 further stated that the many intravenous bags were tucked in there and so the expiration dates might not have been noticed. Registered Nurse #5 stated that additional intravenous fluids can be used to dilute ordered intravenous antibiotics if needed, and they have been using the prefilled intravenous bags that they get them from the pharmacy which is labeled with the correct intravenous fluids for mixing the antibiotics for the past 6 months. On [DATE] at 11:23 AM, the Director of Nursing was interviewed and stated that the pharmacist is remote, and the medication rooms are supposed to be checked by the nurse and unit managers on the unit. 10 NYCRR 415.18(e)(,d+[DATE])

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was stored in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, 1) expired enteral feeding was observed in the nourishment/supplement room in the kitchen, and 2) there was unlabeled food, degraded, rotted food and expired yogurt in the 5th floor unit refrigerator, and expired ice cream in the freezer. This was evident for the Kitchen Task and Dining Task. The findings are: 1. The facility policy titled Food Safety Food Handling revised ,d+[DATE] documented food will be stored, prepared, handled, and served so that they reduce the risk of foodborne illness is minimized. This policy does not contain any information in relation to the rotation of food items or when food items may need to be discarded. The facility policy titled Enteral Nutrition revised ,d+[DATE] documented the facility provides Dietary-Nursing nutritional support to residents unable to obtain nourishment orally and are receiving enteral feeding ordered by a physician and not clinically contraindicated. Central supply or Designee will be responsible for ordering all tube feeding supplies. On [DATE] from 09:39 AM to 10:22 AM, the kitchen tour was conducted with the Assistant Food Service Director. In the supplement/nourishment room an open cardboard box which held 24 cartons was observed to contain 21 cartons of Osmolite 1.0 with a use by date of 01 [DATE]. On [DATE] at 02:25 PM, the Storeroom Dietary Aide #1 was interviewed and stated they manage the storeroom. Nourishments are delivered on Tuesday and they did not notice any expired items. The Storeroom Dietary Aide #1 also stated that when orders come in they rotate items, and a company collects expired goods every other month. On [DATE] at 02:30 PM, the Dietary Supervisor was interviewed and stated that the Dietary Aide is responsible for checking the storeroom for any missing items. The Dietary Supervisor also stated that expired nourishments are supposed to be stored on the side and tagged so they can be picked up and returned to the vendor. The Dietary Supervisor further stated that expired items should not be stored with current items as they can be picked up and given to residents in error. On [DATE] at 11:49 AM, the Assistant Food Service Director was interviewed and stated that they check the storeroom along with the Food Service Director and the storeroom staff. The Assistant Food Service Director also stated that the last time they checked the nourishment room was at the beginning of [DATE] when they conducted a mock survey. The Assistant Food Service Director further stated that they do random checks on Wednesdays to make sure there are no expired oral feeding or enteral feedings and they did not notice any expired items. On [DATE] at 11:51 AM, the Dietary Director was interviewed and stated that when the nourishment vendor switched companies they helped clean out the inventory and they gave the inventory form to purchasing for items to be sent back ,d+[DATE] months ago. 48876 2. The facility policy titled Food - From Outside, last date reviewed [DATE], documented food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination, and safety. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. A label will identify resident name, room number, item, date received and discard date. The policy also documented that all refrigerated food will be discarded within 48 hours. Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal. The nursing staff will discard perishable foods on or before the discard date. The nursing and or food service staff will discard any foods prepared for the resident that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). The facility policy titled Unit Food Storage, last date reviewed ,d+[DATE], documented food items stored for nourishment or brought in by residents shall be stored in designated areas only. The unit area designated for food storage will remain clean and safe for food handling. Food items will be identified with name of owner and date placed in designated refrigerator. All resident food items will be dated with use by date. Dietary and nursing staff will be responsible to ensure food items stored in pantry refrigerators and freezers are not expired or past perish dates. On [DATE] at 10:48 AM, the 5th Floor Pantry/Nourishment Refrigerator was observed with Registered Nurse #3 (the Nurse Manager). One thermal bag was observed with 2 Tupperware bowls. 1 bowl contained spoiled peaches that had become liquified and the other bowl contained 1 plastic bag of dry rotted fruit. In addition, the refrigerator contained one loaf of wheat bread with no expiration date, one 4-ounce cup of strawberry yogurt with an expiration date of [DATE], one 5-ounce cup of strawberry yogurt with an expiration date of [DATE], and multiple cups of ice cream in the freezer with an expiration date of [DATE]. On [DATE] at 10:52 AM, a sign posted on the refrigerator stated all food placed refrigerator must be labeled and discarded after 48 hours. On [DATE] at 10:53 AM, Registered Nurse #3 was interviewed and stated that they ask staff to clean the refrigerators as is posted but a lot of staff have access to the refrigerators including recreation and volunteer staff. On [DATE] at 10:57 AM, the Housekeeping Supervisor was interviewed and stated items were not discarded from the refrigerator because the bread had no expiration date, and the thermal bag is someone's lunch. The Housekeeping Supervisor further stated that staff lunch is supposed to be stored in the refrigerator in the nurses' lounge. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews conducted during the Recertification Survey from 4/29/2024 to 5/6/2024, the facility did not ensure residents remained free from physical restraints. This was evident for 1 (Resident #151) of 1 resident reviewed for Restraints out of 38 total sampled residents. Specifically, Resident #151's right hand was observed wrapping by a towel to prevent the free movement of the hand and there was no documented evidence of an evaluation or physician's order for use of a restraint. The findings are: The facility policy titled Restraint Use with creation date 10/2015 and last revised date 12-2022 documented restraints shall only be used to treat the resident's medical symptom and shall not be imposed for the purposes of discipline, staff convenience or that unnecessarily inhibits a resident's freedom of movement or activity. Resident #151 had diagnoses which included Cerebral infarction, Alzheimer's disease, and Dysphagia. The Quarterly Minimum Data Set 3.0 dated documented Resident #151 had severely impaired cognition, did not reject care, and had no behavioral symptoms. The Minimum Data Set also documented Resident #151 had no restraint and only the representative participated in the assessment. During multiple observations between 04/29/2024 at 11:02 AM and 05/03/2024 at 09:24 AM, Resident #151 was observed lying in bed with their right hand wrapped in a white towel. The Physician's Order dated 4/18/2022 stated apply Right Mitten to reduce risk of digging into skin/pulling gastrostomy tube, and the order was discontinued on 8/29/2022. Review of the medical record revealed that there was no current physician order, care plan, nor restraint assessment for applying right mitten or any other physical restraint to Resident #151. The Certified Nursing Assistant Visual/Bedside Kardex Report documented in the alerts in the Safety section Right hand Mitten to reduce risk of digging into skin/pulling gastrostomy-tube under Safety section. This was not included in the tasks on the Certified Nursing Assistants record. On 05/03/2024 at 09:25 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #151 was confused and required total care for Activities of Daily Living. Certified Nursing Assistant #1 also stated that they applied the right mitten or used the towel to wrap Resident #151's right hand when the mitten was not available to prevent Resident #151 from scratching their body and pulling out the gastrostomy tube. Certified Nursing Assistant #1 further stated that they removed the mitten or the towel to wash Resident #151's hands 1-2 times per shift. Certified Nursing Assistant #1 stated that Resident #151 has had the mitten or towel applied to their right hand for some time now and they did not recall when Resident #151 started using the mitten or the towel. Certified Nursing Assistant #151 also stated that they followed the task in the Kardex to apply the right mitten. On 05/03/2024 at 11:04 AM, Registered Nurse #1 (also the Unit Manager) was interviewed and stated they made rounds on the unit at least three times every day. During this time, they speak to residents and representatives about resident care and looked for safety and environment issues. Registered Nurse #1 also stated that they were not aware Resident #151 had their right hand wrapped with a towel. Registered Nurse #1 further stated that they entered and revised the tasks in the Certified Nursing Assistant accountability for the Certified Nursing Assistant to follow, and they were not sure why Resident #151 had the right-hand mitten listed in the Safety section in the Kardex. Registered Nurse #1 stated there was no active order to apply right mitten to Resident #151, and so the right-hand mitten or towel would be considered as a physical restraint for Resident #151. On 05/03/2024 at 11:37 AM, the Certified Occupational Therapy Assistant was interviewed and stated they provided occupational service 5 days in a week to Resident #151. The Certified Occupational Therapy Assistant also stated that they observed that Resident #151's right hand was wrapped with a towel sometimes and they removed it for right hand movement. The Certified Occupational Therapy Assistant further stated that Resident #151 was not able to remove the towel from the right hand by themselves. On 05/03/2024 at 11:47 AM, the Attending Physician was interviewed and stated they ordered to apply right mitten a while ago to prevent Resident #151 from skin lesions by scratching their body with right hand, and the order was discontinued after a while. The Attending Physician also stated they had not placed an order to apply a mitten or anything else to Resident #151's right hand recently. On 05/03/2024 at 11:55 AM, the Director of Nursing was interviewed and stated they made round to the floors at least once during the day shift and evening shifts where they looked at the residents, their rooms, meals, environment, and wander guard. The Director of Nursing also stated that the interdisciplinary team had to discuss the use of physical restraint, obtain family consent and physician order, conducted the restraint assessment, and removed the physical restraint for 20 minutes every 2 hours. The Director of Nursing further stated that they were not aware that Resident #151's hand had been wrapped with a towel. The Director of Nursing stated it was considered a physical restraint if Resident #151 was unable to remove the towel themselves as it limited Resident #151's right hand movement. 10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and interviews conducted during the Recertification Survey from 04/29/2024 to 05/06/2024, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 1 (Resident #263) of 5 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #263 did not receive bladder/bowel care in a timely manner. The findings are: The facility policy titled Activities of Daily Living (ADL) Care and Support with creation date 8/2016 and current revision date of 3/13/2024 documented that activities of daily living will be provided for residents who are unable to carry out activities of daily living independently, with consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care. Resident #263 had diagnoses which included Non-Hodgkin's Lymphoma, Dysphagia, and Other reduced mobility. The Quarterly Admission Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #263 had severely impaired cognition, did not reject care, and was dependent for toileting hygiene. The Quarterly Admission Minimum Data also documented Resident #263 and their representative participated in the assessment. On 04/29/2024 at 11:33 AM, the Resident Representative was interviewed and stated they often found the incontinent brief was very wet and sometime with feces when they visited Resident #263 at around 10 AM in the morning. The Resident Representative also stated this happened when the regular Certified Nursing Assistant was off. The Resident Representative further stated that the covering Certified Nursing Assistant did not change or check the incontinent brief for Resident #263. The Resident Representative also stated that they had been to the nursing station a few times today to report this but Resident #263 still had not received care. The Comprehensive Care Plan related to Activities of Daily Living initiated 2/1/2020 documented Resident #263 required substantial assistance for toileting hygiene. The Certified Nursing Assistant Accountability record dated April 2024 documented that bladder/bowel continence care was provided each shift for the day, evening, and night shifts. On 04/30/2024 at 10:40 AM, the Resident Representative was observed trying to change the Resident #263's incontinent brief which was soiled with feces. The Resident Representative stated that no staff had checked on or changed the incontinent brief for Resident #263 this morning. There was no documented evidence that bladder/bowel continence care was provided in a timely manner for Resident #263. On 04/30/2024 at 11:47 AM, Certified Nursing Assistant #2 was interviewed and stated they were a floater and they received they report from the medication nurse for the 6 AM to 2 PM shift and so they knew their assignments. Certified Nursing Assistant #2 also stated that they made rounds to the assigned residents first, provided care to residents at high risk of fall and moved them to the dining room. Certified Nursing Assistant #2 stated they were also busy delivering breakfast to residents in the dining room, assisted in feeding residents, and then took their own lunch break from 10:15 AM to 11:15 AM. Certified Nursing Assistant #2 further stated that they had not yet had the opportunity to check if Resident #263 needed continence care since beginning the shift at 6 AM. Certified Nursing Assistant #2 stated that they are supposed to check the bladder/bowel continence of each resident every 2 hours. Certified Nursing Assistant #2 also stated that they only documented continence care once per shift in the Certified Nursing Assistant Accountability record. Certified Nursing Assistant #2 further stated that they were new to the facility and had not reported to anyone that they were not able to provide care to all their residents in a timely manner. On 05/03/2024 at 11:16 AM, the Registered Nurse #1 (also the Unit Manager) was interviewed and stated that the Certified Nursing Assistants are required to check to see if the residents require continence care every 2 hours if the residents required assistance or were dependent on staff for toileting. Registered Nurse #1 also stated that they were not sure if the Certified Nursing Assistants were required to document bladder/bowel continence care every 2 hours or once only for each the shift. Registered Nurse #1 further stated that they made rounds on the unit at least three times per shift and spoke to residents and representatives about their care and environment. Registered Nurse #1 stated that they were not aware that Resident #263 had not received continence care in a timely manner. On 05/03/2024 at 12:02 PM, the Director of Nursing was interviewed and stated they made round to the floors at least once during the day shift and evening shifts where they looked at the residents, their rooms, meals, environment, and wander guard. The Director of Nursing also stated that the Certified Nursing Assistant had received orientation or in-service on their responsibility to check the continence needs of the residents every 2-4 hours and as needed. The Director of Nursing also stated that the settings for documentation of continence care in the Certified Nursing Assistant Accountability only permitted the Certified Nursing Assistant to document that the task was done once per shift and not every 2 hours. The Director of Nursing further stated that they had no documented evidence to show the blader/bowel continence care was provided to Resident #263 every 2-4 hours. 10 NYCRR 415.12(a)(3)

Based on observations, record reviews, and interviews, conducted during the Recertification survey from 04/29/2024 to 05/06/2024, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers and to promote healing. This was evident for 2 (Resident #523 and Resident #380) of 7 residents reviewed for Pressure Ulcer out of 38 sampled residents. Specifically, 1) during multiple observations Resident #523 was observed without heel booties in place as ordered and, 2) Resident #380 was observed during wound assessment with loose stool and an uncovered Stage 3 sacral pressure ulcer. The findings are: The facility policy titled Skin and Pressure Ulcer Injury Prevention effective October 2014, last revised March 13, 2023, documented that the facility will assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice. Risks that increase a resident's susceptibility to develop or to not heal a pressure ulcer injury include impaired/decreased mobility, decreased functional ability and exposure of skin to urinary and fecal incontinence. Once the assessment is conducted and risk factors are identified and characterized, a resident care plan can be created to address the modifiable risk for pressure injuries and skin protection interventions. 1. Resident #523 was admitted to the facility with diagnoses of Diabetes, Malnutrition, Morbid Obesity, and Pressure Ulcer of the sacral region. The Admission Minimum Data Set, dated dated dated [DATE] documented that Resident #523 was moderately cognitively impaired and was dependent on staff for toileting, showers, lower body dressing, putting on footwear and required substantial assistance for personal hygiene. The Minimum Data Set also documented that Resident #523 was at risk of developing pressure ulcers and pressure relieving devices are applied to chair and bed. A Physician's order initiated 04/13/24 documented Heel boots, remove daily for skin monitoring, and notify provider/nurse/supervisor of any new skin alteration or decline. The Braden Scale for predicting pressure sore risk dated 04/15/24 documented that Resident #523 was at high risk for skin breakdown. On 04/29/24 at 11:05 AM, 04/30/24 at 10:45 AM, 05/01/24 at10:42 AM, 05/02/24 at 11:25 AM and at 02:36 PM, and on 05/03/24 at 12:18 PM, Resident #523 was observed in bed with no heel boots in place. On 05/03/24 at 12:19 PM, Certified Nursing Assistant #7 was interviewed and stated that Resident #523 needs two staff assistance for bed mobility and transfer. Certified Nursing Assistant #7 also stated that they receive report at the beginning of the shift and the charge nurse lets them know what the residents' needs are and they also check the Certified Nursing Assistant Accountability sheet to see what each resident needs. Certified Nursing Assistant #7 further stated that they are aware that Resident #523 is supposed to wear heel boots. Certified Nursing Assistant #7 stated that Resident #523's family members do not like the resident to wear the heel boots, and Resident #523 does not like to keep on the boots. Certified Nursing Assistant #7 also stated that the Charge Nurse was not told about Resident #523 refusing to keep the heel boots on. Certified Nursing Assistant #7 stated that all Certified Nursing Assistants assigned to care for Resident #523 were told at the beginning of their shift that the resident had an order for heel boots, and it was also reflected on the Nursing Assistant Accountability sheet. On 05/03/24 at 12:27 PM, Licensed Practical Nurse #3 was interviewed and stated that they give medications and treatments, make rounds, and make the assignments for the Certified Nursing Assistants. Licensed Practical Nurse #3 also stated that they respond to any emergencies that come up, and check to ensure all doctor's orders are carried out. Licensed Practical Nurse #3 further stated that Resident #523's heel boots should have been applied. Licensed Practical Nurse #3 stated they check to ensure all residents with high risk for developing pressure ulcers are being taken care of and ensure that all required interventions to prevent pressure ulcers are being implemented. On 05/06/24 at 11:08 AM, Registered Nurse #4 was interviewed and stated that they manage the unit and supervise all nursing staff and the care that they provide. Registered Nurse #4 also stated that they do rounds very frequently on the unit. In the morning, they go to the resident's rooms to ensure the residents are receiving adequate care, and throughout the day, they do quick rounds on the unit. Registered Nurse #4 further stated that Resident #523 does not like the heel boots, however the heel boots should have been applied. Registered Nurse #4 stated that they will reinforce with staff that Resident #523 is to wear the heel boots and they ensure that the boots are worn. On 05/06/24 at 11:55 AM, the Director of Nursing Services was interviewed and stated that every resident is assessed for pressure ulcers upon admission. If they are determined to be at high risk for developing pressure ulcers, we would initiate an at risk for pressure ulcer care plan and ensure preventive measures are in place. The Director of Nursing Services also stated that the heels boots should have been applied. The Certified Nursing Assistants must follow the Doctors orders and apply the heel boots. If the resident is refusing, the Certified Nursing Assistants must inform the nurse. The Director of Nursing Services further stated that the whole purpose of the heel boots to prevent further injury. The Director of Nursing Services stated that the Charge Nurse and the nurse manager are responsible for ensuring all doctors' orders are being followed and they should have documented Resident #523's refusal to wear the heel boots in the medical record. Heel boots are also supposed to be reflected on Certified Nursing Assistant Accountability sheet. The Director of Nursing Services also stated that the Certified Nursing Assistants must inform the nurses of any refusals so that the resident can be educated and the refusal can be documented in the progress notes. 48876 2. Resident #380 was admitted with diagnoses that included Dementia, Generalized Muscle Weakness, and Osteoarthritis. The Comprehensive Minimum Data Set 3.0 assessment dated [DATE], documented that Resident #380 had severe cognitive impairment, was frequently incontinent of bowel and bladder, was dependent on staff to perform Activities of Daily Living. The Comprehensive Minimum Data Set 3.0 Assessment also documented that Resident #380 was at risk for developing pressure ulcers, and had one unhealed Stage 2 pressure ulcer. The Physician's Order dated 3/27/2024 and renewed 5/1/2024 documented Santyl External Ointment 250 Unit/Gram, apply to the sacrum topically as needed for soilage/displacement for 30 days. Clean with saline. Pat dry. Apply Santyl ointment to wound bed, cover with dry dressing and silicone border. On 5/1/2024 at 10:00 AM, the Wound Care Nurse Practitioner was observed performing the wound assessment and consultation for Resident #380, whose wound had developed into a Stage 3 sacral pressure ulcer. Certified Nursing Assistant #3 removed the incontinence brief and a large amount of loose stool was observed. There was no dressing covering the wound leaving the wound exposed to loose stool. The Nurse Practitioner Wound Progress Note dated 5/1/2024, documented that Resident #380 was noted to have one Stage 3 sacral pressure ulcer measuring 2.8 centimeters in length, 4.5 centimeters in width and 0.3 centimeters in depth. The tissue surrounding the pressure ulcer was documented as bright red. The Wound Progress note also documented that Resident #380 was at risk for further skin breakdown, incontinent of urine and feces, increasing the possibility of contamination. Prevent contamination, cover the wound with moisture proof silicone border gauze and manage incontinence. Plan discussed with nursing. The Certified Nurse Aide Documentation Report dated April 2024, documented urinary catheter care, skin observation, turning and positioning for Resident #380 completed by Certified Nursing Assistant #5 on 4/30/24 at 5:35 AM. The Treatment Administration Record dated 4/1/2024 thru 4/30/2024 documented sacral pressure ulcer treatment performed for Resident #380 by Licensed Practical Nurse #1 on 4/30/24 at 1:05 PM. On 5/1/2024 at 10:00 AM, during observation of the wound, the Wound Care Nurse Practitioner stated that there should be a dressing covering the wound, and wound treatment is ordered daily and as needed. On 5/2/2024 at 12:25 PM, Registered Nurse #3, (Nurse Manager for the floor) was interviewed and stated that when they inquired they found that morning care was performed by Certified Nursing Assistant #5 who did not notify Licensed Practical Nurse #1 that there was no dressing on the Stage 3 sacral pressure ulcer site. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and interview conducted during the Recertification and Complaint (NY 418) survey, the facility did not ensure a resident received adequate supervision to prevent accidents. This was evident for 1 out of 6 residents reviewed out of a sample of 35 (Resident #253). Specifically, Resident #253 required the assistance of 2 people for Activities of Daily Living (ADL) and sustained a left leg tibia/fibula fracture when Certified Nurse Assistant (CNA) #5 attempted to turn Resident #253 in the bed without assistance from a 2nd staff member. This resulted in actual harm to Resident #253 who sustained a left leg tibia/fibula fracture that was not immediate jeopardy. The findings are: The facility policy titled Accident/Incidents (A/I) revised 8/2021 documented the facility monitors and evaluates all accidents or incidents. An incident may be a fall and may involve abuse, neglect, and mistreatment or an injury of unknown origin. Resident #253 had diagnoses of Alzheimer's Disease, Dementia, Depression Diabetes and Chronic Obstructive Pulmonary Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #253 was severely cognitively impaired and required extensive assistance of 2 people for bed mobility. The Comprehensive Care Plan (CCP) related to ADLs and limited mobility was initiated 06/30/2017 and revised 8/21/2020 documenting intervention to use two staff members when assisting Resident #253 with bed mobility. The CNA Accountability Record (CNAAR) dated May 2021 documented Resident #253 required extensive assistance of 2 people for bed mobility. The CNA Assignment sheet dated 5/15/2021 documented CNA #5 was assigned to Resident #253. Nursing Note (NN) dated 5/15/2021 documented Resident #253 was at moderate risk for falling. Registered Nursing Supervisor (RNS) NN dated 5/15/2021 documented Resident #253 was observed lying on the floor in their room. Staff were performing care, was unable to catch Resident #253, and eased Resident #253 to the floor. Resident #253 complained of right knee and hip pain, Physician (MD) was made aware, and pain medications and x-rays were ordered. Staff to provide ADL assistance during care to prevent future incidents. MD Notes dated 5/15/2021 documented x-ray for Resident #253 reported left distal tibia/fibula fracture. The AI Report initiated 5/15/2021, documented the CNA #5 was observed by the Licensed Practical Nurse (LPN) #1 in Resident #253's room supporting Resident #253 on the floor. A statement from CNA #5 documented CNA #5 was giving the resident care and asked the resident to hold the side rail. Resident #253 was unable to hold the side rail and slipped to the floor. The A/I documented CNA #5 phone was disconnected and they were not available for further interview. MD Notes dated 5/16/2021 documented Resident #253 was transferred to the hospital. The hospital discharge summary dated 5/16/2021 documented Resident #253 was diagnosed with acute fracture from fall and left distal femur fracture. The A/I Facility Investigation Overview Form dated 05/17/2021 and signed by the Director of Nursing (DNS) documented Resident #253 sustained a fall from bed during ADL care by assigned CNA (#5). Resident returned to the facility with left tibia/fibula fracture and cast to left leg. Resident #253 required extensive assistance of 2 person for bed mobility. CNA #5 provided care that deviated from the written plan by using one staff to provide care instead of using two staff. On 04/20/22 at 09:22 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated all CNAs are instructed to check a resident's ADL status before giving residents care. LPN #1 was working 05/15/2021 and was alerted by CNA #5 that Resident #253 was on the floor. A statement was gathered from CNA #5 which documented attempted to turn the Resident #253 in bed, could not control the resident, and Resident #253 fell on the floor. On 04/19/22 at 02:52 PM, the DNS was interviewed and stated CNA #5 did not follow the Resident #253's plan of care requiring two staff to assist Resident #253 in bed mobility. CNA #5 was immediately removed form duty and did not return to the facility. 415.12(h)(1)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. This was observed during Kitchen observation. Specifically, 1) expired food was observed in a kitchen refrigerator; and 2) tray line food was not maintained at an acceptable temperature to prevent foodborne illness and were not discarded. The findings are: The facility policy and procedure titled Food Storage Policy revised [DATE] documented left-over food will be stored in covered containers, clearly labeled and dated, and will be checked to assure the food is consumed by the use by dates indicated once food is opened. The facility policy titled Food Safety-Food handling Policy revised on ,d+[DATE] documented there is a potential for foodborne illness with inadequate cooking and improper holding temperatures. The facility policy and procedure titled Food Temperature Policy revised ,d+[DATE] documented food temperatures must be recorded on hot food and cold foods prior to service using the food temperature log. Hot food items will be heated to an internal temperature of 165 degrees. 1) On [DATE] at 09:28 AM, 28 -4 oz plastic cups of cottage cheese labeled with a use by date of [DATE] were observed in Refrigerator #1 of the facility kitchen. On [DATE] at 09:36 AM, Dietary Aide (DA) #1 was interviewed and stated unused cottage cheese is kept in the refrigerator for ,d+[DATE] days to prevent potential foodborne illness. Unused cottage cheese is disposed of by the end of their labeled date. The supervisor is responsible for checking the dates. The unused cottage cheese dated [DATE] should not have been on the refrigerator shelf. On [DATE] at 09:39 AM, the Food Service Supervisor (FSS) #1 stated they were responsible for doing rounds in the morning in the kitchen area. FSS #1 does not check the refrigerators. The FSS on the night shift checks the refrigerators for expired items and the Rabbi checks the refrigerators in the morning. The unused cottage cheese dated [DATE] should not have been on the refrigerator shelf. On [DATE] at 09:45 AM, the Rabbi was interviewed and stated they did rounds this morning but did not check dates of refrigerated items, including the cottage cheese. The Rabbi does not usually check Refrigerator #1. Checking for expiration dates and discarding expired food is not part of the Rabbi's responsibilities. On [DATE] at 10:23 AM, the Assistant Director of Food Services (ADFS) was interviewed and stated the unused expired cottage cheese should have been discarded on the previous night shift. 2) On [DATE] at 11:26 AM, lunch tray line observation took place in the Kitchen with FSS #2. The following foods had internal holding temperatures below 165 Fahrenheit: tuna coquette-150, baked fish-148 F, plain fish-100 F, pureed seasoned fish-112 F. On [DATE] at 11:51 AM, FSS#2 was interviewed and stated that the holding internal temperature of hot foods should be 160 Fahrenheit or greater. The hot food items were not in a deep pan, were open to air, and were not grouped closely together in the pan to maintain temperatures. If food temperature is below 160 Fahrenheit, it should be placed back in the warmer. On [DATE] at 11:59 AM, the Cook #1 was interviewed and stated they prepared the tuna coquette and baked fish but did not take temperatures of the food after it was removed from the warmer. Food temperatures are usually taken before the food goes to the tray line, but the morning was hectic and Cook #1 was unable to do so. Cook #1 keeps a log of cooked food temperatures that is provided to the FSS for review. On [DATE] at 12:08 PM, the Assistant Food Service Director (AFSD) stated that FSS is responsible for ensuring tray line items are maintained at proper temperatures. Food temperatures are taken at the midpoint of service and food outside of proper holding temperatures will be placed in the warmer. On [DATE] at 11:18 AM, the Food Service Director (FSD) was interviewed and stated the FSS on the night shift was responsible for discarding outdated items from the refrigerators. Tray line temperature logs are kept for every meal and reviewed at the end of the week by the FSD. Internal temperatures of hot foods should be kept between 170 and 180 Fahrenheit. Food observed below the acceptable parameters should be reheated. 415.14 (h)

Based on interviews and record review conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not provide the appropriate liability notices were provided to Medicare beneficiaries. Specifically, the facility did not provide residents/representatives with a Notice of Medicare Non-Coverage (NOMNC) at the termination of Medicare Part A benefits within the required timeframes and did not provide residents/representatives with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) when they were remaining in the facility for care. This was evident for 1 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 38 residents. (Resident #263) The findings are: The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- documented that the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. The Form Instructions for Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS- specify that Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary; or considered custodial. The Notice of Medicare Non-Coverage (NOMNC) form documented coverage for Resident #633 would end on 2/19/22. The NOMNC form was signed by the resident's representative on 02/18/22. There was no documented evidence that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form had been provided to the resident or their representative. On 04/21/22 at 11:17 AM, a phone interview was conducted with the Minimum Data Set Assessor (MDSA). The MDSA stated that the notice is supposed to be given 2 days before services expire and can sometimes be given 3 days before. The MDSA also stated that they could not explain why the notice had not been provided to the representative of Resident #633. The MDSA further stated that during that time period each assessor had a heavy workload of letters to provide and that sometimes it is too much to keep up with all the work. On 04/21/22 at 11:11 AM, a telephone interview was conducted with the Director of MDS (DMDS) The DMDS stated that cut letters are supposed to be sent 48 hours before the cut date. The DMDS also stated that for residents who are remaining in the facility for long term care, provision of the letters is optional and is only given to avoid confusion so Resident #633 did not need to receive any letters. The DMDS further stated that they verbally remind staff to send letters out timely or arrange for letters to be given if they are going to be absent on the date that the letter is due. The DMDS stated that all MDS are registered nurses and know what they are supposed to do. 415.3(g)(2)(i)

Based on interviews and record review conducted during a Recertification and Complaint Survey (NY 418, NY 233), the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment resulting in serious bodily injury, were reported to State Survey Agency within 2 hours for 2 (Resident #253 and Resident #510) of 6 residents reviewed for Accidents out of a total sample of 38 residents. Specifically, (1) on 5/15/21, Resident #253 fell from bed during repositioning by the Cetified Nursing Assistant (CNA) and sustained a [CONDITION(S)], and the incident was not reported to New York State Department of Health (NYSDOH) until 5/19/21; (2) Resident #510, a Dementia resident diagnosed with a Urinary Tract Infection ([CONDITION(S)]) and Pnemonia who required limited assistance with toileting, sustained a [CONDITION(S)] in an unwitnessed fall that occurred while attempting to go to bathroom on 2/18/21, and the incident was not reported to NYSDOH. This was evidenced by: The facility policy titled Accidents -Incidents, created 11/2013 and last revised dated 8/2021, documented: An incident is any occurrence not consistent with the routine operation of the center or normal care of the resident. It may be a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or an injury of unknown origin. The incident may be a theft or misappropriation of resident property. The policy further documented the Director of Nursing (DON), and the Administrator (Admin) are responsible to review Incident / Investigation and Conclusion to determine if incident requires reporting to outside agencies such as: DOH, OIG CMS etc. The facility Policy titled Abuse with creation date 9/2012 and last revised date 2/2022 documented should the investigation reveal that abuse occurred, the Administrator shall report such findings to the local police department, the ombudsman, and the state licensing certification agency within 2 hours of the results of the completion of the investigation, as indicated, and to the state survey and certification agency within five (5) days of the completion of the investigation. The alleged staff member could be permanently removed from the schedule. The Policy furthur documented Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation / identification of allegation) by Agency's designated process after identification of alleged/suspected incident. Initiate process according to the Elder Justice Act and State- specific regulations. 1) Resident #253 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #253 had severely impaired cognition with short and long-term memory problems. The resident was rarely never understood. The facility Accident/Incident Investigation Report Form dated 5/17/2021 documented on 5/15/2021 at 8:30 AM, Resident #253 sustained a fall from the bed during the provision of Activity of Daily Living (ADL) care. The investigation report documented an x-ray was ordered, and the results received on 5/16/2021 showed the resident had a fracture of the left Tibia/Fibular. Resident #253 was transferred to the emergency room (ER) for evaluation. The Investigative report further documented resident #253 returned to the facility on [DATE] with a cast to the left lower extremity. The NYSDOH intake form documented the facility reported the fracture involving resident #253 on 5/19/2021 at 7:50 PM. The facility documented the incident occured on 5/15/2021 at 8:30 AM. The facility did not report the incident to NYSDOH within 2 hours. During an interview on 4/20/22 at 02:31 pm, the Director of Nursing (DON) stated the reporting policy/procedure is part of the facility Abuse policy. The DON stated the facility protocol for reporting injury of unknown origin, fracture, major injury, abuse, and neglect should be reported within 2 hours, and other incidents/allegation, such as a witnessed fall, should be reported within 24 hours if there is no major injury. The DON stated if there is a fracture or major injury of unknown origin, it is reported immediately. The DON stated for Resident #253, an x-ray was done and the resident was diagnosed with a fracture. Resident #253 was transferred to the ER for evaluation. The DON stated the investigation was completed, and the incident was reported to DOH. The priority was to address resident needs and investigate. The DON could not remember the exact date this incident was reported to DOH, but they knew it was reported. 2) Resident #510 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 02/18/2021, documented that Resident #510 had severely impaired cognition. The MDS documented the resident required extensive assistance with bed mobility/transfer/dressing/toilet use and personal hygiene. Required supervision with eating. No pressure ulcers and no skin conditions documented. Occupational and physical therapy dates documented. The Admission Minimum Data Set, Assessment Reference Date (ARD) 1/3/2021, documented that Resident #510 had severely impaired cognition. The MDS documented that the resident required supervision with bed mobility, transfer and eating. Limited assistance with dressing, toilet use and personal hygiene. No pressure ulcers and no skin conditions documented. The Nursing Note on 2/18/2021 at 08:27 documented that the unit manager ( RN#11) was called by the charge nurse and on arriving they observed Resident #510 laying on the floor on her roommates bed (B) on their stomach. On assessment by the NP resident complained of pain to the right hip (therefore, resident was unable to be moved until EMT arrived on unit. Resident stated that they were on the way to the bathroom and slid due to urine on wet floor and note wearing any nonskid socks/footwear. Resident did not use call bell for assistance. Nurse Practitioner order: Resident to be transferred to hospital Emergency department status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical provider notification documented. The Team Meeting Note on 2/18/2021 at 09:51 documented on 2/18/2021 Resident #510 was observed lying on the floor in front of roommate's bed. Resident has a BIMS of 5 and stated that they were on the way to the bathroom, and they slipped. Resident appeared to have voided and floor was wet with urine, resident also noted barefoot. Registered Nurse (RN) assessment with provider noted with pain and limited range of motion (ROM) to right hip. Order to transfer to ER for eval. Plan documented resident transferred to hospital ER for further eval. The Nursing Note on 02/18/2021 at 15:31 documented date/time of actual observation/discussion/etc: 02/18/2021 12:00AM resident left unit at 8:40AM via stretcher accompanied by 2 transporters. The Nursing Note on 2/18/2021 at 21:34 documented resident sent to hospital. The Nursing Note on 2/19/2021 at 10:50 documented and resident family was notified of resident's unwitnessed fall. The Accident and Incident Report (Incident # ) documented the occurrence was on 2/18/2021 at 7:35 AM. The report documented a fall and the resident complained of pain to right hip. Documented notification of medical provider and resident representative on 2/18/2021 at 07:35, ambulance called. Documented resident was sent to the hospital on 2/18/2021 at 07:35AM. The RN Supervisor statement, Licensed Practical Nurse statement, Certified Nursing Assistant statement were documented. Documented resident found on floor in room by roommate be, urine on floor and not wearing nonskid socks. The Resident was transferred to hospital ER and admitted for right intertrochanteric fracture. Interventions documented included supportive care, transfer to hospital emergency room , all residents have the potential to be affected, fall risk assessments and Fall Prevention Quality Assurance Process Improvement (QAPI). Investigation Conclusion documented a full investigation was conducted which included interviews, collection of statements, and review of medical records. There was no breach in resident's plan of care, therefore, there is not cause to determine that abuse, neglect or mistreatment occurred on the part of the facility. Resident was ambulating to the bathroom and slipped. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report for compliant NY 233 documented the incident with injury was reported to NYSDOH by Resident #510's family member. There was no documented evidence the facility reported the resident's fall with fracture to NYSDOH. During an interview on 04/19/2022 at 11:47 AM, the assigned Licensed Practical Nurse (LPN#4) stated they cannot recall the fall for the resident. They would notify the supervisor and they would provides accident and incident documentation. Statements would be done for staff present at time of incident. During an interview on 04/19/2022 at 12:40PM, RN#11 stated that they could not recall if the resident had a fall and if everything would be documented in their notes. They stated the resident was alert and oriented x2 with periods of confusion. During an interview on 04/19/2022 at 03:58PM, RN #2 was interviewed and stated they recall the resident had a fall ambulating and attempted to go to the restroom and slipped on urine. RN #2 stated that RN #11 wrote a note at the time. When a resident has an incident, it is reported to the manager, assessment, call physician and family and gets discussed in morning report as a team. If the incident has an injury and resident transferred out, we get notified and if fall with no injury discussed in morning report. RN#2 stated they were working as the Assistant Director of Nursing Services (ADNS) at the time. Look at the incident report review statement, chart, was injury preventable and any measures put into place. We discussed it as a team some instances would report to the administrator and Director of Nursing (DON) are involved in if the incident warrants reporting to Department of Health (DOH). For a fall with injury, we would not ordinarily call the police. The care plan nurse manager and they assist at times to update the care plan. DOH reporting within 24 hours. For all allegation of abuse neglect report within 2 hours. DON and administrator are the reporters for the incident. During an interview on 04/19/2022 at 04:11PM, the Nurse Practitioner (NP) was interviewed and stated the resident had dementia, nurse notified them that the resident had an unwitnessed fall and they were on the floor and urine was on the floor. They complained of excruciating pain to the hip and high suspicion of a fracture and was sent to the hospital. During an interview on 04/20/2022 at 02:38PM, the Administrator stated that they did not recall Resident #510 or the incident. The Administrator stated they sign-off on incident reports that involve major incidents, such as fractures, but he/she did not recall reviewing the incident report for Resident #510. The Administrator stated fractures of unknown origin should be reported to NYSDOH, but injuries of known origin are not reported to DOH. The Administrator stated reporting is determined on a case-by-case basis. Major injuries, elopement, and power outages are reported to NYSDOH within 2 to 3 hours. The ADNS completes the investigation and determines if reporting necessary. The DON is also responsible for reviewing incidents. During an interview on 04/21/2022 at 03:43PM, the Director of Nursing (DON) stated that Resident #510 complained of right hip pain, and they were sent to ED for further medical follow-up. The DON stated if the facility is aware of how the incident happened, such as a fall, they are not required to report the incident. The fracture is not a major injury because we know how it occurred. The DON stated the facility did not report the incident to NYSDOH. Reportable incidents include abuse, neglect mistreatment, misappropriation, if fracture of unknown origin and major disaster. 415.4(b)(1)(i)

Based on record review and interview during a Recertification survey conducted from 4/14/22 to 4/21/22, the facility did ensure that each resident who experiences a significant change in status is comprehensively assessed. Specifically, a Significant Change in Status Assessment was not completed following the start of hospice services. This was evident for 1 of 1 resident reviewed for Hospice and End of Life out of a sample of 38 residents (Resident #245). The findings are: The facility's policy and procedure entitled Change in Resident's Condition dated 2/22 documented a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision to the care plan. It further documented if a significant change conditions occurs, a comprehensive assessment of resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. Resident #245 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident has short-term/long-term memory problem and cognitive skills for daily decision making was severely impaired. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS did not document that the resident was receiving Hospice services. The Certification of Terminal Illness (CTI) dated 2/10/22 documented Resident #245 has a terminal prognosis with a life expectancy of six months or less should the disease run its normal course and that Resident #245 is certified for Hospice benefit effective 02/10/22. The Notification of Hospice admitted d 2/10/22 documented Resident #245 was admitted to hospice services with an effective date of 2/10/22. The Comprehensive Care Plan (CCP) initiated 2/11/22 documented that resident is at the end of life/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing note dated 2/8/22 documented that Interdisciplinary Team (IDT) meeting was held with three family members, social worker, and nurse manager. The note also documented resident's family wishes for resident to be evaluated for palliative/in house hospice care. Attending Physician was made aware of the family wishes. The Social Service note dated 2/9/22 documented Family Meeting/Phone Conference was held on 2/8/22 to review the care plan and palliative/hospice service and that resident's family agreed to place resident in palliative care. The Physician monthly note dated 2/22/22 documented resident on hospice, to provide comfort measures. There was no documented evidence in the medical record that a Significant Change MDS assessment was initiated or completed when the resident was placed on Hospice care. On 4/20/22 at 2:32 PM, an interview was conducted with Director of MDS (DMDS). The DMDS stated that a significant change assessment should be submitted when a resident enrolls in hospice program. The DMDS also stated that the Admission department will send change report if any resident enrolls in hospice program and the MDS department will then submit a significant change assessment. The DMDS further stated they were not made aware of Resident #245's enrollment to hospice care and they did not receive a change report regarding this resident and therefore, it may have been missed. On 4/21/22 at 11:03 AM, Social Worker (SW) #1 was interviewed. SW #1 stated Resident #245's family agreed to place resident on hospice on 2/8/22. The hospice form was signed by the Attending Physician on 2/10/22 and resident was admitted to MJHS Hospice on 2/10/22. On 4/21/22 at 11:35 AM, Nurse Manager (NM) #1 was interviewed. NM #1 stated Resident #245 was evaluated for hospice and was currently receiving hospice services. NM #1 stated that significant change assessment is initiated by MDS department and they did not know why the significant change assessment was not completed for Resident #245. 415.11(a)(3)(ii)

Based on record reviews and interviews conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not ensure they electronically transmitted encoded, accurate, and complete MDS data to the CMS System within 14 days. This was evident for 1 of 2 residents reviewed for Resident Assessment out of a sample of 38 residents. (Resident #3) The findings are: The facility policy titled MDS completion and submission created on 10/2014, last revised 2/2021, documented that the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The timeframe for transmission of MDS assessments is specified as 14 calendar days after completion. Review of the facility Electronic Medical Record (EMR) documented that a Quarterly MDS for Resident #3 dated 2/14/22 was completed on 2/26/22 and not accepted. The EMR also documented a submit by date of 3/12/22. On 04/21/22 at 11:11 AM, an interview was conducted with the Director of MDS (DMDS) who stated that the MDS was accepted on 3/14/22 and the CMS Submission Report was requested. The CMS Submission Report dated 4/21/2022 10:56 with completion date of 4/21/2022 11:01 documented that 1 record was submitted for Resident #3. The Submission Report also documented Record Submitted Late: The submission is more than 14 days after. On 04/21/22 at 1:35 PM, a follow-up phone interview was conducted with the DMDS. The DMDS stated that they did not tell the surveyors when the MDS was submitted, only the date the MDS in question was completed. The DMDS also stated that the MDS was not locked in the system so did not get batched appropriately so that it could be submitted. The DMDS further stated they try to submit everyday and may have missed this MDS. 415.11

Based on record review and interview conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not ensure a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and included the resident's goals, desired outcomes, and preferences were developed. Specifically, care plans were not developed for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 2 of 9 residents reviewed for Nutrition out of a sample of 38 residents. (Resident #120 & Resident #254) The findings are: The facility policy and procedure titled Care Plans - Comprehensive dated 02/2022 documented it was the policy that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. Resident #120 was admitted to facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS dated [DATE] documented that an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] and 3/28/2022 documented that an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject as per sliding scale. The medical record contained no documented evidence that a comprehensive care plan had been created for management of a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/20/22 at 02:19 PM, an interview conducted was Nurse Manager (NM) #3. NM #3 stated that when there are new admissions a major care plan based on diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . NM #3 reviewed the Electronic Medical Record and noted resident was readmitted to the facility in January 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NM #3 that all Registered Nurses are responsible for the creation of care plans on the 5th Floor and they could not explain why the care plan had not been created. 2. Resident #254 was admitted to facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented resident received anticoagulant medication on 4 of 7 days. The Quarterly MDS assessments dated 2/20/22 and 3/23/22 documented resident received anticoagulant medication on 7 of 7 days. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record contained no documented evidence that a comprehensive care plan had been created for management of a resident prescribed anticoagulant medication. On 04/20/22 at 02:19 PM, an interview was conducted with Nurse Manager (NM) #3. NM #3 stated that the care plan for a resident receiving an anticoagulant could be included on the cardiac care plan. NM #3 reviewed the Cardiac care plan in the medical record and noted that the care plan did not document goals and interventions for a resident receiving anticoagulant therapy. NM #3 also stated that side effects for anticoagulant medications include a risk of bleeding and specific monitoring so a care plan should have been created for this issue. On 04/20/22 at 02:35 PM an interview was conducted with Registered Nurse (RN) #3 assigned to the 5th floor Ultra-Care Unit. RN #3 stated that Care plans are done upon admission and a resident prescribed anticoagulant meds would have a cardiac care plan created. RN #3 reviewed the medical record and noted there was no care plan for management of a resident receiving anticoagulant medication. RN #3 also stated that a risk of anticoagulant medication is bleeding so an anticoagulant care plan should have been created and not a cardiovascular function care plan. 415.11 ( c )(1)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that each resident was offered the opportunity to participate in the review of their comprehensive care plan (CCP). This was evident in 1 of 2 residents reviewed out of a sample of 38 residents (Resident # 46). Specifically, a Resident #46 was not invited to their CCP meetings with the interdisciplinary team (IDT). The findings are: The facility policy titled CCPs revised 02/2022 documented residents will be informed of their right to participate in their treatment. Resident # 46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #46 was cognitively intact. The CCP Meeting Attendance Record documented CCP meetings for Resident #46 took place on 04/01/2021, 10/28/2021, and 1/27/2022. Resident #46 signature was not documented on the CCP Attendance Record. There was no documented evidence in the medical record that Resident #46 was invited to the care plan meetings held on 04/01/2021, 10/28/2021, and 01/27/2022. On 04/18/2022 at 3:24 PM, Social Worker (SW) #2 was interviewed and stated Resident #46's initial CCP meeting was held on 04/01/2021 and there is no documented evidence Resident #46 was invited to attend. SW#3 was interviewed on 04/20/2022 at 3:00 PM and stated cognitively intact residents and their RRs are invited to CCP meetings. Resident #46 is cognitively intact and should have been invited to all CCP meetings. 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure the services provided met professional standards. This was evident 1 out of 37 sample residents observed for medication administration (Resident # 295). Specifically, 1) the Registered Nurse (RN) prepared medication in advance and left it in the medication cart, 2) the RN did not wait to ensure that a resident took administered medication. The findings are: The facility policy titled Medications Administration dated 02/20/2021 documented medications shall be administered safely and may not be prepared in advance. and must be administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal order) Resident # 295 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 295 had moderately impaired cognition. On 04/19/2022 at 11:05 AM, Resident #295 was observed walking in the 2 East hallway asking for the medication nurse. RN #1 walked to the medication cart, took a prepared medication cup from the cart, and handed the medication cup to Resident #295. RN #1 walked away from the medication cart without observing Resident #295 take their medication. Resident # 295 stood behind the medication cart, took another medication cup from the cart, transferred medication from their cup into one they took from the cart, left it on the medication cart, and walked away. On 04/19/2022 at 11:10 AM, RN #1 was interviewed and stated they gave Resident # 295 medication but did not wait to see if the resident took the medication. Resident # 295 did not take the orange pill, and this was the medication Resident # 295 left on the medication cart. On 04/19/22 at 11:15 AM, the Assistant Director of Nursing (ADON) was interviewed and stated the medication nurse must stay with the resident until the resident takes their medication. The medication nurse is not supposed to pre-pour medication. They must wait until the resident is available before removing the pills from the blister pack. On 04/20/2022 at 3:42 PM, the Director of Nursing (DON) was interviewed and stated the resident must take the medication before the medication nurse leaves. The medication nurses are not supposed to prepare the medication ahead of time. The DON was unaware that RN #1 gave medication to Resident #295 that was prepared in advance. 415.11(c)(3)(i)

Based on record review, observation, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. Specifically, an emergency medication box with expired medication was not removed from a medication storage room. This was evident for 1 of 7 medication storage rooms observed during the Medication Storage and Labeling task. (Unit 5 East Wing). The findings are: The facility policy and procedure titled Medication - Storage dated ,d+[DATE] documented it was the policy for the facility to provide guidelines for proper storage of medications within the facility. The center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the Department of health guidelines. On [DATE] at 10:57 AM, a sealed Emergency box was observed in the Medication Room on 5 East. The untitled document placed on the emergency box documented Box expires: [DATE] and an expiration date of ,d+[DATE] for [MEDICATION(S)] Inj. ([MEDICATION(S)]) 0.5mg/2mL and [DATE] for [MEDICATION(S)] Inj 1% was noted. An interview was conducted immediately with Licensed Practical Nurse (LPN) #3. LPN #3 stated the emergency box is barely touched and if it is used, it is brought downstairs to the nursing office to be immediately restocked. LPN #3 also stated they were not aware of the emergency box expiration dates and thinks it is the LPN's responsibility to check the expiration date on the emergency box in the medication storage room, but they were not sure. On [DATE] at 12:25 PM, an interview was conducted with Nurse Manager (NM) #3. NM #3 stated that all nurses including the nurse managers check medication rooms and carts. NM #3 also stated that they also check for expired medication removal and restocking of medication carts. NM #3 further stated that all nurses were inserviced on medication storage in the past. On [DATE] at 01:54 PM an interview was conducted with the Director Of Nursing (DON). The DON stated Pharmacy brings emergency boxes and the boxes are kept in nursing supervisor unit. Emergency boxes are placed in each medication room on the floors and extra medication boxes are kept in the facility so boxes can be restocked on units. The DON further stated that the unit manager and nurses on unit are supposed to check the dates and integrity of the boxes and when it is expired, nurses are supposed to remove the expired box off the unit and replace with one from the nursing supervisor office. The DON stated that the nursing supervisor, nurse manager, or nurse can call pharmacy offsite, and notify them of the expired medication and it will then be replaced. The DON also stated that the Pharmacy Consultant mainly does remote monthly audits and does not frequent the facility or inspect medication rooms and carts. The DON further stated they had no record of when the Pharmacy Consultant last visited the facility. 415.18(a)

Based on record reviews, observations and interviews conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not ensure a resident's drug regimen was free of unnecessary medications. Specifically, there was no documented evidence of behavioral monitoring for a resident with a dementia diagnosis who was prescribed an antipsychotic. This was evident for 1of 5 residents reviewed for Unnecessary Medications out of a sample of 38 residents. (Resident #402). The findings are: The facility policy and procedure titled [CONDITION(S)] Medication, created 10/2014 and last revised 2/2022, documented that physicians and mid-level providers will use [CONDITION(S)] medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. The facility policy and procedure titled Antipsychotic Medication use, created 9/2015 and last revised 2/2022, documented that antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Resident # 402 was admitted to the facility on [DATE] with diagnoses that included Non-Alzheimer's Dementia and Depression. On 04/18/22 at 09:32 AM, Resident #402 was observed in their room with a family member. Resident was calmly sitting in wheelchair, watching TV. Resident stated they were tired and was observed dozing off. On 04/19/22 at 09:45 AM, Resident #402 was observed in wheelchair, being wheeled around the unit by family member. Resident was alert, stated doing well. On 04/19/22 at 03:53 PM, resident was observed in the day room, sitting in a wheelchair and next to spouse, participating in recreational activity (craft). On 04/20/22 at 09:52 AM, resident was observed in their room with family member, sitting in wheelchair. Family member stated that the resident had a stroke in 2001 and Dementia started years later. The family also stated that before coming to the facility, the resident was seen by psychiatrist who prescribed medications but they could not recall which medications or what the diagnosis was. The family member also stated that the resident has aggressive outbursts, during which resident refuses to eat, throws food, gets defiant and oppositional and those episodes usually (if not always) coincide with a urinary tract infection. The family also stated that they have noticed that medicines used to control the resident will make the resident too sleepy, which they also do not desire as the resident already spends a lot of time asleep. The Admission Minimum Data Set (MDS) dated [DATE] documented resident was severely cognitively impaired with no behaviors or rejection of care. The MDS also documented the resident received antidepressants on 7 of 7 days. The comprehensive care plan with focus Resident uses [CONDITION(S)] meds, dx (diagnoses) depression dated 8/10/21, and revised 11/17/21 documented goals of decreased episodes of s/sx (signs and symptoms) of depression, anxiety by review date. Interventions included medications as ordered, monitor behaviors, and report side effects to the doctor. Behavior monitoring note dated 10/7/21 documented that resident did not sleep and was placed in a recliner in the hallway. Resident was observed hitting knuckles on the wall and chair and tearing incontinence brief in multiple pieces and talking. Non-pharmacological interventions were provided. There was no documentation regarding the results of the intervention and the note was unsigned. Behavior monitoring note dated 10/20/21 documented resident refused to stay in bed and sat at the edge of the bed and attempted to leave bed. Resident was transferred to recliner by the nursing station for safety and close observation. There were no additional behavior monitoring notes available for review. A nurse practitioner (NP) note dated 10/25/21 stated resident was very sleepy. Recently hospitalized , medications had been changed: [MEDICATION(S)] 0.5mg HS and [MEDICATION(S)] 25mg HS. Both medications held. A medication regimen review dated 10/25/21 documented resident was on [MEDICATION(S)] for dementia, mentioned boxed warning to not use antipsychotics for dementia, consider Psych consult for GDR. Response dated 10/28/21 stated resident was in the hospital. A Psychiatry consult dated 10/26/21 documented resident had recently been readmitted from hospital for agitation. Resident was restless and anxious, with possible paranoia. Medications: [MEDICATION(S)] 0.25mg. Recommendation to discontinue [MEDICATION(S)] and start [MEDICATION(S)], continue [MEDICATION(S)]. A NP note dated 10/28/21 documented resident was lethargic, receiving IV fluids, and was transferred to hospital for [CONDITION(S)] and [CONDITION(S)]. A nursing admission evaluation note dated 11/3/21 documented resident was readmitted from hospital. A NP note dated 11/4/21 documented resident had positive urine culture at the hospital, started antibiotics for [CONDITION(S)]. Meds were adjusted: [MEDICATION(S)] 25mg AM and 50mg HS. A Psychiatry consult dated 11/18/21 documented resident was no longer receiving 2 antipsychotics, appeared anxious, restless, and confused. Resident receiving [MEDICATION(S)] 50mg QHS, recommend [MEDICATION(S)] 25mg QD. No GDR recommended, could exacerbate depression. A NP note dated 11/18/21 documented resident was noted more restless than usual. Urine sample was collected for UA and culture, start antibiotics. A NP note dated 11/19/21 documented resident noted sleepy by family. Meds [MEDICATION(S)] 25mg AM and 50mg HS, will reduce to 50mg QHS. A NP note dated 11/26/21 documented resident still sleepy, will reduce [MEDICATION(S)] to 25mg QHS. A TEAM meeting note dated 12/2/21 documented resident seen by psych, meds [MEDICATION(S)] and [MEDICATION(S)]. Recommendation to start [MEDICATION(S)]. Provider disagrees, no changes made. Urine cultures dated 12/1/21 and 12/2/21 were both positive for Proteus mirabilis. [MEDICATION(S)] started for [CONDITION(S)]. A Psychiatry consult dated 12/16/21 documented meds were [MEDICATION(S)] 25mg QHS. Resident was stable, with no significant anxiety or depression. Recommend GDR trial: d/c [MEDICATION(S)]. A NP note dated 12/17/21 documented resident was seen by psych, who recommended to d/c [MEDICATION(S)]. NP disagreed since resident had been recently hospitalized for agitation. Plan to continue [MEDICATION(S)] 25mg HS. Medication regimen review dated 12/28/21 documented resident on [MEDICATION(S)] 25mg HS for dementia, mentioned boxed warning to not use antipsychotics for dementia, recommends Psych consult for GDR attempt. Response dated 1/6/22 stated psych evaluation done, continue. A NP note dated 12/31/21 documented resident was COVID-19 positive. MD order dated 12/31/21 documented that [MEDICATION(S)] was increased to 50mg QHS. There was no documentation of increased behaviors or a rationale for the increase in [MEDICATION(S)] dosage. A Psychiatry consult dated 1/14/22 documented Meds: [MEDICATION(S)] 50mg QHS. [MEDICATION(S)] was not discontinued as resident has decompensated in the past. Continue w/plan. A Medication regimen review dated 2/24/22 documented resident on [MEDICATION(S)] for dementia. Black box warning not to use [MEDICATION(S)] with or for dementia, please eval for GDR. No response documented. A NP note dated 3/14/22 documented spouse reported resident restless. Start [MEDICATION(S)] based on h/o [CONDITION(S)]. A Nursing note dated 3/14/22 documented resident with increased confusion. On [MEDICATION(S)] for [CONDITION(S)]. A Psychiatry consult dated 3/16/22 stated Meds: [MEDICATION(S)] 50mgQHS. Resident without psych complaints. Recommend decrease [MEDICATION(S)] to 25mg QHS, GDR trial. A Nursing note dated 3/18/22 documented resident complained of pain with urination. A Psychiatry consult effective date 3/31/22, signed 4/5/22. Meds: [MEDICATION(S)] 50mg QHS. MD reports resident restless and agitated at times, decrease in meds would possibly exacerbate agitation, paranoia, restlessness. Recommendation to continue plan. There was no documented evidence of behaviors or behavioral monitoring for a resident prescribed an antipsychotic who had a Dementia diagnosis. On 04/20/22 at 01:55 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated resident primarily speaks Spanish but also understands English. CAN#1 stated family is very involved with resident's care and prefer to have care provided for the resident early in the day as a family comes to spend time with the resident every day. CNA #1 also stated that they have never seen the resident agitated or displaying any behaviors. On 04/20/22 at 01:58 PM, an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated resident has confusion at times and although the resident speaks Spanish, they are able to make their needs known. LPN #2 also stated one or twice a week the resident gets agitated and refuses care and medications and with encouragement of family encourages will comply. When the resident refuses care, staff will return at a later time when resident is more agreeable. LPN #2 further stated they had never observed the resident with violent behavior or hearing voices or seeing things not present. LPN #2 stated behavior notes are written when a resident is displaying aggressive behavior toward others. LPN #2 stated resident's refusal of care should probably have been documented in the medical record but they had not written any behavior notes for this resident. On 04/20/22 at 02:10 PM, an interview was conducted with Nurse Manager (NM) #2. NM #2 stated that Resident #402 does not have any behavior issues and they had not observed the resident have any outbursts or display aggressive behaviors. NM #2 also stated that behavior notes are indicated if someone exhibits behaviors and if a resident has had a change in psych meds and to their recollection resident has had no behaviors documented. On 04/20/22 at 03:51 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated the resident has frequent urinary tract infections ([CONDITION(S)]'s) and recently finished a course of antibiotics and has been prescribed [MEDICATION(S)] to prevent UTIs. NP stated they would review the resident's course on antipsychotic medication and reconvene the interview. On 04/21/22 at 11:23 AM, a follow-up interview was conducted with the NP. The NP stated resident was admitted to the hospital 10/15/21-10/19/21 and diagnosed with [CONDITION(S)] as medical cause for the resident's agitation was ruled out by negative urinalysis. At that time the psychiatrist in the hospital recommended to start the resident on [MEDICATION(S)] and [MEDICATION(S)]. On 10/28/21 resident was again sent to the hospital for drowsiness and altered mental status and the [CONDITION(S)] medications were held. Resident was treated for a [CONDITION(S)] at that time and returned on [MEDICATION(S)] 25mg in the morning and [MEDICATION(S)] 50mg in evening. [MEDICATION(S)] dosage was decreased to 50mg in evenings only on 11/19/21 and on 11/26/21 was decreased to 25mg. The NP also stated that they saw where the dosage was increased on 12/31/21 to 50mg and that this was probably because of increased agitation and restlessness but they did not see a note that documented what was occurring with the resident at that time and why the dosage was increased. The NP further stated that the resident was diagnosed with a [CONDITION(S)] on 12/18/21 and they were aware of the black box warning for use of antipsychotic medication in residents with a diagnosis of Dementia. On 04/21/22 at 12:09 PM, an interview was conducted with the Medical Director (MD) The MD stated that the resident has a prolonged history of auditory hallucinations and agitation which resulted in multiple hospitalization s and the resident being placed on [MEDICATION(S)]. The MD also stated that they did not see documentation of resident behaviors in the preceding months and that the resident did have frequent [CONDITION(S)]'s. The MD further stated they could locate no explanation in the record for the increase in [MEDICATION(S)] on 12/31/21 other than that the resident was diagnosed with COVID-19. The MD stated that they were aware of the black box warning and do attempt gradual dosage reductions for resident but both himself and the NP disagreed with the psychiatrist on need for tapering of [MEDICATION(S)] for this resident. The MD also stated the medical record should reflect what is going on with the resident. 415.18(c)(1)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure the medication error rate was less than five percent (5%). This was evident for 1 of 37 residents observed for medication administration resulting in an error rate of 8.11% (#295). Specifically, 1) Registered Nurse (RN) #1 administered pre-poured prescribed medication to Resident #295 and walked away without observing the resident take their medication, and 2) Resident #295 did not take all prescribed medications and left prescribed medication in a cup on the medication cart. The findings are: The facility policy titled Medications Administration dated 02/20/2021 document medications shall be administered safely and may not be prepared in advance. Resident # 295 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 295 had moderate cognitive impairments. On 04/19/2022 at 11:05 AM, Resident 295 was observed asking for the medication nurse. RN #1 walked to the medication cart, took out Resident # 295's pre-poured prescribed medication in a medication cup, gave the medication cup to Resident #295 and walked away. Resident # 295 stood behind the medication cart, took another empty medication cup from the cart, poured pills from their medication cup into the empty medication cup, left the second medication cup on the cart, and Resident #295 walked away. On 04/19/2022 at 3:06 PM, Resident # 295 was interviewed and stated RN #1 gave Resident #295 potassium. Resident #295 does not like potassium's effect on their legs and did not take the prescribed potassium medication. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDO dated 03/14/2022 documented Resident #295 was prescribed [MEDICATION(S)] 20 mg by PO QD. The MDO dated 04/10/2022 contained Klor-Con 10 meq PO QD. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10 MG PO TID; [MEDICATION(S)] 10mg 1 tablet PO QD; Klor-Con 10 meq 1 tablet by PO QD. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/19/2022 at 11:10 AM, RN #1 was interviewed and stated RN #1 gave Resident #295 morning medication but did not wait to see if the resident took all the pills. RN #1 observed the medication cup left on top of the medication cart by Resident #295 and stated Resident # 295 left the second medication cup on top of the cart and did not take the orange pill. RN #1 was unable to identify which prescribed medication Resident #256 left on top of the cart. On 04/19/2022 at 11:15 AM, the Assistant Director of Nursing (ADON) was interviewed and stated the medication nurse must stay with the resident until they observe the resident take the medication. They are not supposed to pre-pour the medication. On 04/20/2022 at 3:42 PM, the Director of Nursing (DON) was interviewed and stated the resident must take the medication before the nurse leaves. The nurses are not supposed to pre-pour the medication ahead of time. 415.12(m)(1)

Based on observation, record review and interview conducted during the Recertification survey, the facility did not ensure infection control practices were maintained. This was evident for 1 of 7 units (7 Floor Unit; Singer #1, #2, and #3). Specifically, Singer #1, #2, and #3 were observed not wearing surgical facemasks while providing Recreational activities to residents in the 7th floor dining room. The findings are: The facility policy titled Recreation Services -COVID revised 06/07/2021 documented all staff must be masked while in the dining rooms. The facility policy titled PPE Use- Mask revised 02/2022 documented all staff should wear surgical masks while in duty no matter department of work. On 04/14/2022 at 03:50 PM, Recreation staff were observed singing to 16 masked and 1 unmasked resident in the 7th floor dining room. Singers #1, #2, and #3 were observed singing in front of the residents without surgical masks in place. On 04/14/2022 at 04:55 PM, Singer #1 was interviewed and stated they should be wearing a mask when singing to residents but it is difficult to breathe. On 04/14/2022 at 04:57 PM, Singer #2 was interviewed and stated they did not receive instruction re: how to wear masks and sing. The mask is taken off when Singer #2 is singing and put back on after singing has been completed. On 04/14/2022 at 04:58 PM, Singer #3 was interviewed and stated they were unaware of COVID-19 infections in the facility and usually does not wear a mask while singing. On 04/20/2022 at 02:03PM, the Director of Recreation (DOR) was interviewed and stated, although the Singers should don a mask at all time, the DOR was aware some Singers take their masks off. All staff don masks when entering the facility and maintain a distance of 6 feet from residents to promote good infection control practices. On 04/20/2022 at 03:00PM, the Infection Preventionist was interviewed and stated anyone who enters the facility should have a mask on at all times once when they enter the building. 415.19(a)(1),(b)(4)

[NAME] Park Center for Rehabilitation & Healthcare F689 S/S G Exit date: 02/10/2022 Due Date: 02/25/2022 RO:NYC/Jean [NAME] Based on observation, interviews and record review conducted during an abbreviated survey (NY 289) on 01/21/2022, the facility failed to ensure that the environment remained as free of accident hazards as possible and that each reach resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) out of 3 residents reviewed. Specifically, on 10/22/2021, Resident #1 was given a microwaved bowl of soup by Certified Nursing Assistant (CNA) #1. Resident #1 was transporting the reheated soup back to his/her room while self-propelling the wheelchair. The reheated soup spilled, and Resident #1 sustained [CONDITION(S)] to the left wrist and forearm. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The Findings are: Review of Facility's Policy and Procedure entitled Food-Reheating dated 05/2019 documented: Only staff members are to re-heat the resident food and or liquids. The staff member is to use the dial thermometer to ensure that the item or liquid reaches 165 degrees Fahrenheit to prevent food borne illnesses. Temperature should be checked in at least 2 places. A facility Incident Report dated 10/22/2021 documented that Resident #1 sustained blisters to their left wrist and forearm . Resident #1 reported that he/she accidentally spilled hot soup on their arm. The Nursing assessment revealed new skin alterations with [CONDITION(S)] (superficial redness of the skin) and raised [CONDITION(S)] to the left wrist. The summary of investigation documented that Resident #1 reported they accidentally spilled hot soup over their left arm. CNA #1 written statement documented that CNA #1 was in the nurse's lounge on their break when Resident #1 knocked on the door and asked for their soup to be warmed up. CNA #1 warmed up the soup and offered to take the soup to the resident's room. Resident #1 insisted on carrying the soup. CNA #1 gave Resident #1 the soup. The facility concluded after review of statements, interviews, and medical record review, abuse, neglect, or mistreatment could not be substantiated. The facility documented Resident #1 requested for soup to be heated up. Resident#1 had a Brief Interview for mental status (BIMS) of 15/15 (intact cognition) and stated that he/she accidentally spilled the soup over their left wrist and forearm. Resident #1 was initially admitted to the facility with diagnoses including [CONDITION(S)], Diabetes Mellitus, and Left Above Knee Amputation (AKA). The Minimum Data Set (MDS, a resident assessment tool) dated 08/22/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and the ability to recall information) and scored 15/15, associated with intact cognition. The MDS documented that Resident #1 required extensive assistance of one-person physical assist with eating and locomotion on and off the unit. The MDS identified that Resident #1 uses a wheelchair for ambulation. During observations of the resident dining room and staff lounge on 1/21/2022 there were a sign posted near the microwave which read: enforcement-cooling 45degree Fahrenheit and 165-Fahrenheit for reheating. There was thermometer located in the resident dining room, but not staff lounge. An Activities of Daily Living Care Plan dated 08/18/2021 and Kardex Report (instructions for CNAs) dated 09/01/2021 documented that Resident #1 required supervision and setup help. It documented that staff was to observe all eating and drinking for safety for aspiration precautions. Provide one or many verbal prompts to resident while eating or drinking. A Nurse's note dated 10/22/2021 at 6:34PM, by Registered Nurse (RN) #1, documented that Resident #1 was heating up soup in the microwave and spilled the soup over their left wrist and forearm, while transporting the soup back to the room. Resident#1 had no complaints of pain. At the time the soup spilled, the resident skin looked clean, dry, and intact. Shortly after, the skin was observed with blisters on both their left wrist and forearm. Resident #1. Resident #1 with no complaint of current or historical pain, no signs and symptoms of pain noted. The supervisor and the Medical Doctor (MD) were notified. The MD ordered [MEDICATION(S)] cream and dry protective dressing twice a day (BID). The Nursing Supervisor (NS) #1 notified Resident #1's family member. A Physician's Order dated 10/22/2021 documented an order to clean left-hand burn with Normal Saline. Pat dry and applied [MEDICATION(S)] Cream 1% to left hand/wrist topically everyday shift for left wrist and forearm burn. Cover with non-adhesive gauge, one time a day. Cover wound with cling. A Medication Administration Record dated 10/22/2021 to 11/23/2021 revealed that Resident #1 received Tylenol 500mg, 2 tablets by mouth for pain . A Progress Note, by NS #1, dated 10/22/2021 at 6:34PM, documented that Resident #1 had a cluster of blisters to their left wrist and forearm. A Wound note, by NS #1, dated 10/22/2021 at 6:34PM, documented that Resident #1 sustained a burn to left hand (palm) measured 10x10cm. Cause of wound is documented as HOT SOUP. A Care Plan Note dated 10/22/2021 at 8:53PM, documented that Resident had impaired skin integrity related to blister (s), burn injury to the left wrist and left forearm. The MD's Note dated 10/24/2021 at 1:00PM documented that he/she was asked to follow up on Resident #1's left hand burn happened couple days ago. Resident #1 had clusters of blisters. Resident #1 reported that they spilled hot soup. No discomfort, the blisters seem to be going down. The Skin was warm and had good turgor. Discoloration was observed to the left distal forearm into wrist area. Blister (one area) to wrist area looks flat. One small area to forearm opened. No signs and symptoms of infection or [CONDITION(S)]. Continue [MEDICATION(S)] and monitor. Seemed to be healing nicely. Tylenol as needed. During a telephone interview on 01/21/2022 at 12:00 PM, Registered Nurse (RN) #1 stated that they no longer work at the facility. They stated that on 10/22/2021 they were the charge nurse for the unit during the 3:00PM-11:00 PM shift. RN #1 stated that within the hour of starting their shift on 10/22/2021 Resident #1 reported that they reheated their soup in the microwave and spilled it on themselves as they wheeled themself back to their room. RN#1 stated they assessed the resident and did not observe any redness or blisters on resident's hands, wrists, or forearms. RN #1 stated that the RN Supervisor (NS #1) was notified. RN #1 stated that 1-2 hours later they went to check on Resident #1. At that time RN #1 stated they observed blisters on the resident's left wrist and forearm. RN#1 notified the NS#1 of their observation. RN #1 stated the NS #1 went to the resident's room and assessed the resident. At approximately 6:16 PM the MD was notified via telephone of the blisters. RN #1 stated that the MD ordered [MEDICATION(S)] treatment. RN #1 stated that the staff was responsible for reheating the residents' food. RN #1 stated that he/she was responsible for ensuring that the CNAs are assisting the residents with meals. RN #1 stated that the incident occurred before dinner meal around 4:00 PM. RN #1 stated that Resident #1 went to the staff lounge and asked CNA #1 to warm up the soup. RN #1 stated that Resident #1 was sitting in a wheelchair and was carrying the soup in their left hand when the soup spilled. During an interview on 01/21/2022 at approximately 12:10PM, Nursing Supervisor (NS) #1 stated that they received a call from RN #1 notifying them of the accident. NS #1 stated that they went to Resident #1's room and spoke with the resident. NS #1 stated that at first, Resident #1 reported they reheated the soup by themselves, but later reported that they did not want to get anyone in trouble and that a CNA #1 reheated the soup for them. During a follow-up interview on 2/2/2022 at 3:00 PM NS#1 stated t they assessed the resident after RN #1 called to inform them about the blisters. NS#1 then notified the MD at 6:16 PM and the Director of Nursing (DON) at 6:40 PM. NS #1 stated that upon their assessment the resident sustained second degree [CONDITION(S)] on the left forearm and wrist that measured 10cmx10cm. NS #1 stated that the MD performed a visual evaluation of the resident via Facetime. The MD ordered [MEDICATION(S)] to be applied daily and Tylenol 500 milligrams 2 tablets by mouth every 6hrs for pain. NS #1 stated that the resident finally admitted that CNA#1 reheated the soup for them in the microwave located in the staff lounge. NS #1 stated that there is a sign next to that microwave with instructions on how to reheat food for residents. The instructions include testing the food with a thermometer after it is reheated and prior to serving resident the item. NS #1 stated that both NS and RNs are responsible for supervising staff to ensure they are providing and assisting the residents with appropriate care. NS #1 stated that CNA #1 should have carried the soup for the resident, while assisting Resident #1 back to their room. NS #1 stated that Resident #1's plan of care documented that staff should assist the resident with meal set-up and supervision with eating. During an interview on 01/21/2022 at 1:00 PM, the DON stated they were informed of the incident on 10/22/21 at 6:40 PM. They initiated an investigation and interviewed CNA#1. The DON stated that CNA #1 reported that while they were on break Resident #1 knocked on the door and asked if they would reheat the soup. CNA#1 reheated the soup for 30 seconds. The DON stated that the CNA said that the resident insisted on carrying the soup themself and wheeled themself down the hall with soup in their left hand. The DON stated that CNA #1 should have carried the soup for the resident. During an interview on 01/26/2022 at 4:41 PM CNA #1 stated that that they were in the staff lounge room on lunch break when Resident #1 knocked on the door and asked them to reheat the soup. CNA #1 stated that Resident #1 resides on the East side of the unit and CNA #1 works on the West side of the unit. CNA #1 stated that they reheated the soup 30 seconds and offered to take the soup to Resident #1's room. CNA #1 stated that Resident #1 refused and insisted on taking the soup themself. CNA #1 stated that Resident #1 wheeled off with the soup in their hand. CNA #1 stated that the DON informed him/her that the soup burned Resident #1. CNA #1 stated that a thermometer is in the residents' dining room to test reheated food, but not in the staff lounge. That is why they did not test the soup prior to giving to resident. During a follow-up interview on 2/10/2022 at 11:39 AM CNA #1 stated that they were not sure of the time of the incident, but their break time is between 4:00 PM an 5:00 PM. They also stated that they remembered the soup was covered and that the resident was carrying the soup in their left hand and self-propelled themself in the wheelchair down the hall. They were unaware that the resident spilled the soup and was burned. During an interview on 02/02/2022 at 4:15PM, the MD stated that RNS #1 called them on 10/22/2021 at 6:16PM. They reported the accident involving Resident #1. The MD stated that RNS #1 stated that Resident #1 was sitting in their wheelchair and was transporting soup in their left hand and the soup spilled and burned their left wrist and forearm. The MD stated that they Facetimed with RNS #1 and was able to see the blisters. The MD stated that they gave a telephone order for Normal Saline and [MEDICATION(S)] to apply daily until healed. The MD stated that Tylenol was also ordered to be given every 6 hours for pain. The MD stated that the Physician's Assistant examined Resident #1 on 10/24/2021 and blisters were healing. 415.12(h)(2)

Based on interviews and record review conducted during an abbreviated survey (Complaint # NY 153), the facility did not ensure that services were provided in accordance with professional standards of quality, nursing and medical practice in order to prevent potential delay in [DIAGNOSES REDACTED].#1). Specifically, Resident #1 had multiple Doctor's Orders that were not carried out including orders for lab tests of blood and urine and scheduling for an outpatient surgical appointment. Additionally, Medical Doctor #2 (MD #2), examined Resident #1 on two occasions and did not document resident status or MD recommendations in Resident #1's medical record. MD #2 also recommended transfer of Resident #1 to the hospital. MD #2 did not write a doctor's order for transfer, did not direct staff to transfer the resident and did not take necessary steps to accomplish transfer of the resident to the hospital. The findings include: Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 10/12/2016, the resident had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 9 out of 15, associated with moderate impairment (00-07 Severe impairment, 8-12 Moderate impairment & 13-15 Cognitively intact). A physician's note written by MD #1, the resident's attending physician, dated 10/06/2016 at 9:12 AM documented that MD #2 (a [MEDICATION NAME] (GI)), examined Resident #1 for a leaking J tube (jejunostomy feeding tube surgically inserted through the abdomen). Recommendations were made for lab tests and to consider CT scan of the abdomen and pelvis. There was no documented evidence, and the facility provided no evidence, that MD #2 documented progress notes for the visit. An Order Listing Report dated 10/10/2016 documented that an appointment for outpatient surgery clinic, for a [DIAGNOSES REDACTED]. There was no documented evidence, and the facility provided no evidence, that the appointment was scheduled. A General Documentation nurse's note dated 10/13/2016 documented that MD #2, who was the physician covering the resident's care in the absence of MD #1, ordered lab tests including Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). An Order Listing Report dated 10/13/2016 documented that lab tests for Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) were ordered. There was no documented evidence, and the facility provided no evidence, that the blood tests were performed. There was no documented evidence that MD #2 completed progress notes to address the indication for, or further recommendations based on, the ordered lab tests. An Order Listing Report dated 10/14/2016 documented that CBC, CMP, Urine Analysis and Urine Culture were ordered for a [DIAGNOSES REDACTED]. There was no documented evidence, and the facility provided no evidence, that the blood and urine lab tests were performed. A General Documentation nurse's note dated 10/14/16 at 6:23 PM documented that, upon starting tube feeding, the J tube was noted to be leaking at the base. MD #2 was notified, ordered the feeding rate to be lowered and will follow up. There was no documented evidence that MD #2 completed progress notes to address the issue or the intervention ordered. A Comprehensive Care Path nurse's note dated 10/14/2016 at 11:31 PM documented that formula was infusing by the feeding tube and Resident #1's gown and bed linens were wet from the leaking tube feeding. The tube was leaking from the insertion site. The Registered Nurse Manager (RNM) and MD #2 were on the unit at 11:30 PM and were aware. Intravenous Fluid (IVF) started per order. A General Documentation Note written by the RNM dated 10/14/2016 at 11:48 PM documented that Resident #1 was observed sleeping in bed with leaking J tube at the suture line and that MD #2 examined Resident #1. The RNM documented that, Awaiting approval for transfer to the hospital from Medical Director. There was no evidence that MD #2 documented examination findings, interventions, recommendations or an order to transfer the resident to the hospital. A Transfer to Acute Hospital Form dated 10/15/2016 was completed by an RN and documented to transfer to the hospital for gastrostomy tube status and to evaluate. The resident was not transferred to the hospital. A copy of all the lab tests that were conducted for Resident #1 was received from the Diagnostic Company on 07/13/2017. There was no evidence of lab tests done on 10/13/2016 and 10/14/2016 as ordered. The Administrative Assistant at the Diagnostic Company was interviewed via telephone on 07/18/2017 at 2:45PM. She stated that the company performed no lab tests on 10/13/2016 or 10/14/2016 for Resident #1 and no test were requested for the resident on those dates. Upon request on 04/03/2017 between 1:30 PM and 2:30 PM during an onsite visit, the Director of Nursing Service (DNS) found no evidence of test results for the labs ordered for 10/13/2016 and 10/14/2016 in Resident #1's electronic medical record or elsewhere in the facility's computer system. The DNS also found no evidence that the 10/10/2016 appointment for outpatient surgery clinic ordered on [DATE] was scheduled or completed. A subsequent telephone interview was conducted with the Director of Nursing Service on 11/14/2017 at 2:23 PM. She responded to a question regarding the procedure for outside appointment. She stated that the nurse who picked up the doctor's order should have printed the lab slips and written the consult (written request for consultation appointment). The consult is placed in an inbox on the unit and someone from the transportation department comes to the unit and picks up the consult, makes the appointment and transportation arrangements and then returns the consult to the unit. The Transportation Coordinator, who is responsible for making appointments and transportation arrangements, was interviewed on 07/13/2017 via telephone. The Transportation Coordinator stated that she goes to the units daily and collects the consults, makes the appointments and transportation arrangements. Then she takes the consults with the residents' Face Sheets back to the units and she puts the information back in the box on the unit. She checked the computer (as she was being interviewed) and observed a doctor's order dated 10/10/2016 for an outpatient surgical appointment. She stated that she did not receive a consult for the appointment and that she did not schedule any appointment for Resident #1. MD #1 was interviewed on 10/30/2017 at 5:54 PM via telephone. MD #1 stated that MD #2 was covering, as he was away at a conference, from 10/13/2016 to 10/15/2016. He stated that the covering physician is responsible for the total care of the residents. He further stated that the covering physician can write or give telephone orders and transfer a resident to the hospital if needed. MD #1 also stated that he was not aware that the outpatient appointment was not scheduled and that the staff would not have informed him that the appointment was scheduled. MD #2 was interviewed on 07/10/2017 at 12:27 PM via telephone. He stated that he covered for MD #1 for a few days. He affirmed that on 10/06/2016 MD #1 asked him to come see Resident #1. He stated that he examined Resident #1 on 10/06/2016 and the J tube was leaking and not working well. He verbalized that the J tube was beyond the scope of his expertise, not a tube for a GI doctor. MD #2 stated that, I don't deal with a J tube often. He also stated that he recommended that Resident #1 be evaluated by radiology or surgery. He stated that he adjusted the feeding to 30cc/hr. MD #2 responded to a question regarding the documentation of his examination and recommendation. He stated that he did not document in Resident #1's medical record. MD #2 responded to a question regarding his examination and recommendation of Resident #1 on 10/14/2016. He stated that he examined Resident #1 for the leaking tube and recommend transfer to the hospital. He further stated that he spoke with the RNM instructing her to call the Medical Director or the on-call physician for a decision. Upon inquiry, MD #2 stated I was the covering physician, I am not required to write a doctor's order. When MD #2 was asked if he had documented his examination and recommendation in Resident #1's medical record, he stated, No. The Registered Nurse Manager (RNM) was interviewed on 07/11/2017 at 2:04PM via telephone. She stated that she oversees the residents on the unit and the unit staff. She stated that she did not see lab test orders for 10/13/2016 and 10/14/2016. She further stated that the nurse who picks up the order is responsible for making out the lab slip and putting the slip in the lab book. The RNM also responded that she did not recall seeing a 10/10/2016 order for an out-patient appointment for Resident #1. She stated that the nurse who picked up the order should have written up a consult. The RNM also stated that on 10/14/2016 (she did not remember the time) MD #2 examined Resident #1 for the leaking J tube and verbalized that that the tube needs to be fixed in the hospital. She affirmed that MD #2 stated that Resident #1 needed to be transferred to the hospital, but that MD #2 did not write an order to transfer Resident #1. The RNM also stated that the Medical Director has the final call. She also stated that MD #2 stated that he tried to contact the Medical Director, but the Medical Director did not respond. She stated at approximately 11:00 PM on 10/14/2016, she called the Medical Director, but he did not respond. She added at approximately 11:30PM she informed the Registered Nurse Supervisor (RNS) that the feeding tube was leaking and that she wanted to transfer Resident #1, but she was waiting for the Medical Director to call back. The former Medical Director, who was the Medical Director on 10/14/2016 and 10/15/2016, was interviewed on 10/26/17 at 10:26 AM. He responded to a question regarding the responsibilities of the covering physician and the attending primary physicians. He stated that a covering physician is responsible for the total care of the resident which includes writing a doctor's order to transfer a resident to the hospital. He further stated that he was available to the physicians to discuss resident care including transfers to the hospital. He added that a physician does not need to wait for a response from him to transfer a resident to the hospital. He stated that it is up to the physician or covering physician to transfer a resident. He stated that he would like to know when a resident is being transferred out of the facility. The Medical Director also stated that it is standard medical practice for a physician to document their examination and interventions performed in a resident chart. He stated that he was not aware MD #2 was not documenting in Resident #1's medical record. 415.21(a)

Based on record review and staff interviews, the facility did not ensure that the necessary care and services were provided to attain or maintain the highest practicable physical well-being of the resident. Specifically, the Nurses: 1) administered [MEDICATION NAME] without a physician's orders [REDACTED]. This was evident for 1 of 10 sampled residents reviewed for Unnecessary Medication Use (Resident #287). This resulted in actual harm that is not Immediate Jeopardy. The finding is: Resident # 287 is an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident had moderately impaired cognition and was receiving [MEDICATION NAME] (an anticoagulant-blood thinner). The Comprehensive Care Plan (CCP) for "Anticoagulation Therapy" dated 2/16/12 documented "Problem/Need: Resident receives [MEDICATION NAME]: Resident will have lab values within therapeutic range for the next 30 days...will have no signs of abnormal bleeding...Interventions: Monitor lab work as ordered...Evaluate medication based on lab results...Administer medication as ordered...Assess for signs of abnormal bleeding (e.g. monitor for signs and symptoms such as hematurea, bleeding gums, tarry stools, petechia, etc.)...report any changes in skin condition (e.g. discoloration ecchymosis)...or side effects of medications to physician". The Admitting "Physician Admission/Reassessment Form" dated 2/16/12 documented "[MEDICATION NAME] 5mg (milligrams) po (by mouth) QHS (at bedtime) starting March 1, 2012 ... PT / INR ([MEDICATION NAME] Time/International Normalized Ratio) Q (every) Mon /Thursday once [MEDICATION NAME] RX (therapy) started." A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 5mg by mouth" was administered to the resident from 2/16/12 to 2/19/12 at 9PM . There was no documented evidence in the medical record of a physician's orders [REDACTED]. There was also no documented evidence in the medical record that the resident was monitored for abnormal bleeding from 2/16/12 to 2/20/12 at 8:30pm, a total of 5 days. A Laboratory Report dated 2/20/12 documented "Collected at 8:[MEDICATION NAME] Time (PT) 44.9 seconds (sec) (reference range 9.8-11.9 sec) and INR of 4.4 (reference range 1.0-2.0)...Reported to (Registered Nurse (RN) Supervisor #1) at 2/20/12 04:38pm." A Physician's Assistant Interim Order dated 2/20/12 at 12:00pm documented "T/O (telephone order)...Hold [MEDICATION NAME] for INR 4.4 until further notice". A Nursing Progress Note dated 2/20/12 at 8:30pm, written by a Licensed Practical Nurse (LPN), documented "Resident PT/INR result INR 4.4 [MEDICATION NAME] on hold for 2/20/12. Supervisor (Name) aware. No bleeding noted." There was no documented evidence in the medical record that the resident was assessed by a Registered Nurse (RN) or the medical staff after receiving the abnormal lab results of an INR of 4.4. The Physician's Progress Note dated 2/22/12 at 3:30pm documented "INR 2/20/12 - 4.4 [MEDICATION NAME] on hold. No evidence of bleeding. Plan repeat INR tomorrow." An Interim physician's orders [REDACTED]." The Laboratory Report dated 2/22/12 documented "collected at 08:[MEDICATION NAME] Time 50.2...INR 5.0...Reported to (name of facility staff) at 2/22/12 04:07pm..." There was no documented evidence in the medical record that the resident was monitored and assessed by the nurses for abnormal bleeding from 2/20/12 at 8:30pm to 2/23/12 at 6 pm. There was also no documented evidence that the resident was monitored for adverse reactions resulting from holding the [MEDICATION NAME] from 2/20/12 at 8:30pm to 3/4/12. The Laboratory Report dated 2/23/12 documented "collected 07:45am...received 12:10pm...PT >100.0...INR > (greater than) 10.0...Reported to: (name of facility staff) at 2/23/12 04:02pm." A Physician's Progress Note dated 2/23/12 documented "PT with INR of 10 today...pt not responding to even painful stimuli. Pt on [MEDICATION NAME] c (with) toxicity...A/P (assessment/plan) AMS (Altered Mental Status)[MEDICATION NAME] toxicity R/O (rule out) Bleed ...Ambulance called." Physician's Interim order dated 2/23/12 documented " send to hospital for AMS." The Nursing Progress Note dated 2/23/12 at 6:00 pm documented "...INR=10.0. Altered Mental Status. MD made aware. After assessing Patient ordered transfer to ER (emergency room ) for evaluation. Ambulance called + (and) picked up Patient at 5:20pm." The facility " Patient Transfer Form" dated 2/23/12 documented "Assessment: Altered Mental Status Res (resident) is lethargic. INR 10.0 ...." The facility " Notice of Transfer/Discharge " dated 2/23/12 documented "...An immediate transfer or discharge was required due to the residents urgent medical need. please specify: AMS." The Nursing Progress Note dated 2/24/12 at 5:00am documented "...Resident returned from ER at 3:45am..." An Interim physician's orders [REDACTED].> 10) INR in AM on 02/25/12." The Laboratory Report dated 2/25/12 documented "...collected 08:00 am...Reported 2/25/12 at 06:56 [MEDICATION NAME] Time 61.1 seconds INR 6.1." An Interim physician's orders [REDACTED].@ (at) 60ml/hr (milliliters per hour) x 24 hrs...(Dx hydration)." There was no documented evidence in the medical record that the resident was assessed and monitored by the Licensed and Registered nurses for bleeding upon return from the hospital emergency room at 3:45am on 2/23/12 through 3/9/12. The evening shift RNS (Registered Nurse Supervisor) was interviewed on 4/27/12 at approximately 3:00PM. The RNS stated that he did not recall being notified about the residents elevated INR result and that had he been notified, he would have notified the Physician. The RNS further stated that the resident should have been assessed by an RN, monitored by the nurses and their findings documented in the nursing progress notes. The RNS added that he does not recall if he assessed the resident that evening but that there should be documentation in the chart. The evening shift LPN (Licensed Practical Nurse) who administered [MEDICATION NAME] to the resident on 2/16/12 and 2/17/12 was interviewed on 4/27/12 at 3:30 pm. The LPN stated that her practice is to call the nursing supervisor to find out the resident's INR level, and if it is within normal range, she gives [MEDICATION NAME] to the resident. She stated that the nursing supervisor told her the levels were within the normal range, and that she had seen the physician's orders [REDACTED]. The nurse further stated that there must have been a physician's orders [REDACTED]. On 4/30/12 at approximately 8:30AM, the day shift Registered Nurse Supervisor was interviewed and stated that if a resident is prescribed [MEDICATION NAME], the first line of assessment lies with the " desk nurse, an RN." She's responsible for monitoring the resident for signs and symptoms of bleeding. If the nurse is unclear about anything, she would tell the Nursing Supervisor who would further assess the resident. She also stated that LPNs cannot conduct assessments but are educated on the normal INR ranges and what to report it to the RN. The unit Physician was interviewed on 4/30/12 at 8:45 AM. The Physician stated that he wrote the admitting orders for [MEDICATION NAME] to be administered on March 1, 2012, and was unaware that it had been given prior to that start date and added that it must have been given in error. He was also unaware that PT / INR levels were drawn prior to the [MEDICATION NAME] start date which was not his intent. He also stated that he was not notified about the resident ' s condition until 2/23/12 when he saw the elevated INR level of > (greater than) 10. He stated at that time he went in to see the resident and sent her out due to Altered Mental Status and Lethargy. He stated that although the [MEDICATION NAME] was held after 2/20/12, it is still possible for the INR level to fluctuate, and so it is very important to monitor the resident closely. He stated that he did not see the 2/20/12 INR results until 2/22/12. On 4/30/12 at approximately 10:15AM, the evening shift supervisor was interviewed and stated that she did not recall being notified by the LPN of any abnormal INR levels for the resident. She further stated that the resident had just been admitted to the facility and was not aware that she had an order for [REDACTED]. On 4/30/12 at approximately 10:30AM, Licensed Practical Nurse # 1 (who originally picked up the physician's orders [REDACTED]. He stated that the nurses should document the residents condition on the 24 hour shift report and in the Progress Notes. On 4/30/12 at approximately 3:30pm, the Director of Nursing was interviewed and stated that the Nursing Supervisors are responsible for retrieving all labs. If a critical lab comes in it is the Nursing Supervisor's responsibility to pick up the lab results that are faxed and to assess the resident as needed if an elevated level is obtained. On 4/30/12 at 3:36pm, the Laboratory Manager was interviewed and stated that the "critical" range for INR at the facility is 3.5, which would require the lab to call the RN Supervisor then fax the result. He further stated that on 2/20/12 at 4:38pm, the RN Supervisor was contacted by phone regarding the INR result of 4.4. On 4/30/12 at 4:00pm, the RN Unit Manager was interviewed and stated that she was informed about the 4.4 INR by the Physician's Assistant (PA) during the day shift on 2/20/12. The RN stated that the PA often goes downstairs and checks to see if the lab results have been faxed over, and that the PA must have gotten the lab results and called her about the elevated level, which was why she took a telephone order to hold the [MEDICATION NAME] until further notice. The RN stated that she did not recall assessing the resident that day, informing the LPN who was caring for the resident or telling anyone about the lab result. On 4/30/12 at 4:20PM, the Licensed Practical Nurse # 2 (who reviewed the physicians order sheet dated 2/16/12) was interviewed. She stated that the first nurse signs (pick up) the physician's order [REDACTED]. The nurse stated that she is a back-up to ensure the orders are transcribed correctly and did not recall any transcription errors. The undated policy and procedure entitled "Anticoagulation Monitoring in Residents / Patients taking [MEDICATION NAME] / [MEDICATION NAME] " documented that the nurse ' s responsibility was to "Monitor resident on a regular basis for adverse effects of [MEDICATION NAME] (bleeding). The nurse should also, "Pick up the physician' s order and transcribe order onto MAR. Box off the dates when the medication is to be given." 415.12