Every finding on record at Chapin Home for the Aging

Based on interviews and record review conducted during a Recertification and Complaint survey (NY00343925) from 09/03/2024 to 09/10/2024, the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for 2 of 2 residents (Resident #139 & Resident #140) investigated for Accidents, out of an investigative sample of 32 residents. Specifically, on 05/31/2024 at 4:45 PM, (Resident #139 & Resident #140) left the facility unannounced. Video footage dated 5/31/24 revealed that Residents #139 & Resident#140 left the unit via dietary elevator ground floor at 06:17PM and exited the back door at 06:19PM. They walked to the side of the building, then out of the gate to the backyard. Resident #140 was located at their prior apartment and Resident#139 was located at a Manhattan precinct. The findings are: The facility's policy and procedure dated Elopement Protocol Response Plan Policy last 6/2/24, documented that prevention of an elopement is the facility's 1st priority, and that identifying residents at risk and monitoring their movement is especially important. Resident #140 was admitted to the facility with diagnoses that include Vascular Dementia mild with Anxiety and Alzheimer's Disease. The Admission Minimum Data Set, dated dated dated [DATE] documented Resident's #140 cognition as severely impaired with a Brief Mental Status of 3, wandering with behavior occurring, wandering significantly intrude on the privacy or activities of others and no elopement alarm used. The Admission Minimum Data Set also documented independent with eating, bed mobility, supervision with toileting and transfers, and supervision for walking. The elopement risk assessment dated [DATE] documented Resident#140 as ambulatory or independent in wheelchair locomotion, has risk factors does not exhibit any additional elopement risk criteria, and that elopement care plan not initiated, see comments, not applicable. A Comprehensive Care Plan on Behavioral symptoms, was initiated on 4/18/24. The care plan documented that Resident#140 is at risk for elopement, packs all belongings and look for exit. The goals included resident will adjust to facility, and not elope from facility, edited 7/18/24, target date 10/9/24. The interventions include ensure resident ID band is in place every shift, monitor resident's behavior and provide diversional activities, such as social activities, games, and music. A Nurse's note dated 5/31/24 at 6.02PM, documented that Resident#140 was seen by staff around 3.45PM, and that around 4.30PM, code M was called for the said Resident #140. A search of the building was activated, the Director of Nursing and the Administrator was made aware after the initial search. A Nurse's note dated 06/01/24 at 2:30PM, documented that around 1:57AM, resident returned to the facility accompanied by 2 staff members, appears to be in good stable condition, no changes in ambulation, skin integrity and that a right ankle wander guard was initiated. A Physician's note dated 6/5/24, documented patient recently eloped, no injuries noted. Patient remains alert, no significant change in cognitive status, and caution to prevent elopement. An elopement evaluation dated 6/1/24 documented resident is ambulatory, is cognitively impaired, poor decision-making skills, makes statements that they are leaving, elopement care plan initiated, wander guard placed to ankle. Resident#139 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease and Anxiety Disorder. The Admission Minimum Data Set, dated dated dated [DATE] documented that resident's cognition as severely impaired, Brief Interview of Mental Status score of 4, no wandering, no behaviors, independent with mobility, supervision with transfers and walking, and no wander/ elopement alarm. The elopement risk evaluation dated 3/21/24 documented resident is ambulatory, is cognitively impaired, poor decision-making skills, displays behavior that may indicate an attempt to leave, body language etc. and that elopement care plan initiated. The Comprehensive Care Plan titled Behavioral symptoms, initiated 3/21/24, documented resident is at risk for elopement, waits in front of the elevator. The goals included resident will adjust to the facility, target date 06/21/24. Interventions included to monitor resident's behavior and provide diversional activities encourage sitting with peers in day room. Provide comfort items offer adult coloring, staff to monitor resident via visual check throughout shift during all activities. A Nurse's note dated 05/31/24, documented that Resident #139 who has periods of forgetfulness and confusion, but alert and verbally responsive was last seen by Staff around 3.45PM. Around 4:30pm, code M was called for the said resident, searched the building was activated. The Director of Nursing and the Administrator were made aware after the initial search. A Nurse's note dated 6/1/24 documented that around 1:20AM, Resident#139 returned to facility with 2 Staff, appears in good spirits, no changes in ambulation. The facility's incident report dated 06/02/24, documented that on 05/31/24, Resident # 140 and Resident # 139 were unaccounted for by Staff at dinnertime. Staff initiated a search, called other units to inform them of the situation and then notified security. The summary also documented that Residents #139 and #140 were seen at the beginning at the shift ambulating in the hallway, however, they were not seen at dinnertime. Checks were done on the unit, and they were unable to locate both residents. The security was notified, Code Houdini was called, which is the Elopement code. All rooms, floors, and camera reviewed to determine route to egress. On 06/01/24,the New York Stated Department of Health intake report documented that the Director of Nursing reported that Residents #139 and #140 who eloped together, were found off premises by 11:30PM, and there was no harm to either resident. The 5-day summary investigation reported to the New York Stated Department of Health dated 6/7/24, documented that New York Police Department was called and notified of the event and responded to the facility at 9:45PM. Based on the investigation, corrective action included the mezzanine unit with the Dementia residents were placed on a 30 minute visible head count x 14 days. In order to correct the systemic changes, both elevator F, G are key locked, maintenance will be installing key pads code box, to both elevators that will require Staff to key in codes. The rear administrative parking lot gates remain closed except for shift changes. A Quality Assurance Performance Improvement meeting was held on 6/3/24 and revealed that Residents' #139 and 140 elopement was discussed. Project overview involved reduction of elopement risk, remodeling of current safety interventions, unique to the residents on the Mezzanine level. The Quality Assurance Performance Improvement was reviewed and revealed that the interventions implemented for the elopment was completed on 08/15/24. On 09/05/24 at 02:11 PM, Certified Nursing Assistant #3 was interviewed and stated that they work on 2:30PM-10:30PM shift on 05/31/24. Certified Nursing Assistant #3 also stated that when they came on the unit, they do rounds. and that all the residents were accounted for at that time. Certified Nursing Assistant #3 also said that they realized that Resident #139 and Resident #140 were missing when it was time to serve the dinner, around 4:30PM and 5:00 PM, and the Staff all started looking from room to room. Certified Nursing Assistant #3 said that the staff first realized that Resident #140 was not on the unit, and then realized that Resident #139 is also missing . The Certified Nursing Assistant #3 stated that they knew Resident #139 is candidate for elopement, so they would always closely monitor the resident. Certified Nursing Assistant #3 stated that when they viewed the camera footage, they saw that the dietary elevator came up by itself, unmanned, and that both residents (Resident #139 and Resident #140) went into the elevator. Certified Nursing Assistant #3 stated that they have been in serviced on Elopement. On 09/05/24 at 02:24 PM, Certified Nursing Assistant #4, was interviewed and stated that they worked on 05/31/24 on the 2:30PM-10:30PM shift, and that they were assigned to the dining room for supervision. Certified Nursing Assistant #4 stated that on that day, both residents (Resident #139 and Resident #140) were in the dining room initially, and then Resident #139 came out 1st, then Resident #140 came out. Certified Nursing Assistant #4 stated that don't recall the time, but said that it was around dinner time, at 5:00pm, when they realized that Resident #139 and Resident #140 were missing, Certified Nursing Assistant #4 said that they started looking in all the rooms, notified the charge nurse, who informed the Registered Nurse Supervisor. An elopement code M was then called. Certified Nursing Assistant #4 said that they have been in serviced on Elopement. On 09/05/24 at 02:36 PM, Licensed Practical Nurse #2 was interviewed and stated that they are the primary Licensed Practical Nurse for the unit Mezzanine, on the 6:30AM- 2:30PM shift. Licensed Practical Nurse #2 stated that Resident #140 have always exhibited exit seeking behaviors and looking to get out. Licensed Practical Nurse #2 also stated that they did not work on 05/31/24, and that neither Residents #139 nor Resident #140 had wander guards, however, they are always supervised by Staff when they walk in the hallway. Licensed Practical Nurse #2 also stated that they have been in serviced on Elopement. On 09/05/24 at 02:54 PM, Licensed Practical Nurse #3 was interviewed and stated that they are the primary Licensed Practical Nurse for the unit Mezzanine, on the 2:30PM- 10:30PM shift, but did not work on 5/31/24. Licensed Practical Nurse #3 stated that Resident #140 has been exhibiting exit seeking behavior since admission, and that the behavior had escalated, but had calmed down. Resident#139 would walk up and down the hallway but did not attempt to get on the elevator. Licensed Practical Nurse #2 stated that on admission, the Supervisor would do an elopement risk assessment, and the nurses would monitor the resident. Licensed Practical Nurse #3 stated they have been in serviced on Elopement. On 09/06/24 at 06:21AM, Licensed Practical Nurse #4 was interviewed and stated that they worked on 05/31/24, on the 2:30-10:30PM shift. Licensed Practical Nurse #4 stated that when they came on the unit, they saw Resident #140, just before 4:00PM. At around 4:45PM, at the start of the dinner, the staff did a head count and noticed that Resident#140 and Resident #139 were missing. The Licensed Practical Nurse#4 also stated that prior to the dinner, the residents displayed no exit seeking behaviors. The staff then checked all the rooms and adjoining areas, and when they did not locate the residents, they notified the Registered Nurse Supervisor. An elopement code was called, and the Licensed Practical Nurse #4 stated that they went outside, but the residents could not be found. Both Residents#139 and #140 did not have on any wander guards and that the dietary elevator door can only be opened by a key. Licensed Practical Nurse #4 said since it is the Dementia unit, the staff supervise them all the time. The staff now must have 30-minute monitoring for all the residents. Licensed Practical Nurse #4 said that they have been in serviced on Elopement. On 09/06/24 at 10:19 AM, the Director of Nursing was interviewed and stated that the Mezzanine unit is a unique unit for the Dementia residents, the residents are supervised and allowed to walk on the unit. Prior to the elopement of Residents #139 and Resident #140, the elevators were operated by keys, and that visitors to the units would be escorted by Staff. Staff would also use the stairwell to lessen the opening of the elevators. The Director of Nursing also stated that the dietary elevator, which is a separate elevator, on the other side of the hallway, does not open by itself, and is used mostly by dietary staff. The Director of Nursing stated that they did not know how the dietary elevator doors opened by itself, allowing Residents#139 and Resident#140 to get into the elevator, as the facility later saw when they reviewed the camera footage. The Director of Nursing stated that once the Residents #139 Resident#140 were found to be missing, the elopement code was initiated and a search, both inside and outside the facility, was initiated. The residents were later found later that night: Resident #139 was at a Police precinct in Manhattan, and Resident #140 was found at their home. The Director of Nursing stated that an elopement risk re-assessment was subsequently done on all the residents in the facility, Staff was in-serviced on elopement and an elopement drill was done. Aa Quality Assurance Performance Improvement meeting was held on 06/3/24 and a plan was discussed to prevent further elopements. The Director of Nursing also stated that the elopement risks are done on Admission, quarterly and periodically. On 09/06/24 at 10:38 AM, The Administrator was interviewed and stated that when Residents #139 and Resident#140 elopement occurred, they were not in the facility. The Administrator stated that they were notified immediately, came back to the facility, and called 911.The Administrator stated that the residents were later found in separate areas, in [NAME] and Manhattan. The Administrator stated they cannot figure out how the elevator door for the dietary elevator, opened. The Administrator stated they do not overuse the wander guard, and the facility tries not to overreact by using wander guards. The Administrator stated that security enhancements have been made in the facility. The vulnerability is monitored by the cameras, and that the outside gates are now improved. On 09/10/24 at 10:40 AM, the Security Supervisor of Security, was interviewed and stated that they worked on 05/31/24, and there are 2 security guards until 6:00PM. The Security Supervisor stated that they were notified by a Certified Nursing Assistant, that the 2 residents were missing. Security Supervisor stated that they called the code for missing residents, they organized and handled the whole operation at that time for the elopement. The Security Supervisor stated that a lot of changes have been made since that time of the elopement, and that prior to the elopement, they (security) would have heard just a chime, and seen the camera, but the gates are back gates to the parking lot are not kept open anymore, and are opened only when a car comes in. The Security Supervisor also said that at that time of the Residents' exit on 05/31/24, they were not in front of the cameras, and that there was another security guard, who was busy with an event that was being held, but the Security Supervisor was in the charge of the elopement protocol. On 09/10/24 01:18 PM the Administrator was interviewed and stated that they were aware that there was another security guard, who was involved in the search and that the security was aware of the elopement. The Administrator stated that they did not know if the security guard submitted a statement and or was interviewed. The Administrator stated that the security guard has since left due to illness. The facility implemented corrective actions and was found to be in substantial compliance on 08/15/2024, prior to the start of the Recertification Survey on 09/03/2024. Resident #140 was located at their prior home and returned to the facility on [DATE] at around 1:57AM, accompanied by 2 staff, without injury. Resident #139 was located at a Manhattan Police precinct and returned to the facility on [DATE] at around 1:57AM, accompanied by 2 staff, without injury. Immediately after event on 06/01/24, all residents were reassessed for elopement risk. An elopement risk assessment done on 6/1/24, documented Resident#140 as ambulatory or independent in wheelchair locomotion, has risk factors exhibits additional elopement risk criteria, and that elopement care plan was initiated. A Comprehensive Care plan for Elopement for Resident #140 was initiated on 06/01/24. The Comprehensive Care plan for Elopement for Resident #139 was updated on 06/01/24. The Elopement prevention policy dated 6/20/24 was reviewed and updated. All residents on the mezzanine unit were placed on 30-minute rounds monitoring. A facility wide in-service on Elopement and Elopement Drills were initiated on 05/31/24 and completed on 08/30/24. Residents#139 and #140 were seen by their primary medical doctor. As of 8/15/24, on the Mezzanine unit, all residents remain on 30-minute monitoring round by staff and documentation will be done daily on the residents' activities, behavior, and care. The Dietary staff will continue to enter the elevator code to deliver food trays. A new keypad was implemented to alert keypad to stop the elevator from closing when a resident with a wander guard gets on the elevator. This code is also to access the mezzanine. All staff have been in-serviced with the code. The keypads have been placed in the elevators and outside the elevator on the mezzanine. The same code is required to exit the unit. All staff have been in-serviced to use stairwell B to access the mezzanine units as well to minimize the elevator opening. Visitors to the mezzanine are scheduled and escorted by staff who input the code to access the elevator, prior to pushing the call button for mezzanines. The outside gate automation was activated on 08/08/24. On 8/8/24, the rear gate reconstruction was completed, and the gate activated. The rear gate requires an intercom and keypad, to allow access to the rear parking lot. Once any vehicle has exited the parking lot, the gate will automatically close behind the vehicle, triggered by sensors. On 08/14/24 door upgrades have been completed and implemented by a service company. The activities door, the first floor A stairwell, the mezzanine B stairwell, the ground floor C & D stairwells and the ground floor delivery entrance, now have perimeter mode mag locks and anti-tailgate with a 15 second emergency release. All additional doors have a bypass keypad that requires a code to open the door for 10 seconds. The delivery entrance will continue to let the staff exit to the rear parking lot, by touching the crash bar. Exit doors A, B, C, D have passive locking systems which will require the crash bar to be pushed for 15 seconds. The front desk staff could monitor all exit doors with the wander guard system. 415.12(h)(2)

Based on observations, record review, and staff interviews during the Recertification survey between 09/03/2024 and 09/10/2024, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident with an order to apply shrinker to left knee was observed with no device as per Physician's order. This was evident for 1 resident reviewed for Limited Range of Motion, (Resident #96) out of 32 sampled residents, The findings are: The facility's Policy and Procedure for .Equipment/Devices and Nursing Rehab Program dated 08/2014, documented: .Upon assessment, the Rehab team will provide recommendations for necessary skilled therapy, maintenance program (via Nursing Program), and for any equipment and or/devices the resident may require at that time. Resident #96 was admitted to the facility with diagnoses that included: Hypertension; Asthma, Chronic Obstructive Pulmonary Disease; Cataracts, Glaucoma, or Macular Degeneration. The Annual Minimum Data Set, dated dated dated [DATE] documented the resident has moderate impairment in cognition and is total dependence of staff for most activities of daily living. The Comprehensive Care Plan for Activities of Daily Living Functional Status/Rehabilitation Potential dated 07/23/2021, last reviewed 06/26/2024 documented, that Resident has gait dysfunction, impaired balance, weakness, and decrease in range of motion. Goals are to maintain current functional status, prevent decline and contracture. Interventions included Active Range of Motion to both upper extremities and passive range of motion to both lower extremities. Left knee shrinker to be worn at all times. Remove for hygiene and skin check. There is no documented evidence in Resident #96 Comprehensive Care Plan updated as at 06/26/2024 that the resident is refusing to wear the shrinker or any device ordered for the resident. Physician's Order dated 09/10/2021 documented Rehab: Left knee shrinker to be worn at all times remove for hygiene and skin check. On 09/03/24 at 10:41 AM, Resident #96 was observed in bed, alert and oriented and noted with a below left knee amputation. Resident was interviewed and stated that the staff are not applying anything on their left stump. Resident also stated that the staff were applying some dressing on the right foot before, but they are no longer applying the dressing and they don't know why. Between 09/03/24 and 09/09/24, Resident #96 was observed in bed daily. There was no device applied to the resident's left stump, and there was no device observed in the resident's room. On 09/09/24 at 10:10 AM, an interview was conducted with the Certified Nursing Assistant #1. Certified Nursing Assistant #1 stated that they have been working in the facility for [AGE] years and has been taking care of Resident #96 since after the COVID-19 outbreak. Certified Nursing Assistant #1 also stated that resident is washed, changed, and given a bed bath every day because resident refuses to take showers. They also refusing to come out of bed. Certified Nursing Assistant #1 further stated that resident has a booty applied to the left leg heel all the times but has no device on the left stump because it is amputated. Certified Nursing Assistant #1 stated that they are not aware of any other device to be applied to the left leg apart from the prosthesis that is given to the resident when out of bed. On 09/09/24 at 11:10 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #96 is provided with a booty on right leg all the time, which resident sometimes refuses. Resident will ask the staff to come back later to apply the booty. Licensed Practical Nurse #1 stated that Resident does not have any device on the left leg anymore. Licensed Practical Nurse #1 stated that resident was having something like stocking on the left stump before, but they have not been seen the device anymore and they could not recollect the last time they saw Resident #96 with the left stump device. On 09/09/24 at 11:48 AM, an interview was conducted with the Assistant Director of Nursing who, stated that Resident #96 has order for the heel booty for the right leg, the left leg is amputated, and has an order to have left shrinker all the time. Assistant Director of Nursing stated that they have not seen the resident with the shrinker, and they don't know why they have not been putting it on the resident. Assistant Director of Nursing further stated that they will have to follow up with the Rehab department because Physical Therapy/Occupational Therapy are supposed to provide the device. On 09/09/24 at 12:08 PM an interview was conducted with the Director of Physical Therapy, stated that: Resident #96 is on range of motion program done by nursing - supposed to be twice daily, has the prosthesis when first admitted , but has been declining and has stiffness on the right knee. The left leg is amputated, within functional limit, has an order for the shrinker to be applied to the stump at all times, remove for skin check by nursing. Physical Therapist Director stated that when they screened the resident, they make sure that all equipment and devices are there, they don't normally check regularly if resident is wearing it or not unless they are notified by nursing that resident is not having it or not wearing it. Therapist stated that rehab has not been notified that the device is missing or that resident is not using it. Rehab order recommendation by (Director of Physical Therapy dated 09/10/2021 documented Left knee shrinker to be worn at all times remove for hygiene and skin check. On 09/10/24 at 10:29 AM, the Nurse Educator was interviewed and stated that the Certified Nursing Assistants have been educated on how to check their tasks to see what devices have been ordered for the residents and how to apply them, they were also educated to notify the manager/Rehab staff if the device is missing or if resident is refusing the device; the unit nurses have also been educated to ensure that they are monitoring the Certified Nursing Assistants that they are carrying out their assigned responsibilities as per residents' plan of care. Nurse Educator stated that they are surprised that the Certified Nursing Assistant does not know that Resident #96 has the device, and they are signing for it. Nurse Educator further stated that staff have been educated several times, it is unbelievable that Certified Nursing Assistants/Nurses are still not doing things right despite the education. On 09/10/24 at 10:29 AM, an interview was conducted with the Director of Nursing. The Director of Nursing stated that Certified Nursing Assistants are trained to apply ordered devices for the residents, the devices are documented in their Care Tasks to check and carry out the task as instructed. Director of Nursing stated that Resident #96 device is being documented by the Certified Nursing Assistant that resident has been refusing it. Director of Nursing stated that they cannot explain why the staff are signing that resident is refusing when they don't know that resident has the device as per their response to interview. 10NYCRR 415.12 (e)(2).

Based on observation, record review and interviews conducted during the Recertification Survey from 09/03/2024- 09/10/2024, the facility did not ensure that Nurse Staffing was posted appropriately. Specifically, the posting of daily nurse staffing information was not posted in a prominent area which was readily accessible to residents and visitors. The findings are: The facility policy and procedure titled Nurse Staffing Coverage Plan dated 9/11/2009 and last revised on 5/16/2024 documents; daily nursing schedules will be posted on the nursing supervisor door along with daily nursing data sheet which is readily accessible to residents, visitors and staff. During observations conducted on 09/03/2024at 9:05AM, 09/04/2024 at 9:10AM, 09/05/2024 at 2:15PM, and 09/06/2024 at 9:00AM, the postings of the daily nurse staffing levels for each shift could not be located nor any signage instructing residents or visitors where it was located. On 09/06/2024 at 3:14 PM, the State Surveyor asked the Staffing Coordinator where the staffing information was located and was shown the posting located in front of the first-floor supervisor's office door in a hallway. This area was not readily accessible to residents or visitors. On 09/06/2024 at 3:16 PM, the Staffing Coordinator was interviewed and stated that the staffing roster and data sheet has always been placed in front of the supervisor's door. The Staffing Coordinator stated they were not aware it had to be posted in visible area for all staff, residents and visitors to see. The Staffing Coordinator stated that moving forward it will be posted in a more visible area. On 09/09/2024 at 02:48 PM, The Director of Nursing Services was interviewed and stated that the staffing schedule has always been in front of the supervisor's door on the first floor for many years. Usually, it was a place where residents and visitors passed through. However, during COVID, the set up had to be changed within the facility and this may have impacted the places where residents and visitors walk through currently in the facility. 10 NYCRR 415.13

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure residents were involved in developing their comprehensive care plan (CCP) with the interdisciplinary team (IDT). This was evident for 1 (Resident #66) of 33 sampled residents. Specifically, Resident #66 was not invited to several CCP meetings conducted The findings are: The facility policy titled CCP last revised 1/15/2022 documented the facility must develop and implement a CCPs for each resident consistent with the resident rights. If the facility determines that the inclusion of the resident and/or resident representative is not practicable, documentation of the reasons, including the steps the facility took must be included in the resident's medical record. Resident #66 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Date Set 3.0 (MDS) assessment dated [DATE] documented Resident #66 was cognitively intact, usually able make self understood, and usually able to understand others. Resident #66 was interviewed on 06/27/22 at 12:51 PM and stated he does not have care plan with anybody in the facility. Nobody talks to him about having a care plan meeting. The activity progress notes dated 2/5/22 documented Resident #66 was able to make their interest known and was able to participate in the interview related to preferences. The nursing progress note dated 5/27/2022 documented Resident #66 was alert and oriented times 4 and able to make all needs known. The CCP Meeting Sign-In sheet dated 2/11/21, 5/13/21, 7/8/21, 2/10/22, 4/14/22, and 5/19/22 documented CCP meetings were held for Resident #66 with signatures of the IDT. There was no documented evidence in the medical record that Resident #66 was invited to or attended scheduled CCP meetings. On 7/5/22 at 3:13 PM, Social Worker #1 was interviewed and stated Resident #66 was not always alert and oriented and had periods of confusion and forgetfulness. On 7/1/2022 at 3:32 PM, the Director of Social Service (DSS) was interviewed and stated the facility received permission from the Resident #66's designated representative to contact to discuss the resident's concerns and to contact the designated representative if there were problems. A follow-up interview was conducted with the DSS on 7/5/2022 at 3:24 PM and the DSS stated there was no documented evidence Resident #66 gave the designated representative permission to represent the resident in CCP meetings. Residents are invited to CCP meetings but Resident #66 was not a candidate to be invited and the Social Worker did not invite Resident #66 to any CCP meetings. 415.11(c)(2)(i-iii)

Based on interviews and record review conducted during an abbreviated survey (NY 212), the facility did not notify a resident or resident's representative of a discharge and the reasons for the move in a language and manner they understand. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, on 02/19/2020, Resident #1 was transferred to the emergency room (ER) for complaints of chest pain. The facility refused to readmit the resident and stated that a Transfer/Discharge notice was mailed to the resident's representative. The Findings Include: The facility's Transfer and Discharge Interdisciplinary Policy revised 01/17/2020, documented that the objective of the Policy is to ensure that the resident is informed of an impending discharge and their right to appeal the discharge. The resident and representative will receive timely notification. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 02/19/2020 documented that the resident had short term memory problem and modified independence for daily decision-making (some difficulty in new situations only). A Nursing Progress Note dated 02/19/2020 at 8:00AM documented that on 02/18/2020, the writer met with Resident #1 and her family regarding concerns. Resident #1's family member (contact #2) discussed short/long term placement. The writer spoke with Resident #1 regarding her desire to belong and the resident expressed her desire to go home. Review of the facility's Notice of Transfer/discharge date d 02/20/2020 documented that this notice is to inform you in accordance with Federal and State regulations that you will be discharged /transferred from the facility. The effective date of discharge or transfer is 02/19/2020. The location to be safely discharged or transferred to is the hospital. The reason for the discharge or transfer: Necessary for the resident's welfare and his/her needs cannot be met in the facility. This document did not clearly identify if Resident #1 was being transferred or discharged from the facility. A Medical Discharge Summary dated 03/17/2020 documented that the Resident #1 left from hospital to an alternative location. Final Diagnoses/Condition upon discharge were Chest Pain and Irritable Bowel Syndrome. The complainant was interviewed on 08/04/2020 at 5:20PM. Upon inquiry, the complainant stated that a transfer or discharge notice was not received from the facility. A follow up telephone interview was conducted with Social Worker #1 (SW #1) on 08/12/2020 at 3:41PM. The SW stated that she did not give Resident #1 a discharge notice with appeal rights. On inquiry, the SW stated that she did not communicate verbally with Resident #1 or Resident #1's representative regarding Resident #1's transfer or discharge from the facility. The SW stated that a Notice of Discharge/Transfer was mailed to the complainant on 02/20/2020. 415.3(h)(1)(iii)(a-c)

Based on interviews and record review conducted during an abbreviated survey (NY 212), the facility did not permit a resident to return to the facility after hospitalization . This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, Resident #1 was transferred to the hospital on [DATE] for evaluation of Chest Pain. On [DATE], the hospital notified the facility that Resident #1 was ready for discharge back to the facility. Resident #1 was denied readmission. The Findings Include: The facility's undated Admissions Policy and Procedure documented that the Patient Review Instrument is reviewed by the clinical team to evaluate if the facility can render care/services and meet the clinical needs of the applicant throughout their stay at the facility. If the facility cannot meet the applicant's needs, unfortunately they will deny the case. The facility's undated Medical Leave of Absence Policy documented that a bed will only be reserved when there is a payor source. If a resident's bed is not reserved, there is no guarantee that the resident's bed, or a bed at the facility will be available when the resident is discharged from the hospital. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented that the resident had short term memory problem and modified independence for daily decision-making (some difficulty in new situations only). A Nursing Progress Note dated [DATE] at 3:24PM documented that Resident #1 complained of chest pain. Resident #1's family member (contact #2) was at the resident's bedside and requested that the resident be transferred to the hospital. The Physician was informed, and an order was obtained to transfer Resident #1 to the hospital. A Notice of Transfer/ Discharge notice dated [DATE], documented that Resident #1 was transferred or discharged to hospital on [DATE]. Resident #1 had Chest Pain and the discharge or transfer was necessary for the resident's welfare. Resident #1's needs could not be met in the facility. The complainant was interviewed on [DATE] at 5:20PM and stated that on [DATE], the hospital Social Worker (SW) informed her that Resident #1 was ready for discharge and that the facility refused to take the resident back. The complainant added that she called the facility for five (5) days and left messages, but no one from the facility returned her calls. The Admissions Coordinator (AC) was interviewed on [DATE] at 1:00PM and stated that she received a (Hospital and Community Patient Review Instrument (HCPRI) from the hospital on [DATE]. The AC stated that the Director of Nursing (DON) reviewed the HCPRI and told the AC that Resident #1 was not being accepted back to the facility. Resident #1 did not want to stay in the facility. The AC verbalized that she informed the hospital's Case Manager that the facility would not be readmitting Resident #1. The DON was interviewed on [DATE] at 2:35PM and stated that she reviewed the PRI and did not accept Resident #1's readmission to the facility. Upon inquiry, the DON stated that Resident #1 did not want to stay in the facility. On [DATE] at 3:35PM, subsequent telephone interview was conducted with the Director of Nursing (DON). Upon inquiry, the DON stated that it was her intent to readmit Resident #1, if the resident wanted to return to the facility. Resident #1 had previously (while resident was in the facility) stated that she did not want to stay in the facility. 415.3(h)(4)(iii)

Based on observation, record review, and staff interviews during the re-certification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the residents on oxygen/nebulizer treatment were observed with the tubing not properly labelled and dated to indicate the time the tubing was replaced. This was evident in 2 of 5 residents reviewed for respiratory care area/oxygen use. (Residents #2 and #128). The findings are: The facility policy and procedure titled Oxygen Therapy Administration dated 12/2018, documented the following: Infection Control, 1. Cannulas, facemask, and tubing are to be changed every 24 hours, as long as in use. 2. Humidifier bottles are changed when the level of distilled water reaches the low-level indicator .Humidifier bottle - to be changed daily. 1) Resident #2 is [AGE] year-old admitted to the facility 10/08/12: physician's orders [REDACTED]. Keep Oxygen at 92%. if oxygen drops below 92%, give oxygen via Nasal cannula at 2 liters per min. every shift for [DIAGNOSES REDACTED]. The following multiple observations were done: On 09/25/19 at 09:33 AM, resident was observed in bed, on continuous oxygen via NC (concentrator). No date noted on the oxygen tubing. Label attached to the oxygen concentrator dated 12/11/17, documented Good. On 09/26/19 at 08:15 AM, resident observed in room with oxygen running via NC, no date on tubing. On 09/27/19 at 08:19 AM, resident observed in bed, awake, oxygen in progress via NC at 2.5L/M. No date noted on oxygen tubing. On 09/30/19 at 07:56 AM, resident was observed with oxygen in progress via NC. No date on oxygen tubing. On 09/30/19 at 11:37 AM, observed LPN #1 pulled out humidifier bottle kept in a bag attached to the concentrator supplying oxygen to the resident, the label on the bottle was dated 9/26/19. The LPN stated that the nasal canular tubing is always changed with the humidifier bottle. 2) Resident #128 is [AGE] year-old admitted to the facility 09/24/12 with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Titrate oxygen to maintain SPO2 greater than 94% every shift for [MEDICAL CONDITION] Check that O2 delivery device (mask or nasal Cannula) has padding to protect skin every shift Clean air filter on O2 concentrator weekly on Saturday Oxygen 2L via Nasal Cannula to maintain SPO2 greater than 94% for DX of [MEDICAL CONDITION] every shift (10/01/19). The following multiple observations were made on the resident: On 09/25/19 at 09:53 AM, resident was observed sleeping in his room, on continuous oxygen from concentrator via Nasal Canula (NC), no date noted on oxygen tubing. Paper tag attached to the concentrator humidifier was dated 6/19/17, and another tag on concentrator tank dated 8/1/19. On 09/26/19 at 08:08 AM, oxygen in progress via NC. Tubing not dated. On 09/27/19 at 08:13 AM, resident observed sleeping on left side in bed. Oxygen in progress at 2L/M, no date noted on tubing. On 09/30/19 at 11:30 AM, observed LPN #1 pulled out humidifier bottle kept in a bag attached to the concentrator supplying oxygen to the resident, the label on the bottle was dated 9/26/19. The LPN stated that the nasal canular tubing is always changed with the humidifier bottle. On 09/30/19 at 11:15 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). The LPN stated that she has been working in the facility for about 1 year. LPN #1 stated that the nurse medication nurse provides oxygen care and oxygen monitoring by checking the resident's oxygen saturation (O2 sat). LPN stated that resident's O2 sat is checked by pulse oximeter every shift and as needed, oxygen is administered as per doctor's order. LPN stated that the O2 sat checked every morning and oxygen is being administered on continuous basis to keep the level up. LPN #3 further stated that the oxygen tubing is supposed to be changed daily by the night nurse, but has not been taking note if the tubing is being dated. The LPN further stated that she was given training on the care and handling of oxygen both at school and when employed by the facility, and that staff are assessed for competency once every 3 months to ensure proper handling of oxygen equipement and on infection control protocol to be followed when giving care to the resident with respiratory problem in need of oxygen in need of oxygen therapy. LPN stated that whenever a resident needs oxygen equipment/supplies, the maintenance/housekeeping is called to set up the equipment, and the equipment is serviced and assessed for proper functioning by the maintenance. LPN stated that the nebulizer tubing is changed as needed but has not been noticing it dated, while the oxygen tubing is supposed to be changed daily by the night shift. On 09/30/19 at 11:49 AM an interview was conducted with the Registered Nurse /Unit Manager (RN #1). The RN stated that he has been covering as the unit Manager since the regular Manager resigned about 2 weeks ago. RN #1 stated that the medication nurse provides oxygen care to the residents and monitoring of the residents' oxygen level, and the medication nurses are expected to check that the tubings in use are clean and regularly changed as per protocol. The RN #1 further stated that all the nurses are given in-service training on infection prevention procol, which includes regular changing and dating of oxygen tubing and all other disposable supply items used for the care of the residents to prevent infection, the training is given when they are employed, while the competencies assessed after the 1st 3 months, then the 2nd 3 months, and every 6 months thereafter. RN #1 stated that the housekeeping is called to re-stock the oxygen supply as the supply goes down in the storage room on the units. RN stated that oxygen concentrator is usually provided for the long- term residents, while oxygen tank is provided to the short-term residents. RN stated that the house-keeping staff maintains the concentrator by changing the filter and repair or replace the malfunction parts, but is not sure of how often. RN stated that the oxygen tubing for nasal canula is supposed to be changed every 24 hours and the nebulizer tubing changed every 3 days by the medication nurse. RN stated that the tubing supposed to be labelled and dated when it is changed. RN stated that the morning shift nurse is expected to check and verify if it is changed and dated and was surprised while the tubing is not changed. RN stated that the Manager will be checking daily that the tubing is changed as per protocol henceforth. On 09/30/19 at 12:17 PM, the DOE (Director of Engineering /Maintenance), was interviewed. The director of engineering stated that he has been working in the facility for [AGE] years. The DOE stated that full-service maintenance (Internal) of the concentrator is done quarterly, while the external maintenance, which includes changing of the air filter is done on monthly basis. The DOE stated that a log is kept to monitor the work done and is kept downstairs in the office. The director of engineering further stated that the labelled tagged to the concentrator could not have been affixed by the maintenance staff and did not understand why the staff has not removed the labelled dated 12/11/17, documented Good affixed to the concentrator. DOE stated that the labels must have been attached frorm and should have been removed by the maintenance staff. On 10/01/19 at 08:08 AM, the Director of Nursing Services, (DON) was interviewed. The DON stated that she has been in the facility since (MONTH) (YEAR). DON stated that the night supervisor checks to ensure that the oxygen tubing are changed as per protocol. DON stated that in-services are given to all the nursing staff about the facility protocol on the change of tubing and the need to date the tubing. DON stated that she cannot speculate why the nurses are not doing what they are expected to do, but can say that the staff will be disciplined for not doing their job. DON stated that further in-service will be given to the staff to ensure compliance. Attempts make to contact the nurses that worked on the unit on night shift 9/25/19 to 9/27/19 for interview were unsuccessful. 415.19(b)(4)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. Specifically, the facility did not provide a resident/representative with the Notice of Medicare Non Coverage (NOMNC) within the required time frame. This was evident for 1 of 3 residents reviewed for Beneficiary Protection Notification Rights (Resident # 271). The findings are: Upon request, the facility provided the state agency list of residents with this who were discharged from a Medicare part A stay with benefits days remain within the past 6 months. Three residents were selected from the list for a review. As per staff, the facility did not have a policy and procedure related to Beneficiary Protection Notification Rights. Resident #271 was admitted to the facility on [DATE] on Medicare Part A Skilled Services. The last covered day by Medicare Part A was 6/14/19. The resident received a Notice of Medicare Non Coverage (NOMNC) on 6/13/19. This notice was offered 24 hours prior to termination of services. On 10/01/19 at 02:48 PM, an interview conducted with the Resident Relation Liaison staff. She stated that providing the NOMNC is part of the social work department's responsibilities. She stated the director of social work at the time asked her if she was familiar with NOMNC. She further stated that she informed the Director that she was familiar with the NOMNC, but had not done it before. She stated that she was aware that the notice was to be offered at least 48 hours prior to the last covered day, but she was unable to explain why notice was offered 24 hours prior to the last covered day. 415.3(g)(2)(i)

Based on records review and staff interviews, the facility did not ensure that the attending physicians reviewed the residents total program of care on each visit that is required by this regulation. Specifically,there were no adequate clinical indications documented in the clinical record to justify the needs for [MEDICAL CONDITION] prescribed medications. 2.) No Gradual Dose Reduction (GDR) attempted for a Dementia resident who received Antipsychotic medication for over a year. This was evident for 1 of 3 residents reviewed for Unnecessary Medications-Not Sampled out of a total sample of 37 residents. (Resident # 61) Finding is: The facility policy for [MEDICAL CONDITION] drug use dated 8/2017 documented the following: During the treatment with antipsychotic drugs, the Psychiatrist and or the attending physician will document in the medical record the clinical indication and rationale for the use. The medical rationale for the use of antipsychotic medication that is contraindicated or to be used under special consideration, and medical rationale why gradual dose reduction is contraindicated. Resident #61 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] documented that the resident has active [DIAGNOSES REDACTED]. The MDS also documented that the resident had severely impaired cognition, and the resident required total assistance with transfer, toilet use, bathing and personal hygiene. On 09/25/19 at 10:00 AM, during the initial tour of the unit, the resident was observed in bed. She had her eyes closed and appeared lethargic. On 09/26/19 at 11:28AM, the resident was observed in her room asleep in bed. Her husband was sitting by the door in the hallway. On 09/30/19 at 01:13 PM, the resident was observed in the day room, alert and awake. The resident appeared confused and talked to herself non-stop. On 10/01/19 at 10:06 AM, the resident was observed sitting quietly in front of the nursing station. She appeared confused and was unable to respond when her name was called. The Admission physician's orders [REDACTED]. The physician's orders [REDACTED]. A physician's orders [REDACTED]. On 3/2/17, the physician order [REDACTED]. A Psychiatry Consult dated 07/5/18 documented the resident had Lewy Body [MEDICAL CONDITION] now managed on [MEDICATION NAME], and [MEDICATION NAME]. History of difficult agitation when medication was tapered, stable, controlled with no report of aggressive behavior. alert at this time , will continue observed, reviewed in 2 months. A Psychiatry Consult dated 01/24/19 documented the resident had LBD with [MEDICAL CONDITION] with a recent hx failed [MEDICATION NAME] GDR. The resident therefore remains on [MEDICATION NAME] with [MEDICATION NAME] and [MEDICATION NAME]. The resident had good control and was responsive with largely relevant replies, No Adverse Drug Reactions were noted. A Psychiatry note dated 01/31/19 documented the review of [MEDICATION NAME]. The resident was stable and had a prior failed attempted GDR of [MEDICATION NAME]. The resident had good control on the current regimen. The recommendation was to continue the same medication given the failed drug taper. The Comprehensive Care Plan for [MEDICAL CONDITION] drug use dated 7/18/19 documented the following interventions: Assess/record effectiveness of drug treatment, monitor and report signs of sedation, [MEDICATION NAME] and/or extrapyramidal symptoms, attempt to give the lowest dose possible, attempt a gradual dose reduction. A Psychiatry Note dated 05/13/19 documented the following: resident with stable and occasionally agitated during Activity of Daily Living (ADLS). The resident was on [MEDICAL CONDITION] medications of [MEDICATION NAME], and [MEDICATION NAME]. The resident had no symptoms of Adverse Drug reactions (ADR). The physician assessment dated [DATE] documented the following: Dementia: seen by psychiatrist 8/29/19 with no recommendation. Continue same regimen. The note also documented that the resident has a [DIAGNOSES REDACTED]. Continue [MEDICATION NAME] and [MEDICATION NAME]. Weekly behavioral note dated 3/18/19, 4/7/19, 4/17/19, 5/7/19, 5/17/19, 6/10/19, 6/13/19, 6/10/19, 7/1/19, 9/14/19, 9/29/19 consistently documented no physical behavioral symptoms directed toward others(e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no verbal behavioral symptoms directed toward others(e.g., threatening others, screaming at others, cursing at others) On 10/1/19, a review of current physician order [REDACTED]. [MEDICATION NAME] 3mg 1 tablet daily for Primary [MEDICAL CONDITION] started 7/23/18. No GDR of [MEDICATION NAME] 100mg was attempted since 03/2/17. In addition, no GDR was attempted for [MEDICATION NAME] 0.5mg 1 tab by mouth three times a day since 10/16/16. There were no behavioral issues with this resident, and the physician did not document the clinical rational for why a GDR would be contraindicated. There was no description of the targeted behaviors and why the risks outweigh the benefits. The Drug Regimen Review notes from 02/22/19 to 09/25/19 documented the medications were reviewed, and there were no recommendations. On 10/01/19 at 10:29 AM, an interview conducted with Certified Nurse (CNA). She stated she has known the resident for over 3 years. She stated that when the resident came here, she used to talk and tell her about her family. The resident was stronger and used to stand and move around, but she was forgetful. Now the resident is more confused and talks a lot about things. Sometimes the resident holds onto herself and will not release herself when she is receiving care. The CNA stated the resident used to refuse care. She did not want staff to take her clothes off when she was first admitted . She stated that the resident was not combative. She stated that the resident only talked randomly. The CNA stated the resident was not hallucinating,and the resident does not say she sees things that are not there. On 10/01/19 at 10:40 AM, an interview conducted with the CN[NAME] She stated she came on the unit a month ago. She stated that the resident was always calm in the chair and talks to herself. On 10/01/19 at 11:47 AM, an interview was conducted with the Registered Nurse Manager (RNM). She stated the husband always comes and goes to activities with the resident. The resident is very calm, sometimes smiles, and always likes to talk. Sometimes the conversation is off and on. She stated the resident was not aggressive toward staff . She stated that the resident just talks with no hallucinations or delusions. On 10/01/19 at 01:52 PM, an interview was conducted with the psychiatrist. He stated that [MEDICATION NAME] is used for anxiety, not for Dementia with behavioral disturbances. Dementia is not the correct indication for [MEDICATION NAME]. He stated [MEDICATION NAME] is an antipsychotic used for [MEDICAL CONDITION]. [MEDICATION NAME] should only be used for Dementia residents with [MEDICAL CONDITION] symptoms such as when the resident is delusional, afraid of everybody around her, and strikes out (ie, hitting). He stated that the resident had a GDR a while back and became psychotic. The Psychiatrist further stated that husband came to him and begged him not to reduce the medication dose again . He stated that in this case, he believed the husband who loves his wife very much. He stated that he is aware of the black box warning for using antipsychotic for Dementia residents, but the benefit outweigh the risks. He stated it would be inappropriate to reduce the dose. On 10/01/19 at 02:17 PM, an interview was conducted with the Consulting Pharmacist. She stated that she comes to the facility on ce a week. She stated that she look at the active orders, see if anything is discontinued, med orders, labs, consults, progress notes, etc. She stated she also reviewed the psychiatry evaluations. She stated the med supposed to be used for particular diagnosis. he stated that she question the mix matched diagnosis. She also stated she is aware of the black box warning because of an increased mortality rate. She stated that in her notes they did a trial GDR in 1/2017 that went badly, and she believed further GDRs were contraindicated. In 0ct (YEAR), the GDR of [MEDICATION NAME] and [MEDICATION NAME] was necessary. The behavior for resisting to care was noted on the progress note on 5/13/19. She stated that once she sees that the psychiatrist wrote continue current medications, it consider that no concerns On 10/01/19 at 03:23 PM, an interview conducted wth the attending physician. He stated that he saw the resident last on 9/24/19. He stated that he has know the resident. He stated that whatever the psych recommends he confirms it. His field is medical and he is psych. He stated that he needs to follow the plan the pyshciatrist indicated. He trusts the psychiatrist, and his recommendations are okay. 415.12(b)(2)(iii)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that medically -related social services were provided to attain or maintain the highest practicable physical,mental and psychosocial well-being of each resident. This was evident in 1 of 3 residents reviewed for care . Specifically, a resident was not provided with clothing that will enhance his appearance and dignity (Resident #162) . The finding is: The facility policy and procedures on clothing control states each resident is expected to have an average ( 4-6 days ) supply of washable clothing --- Given the frequent use and washing of residents clothing , we do not expect any item to last longer than 18 months . Resident #162 was admitted [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS ) 3.0 assessment dated [DATE] identified the resident had severe cognitive impairment and completely dependent on staff for all activities of daily living , dressing , positioning , feeding and more. On 09/30/2019 at 10:42 AM, the resident was observed in his room seated in his geri chair dressed with a green T-shirt , with his bilateral hand rolls , bilateral booties with no socks , a towel used as a bib and observed with foaming saliva from his mouth . LPN # 2 came into the room and suctioned the resident. On 9/30/19 at 11:30 AM, the resident's closet and drawers were inspected with the Certified Nursing Assistant (CNA #3). There were no socks, several pants, and several T-shirts 4-5 of them. All of the shirts were brown in color and one was torn on the back. None of the shirts had the resident's name on them. The resident's financial account with the facility from 08/31/2018 to 05/03/2019 has a total deposit of thirty eight dollars ($38.00 ) Review of the clothing list record documented the following : 09/20/2016 --- 5 shirt / 5 pants / 1 undershirt 09/22/2016-----6 shirt / 5 pants / 3 socks / 1 T -shirt / 3 sweaters 10/16/2016 -----1 undershirt / 1 T shirt /2 sweaters 10/24/2016 -----5 underpants / 4 socks /6 T shirt /1 sweater / 2 pajamas /1 belt 12/18/2018 ----1 blanket / 5 shirt 01/29/2019 ---- 2 T-shirt /1 Long sleeve shirt /1 sweat pants On 09/30/2019 at 11:30 AM the certified nursing assistant (CNA ) #3 was interviewed and stated he is total care and every so often , I have to change his shirt because it gets wet from his sweat and secretions coming from his mouth , I wipe it and I call the nurse . Surveyor asked why he has no socks on ? The CNA states I did not find any socks this morning and I went to take care of another resident and I told the nurse , so she gave me non- skid socks . The CNA further states he really does not have that much clothing , and maybe some are still in the laundry . When further asked if she told anybody ? she stated everybody knows he does not have much clothing . On 09/30/2019 at 12:00 PM, the Social worker, staff # 8 and RN # 4 both were interviewed and shown the T-shirts of the residents and both reacted saying the T-shirts are threadbare and looks bad. Both stated The CNA were to communicate with them , if a resident needs clothing. Social worker further stated, if a resident needs clothing , I will call and contact the family but if nobody tells me , then I will not know . 483.40(d)

Based on record review, staff interviews during the recertification survey it was noted that the facility did not ensure that the attending physician documented in the resident's medical record that an irregularity identified by the consultant pharmacist had been reviewed and what, if any, action has been taken to address the issue. Specifically, the pharmacist did not identify a drug irregularity for a resident with [DIAGNOSES REDACTED] being treated with [MEDICATION NAME] and [MEDICATION NAME] with no Gradual Dose Reduction in over 2 years in the absence of behaviors. This was evident for 1 of 3 residents reviewed for Unnecessary Medications-Not Sampled out of a total sample of 37 residents. (Resident # 61) Finding is: Resident #61 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] documented that the resident has active [DIAGNOSES REDACTED]. The MDS also documented that the resident had severely impaired cognition, and the resident required total assistance with transfer, toilet use, bathing and personal hygiene. On 09/25/19 at 10:00 AM, during the initial tour of the unit, the resident was observed in bed. She had her eyes closed and appeared lethargic. On 09/26/19 at 11:28 AM, the resident was observed in her room asleep in bed. Her husband was sitting by the door in the hallway. On 09/30/19 at 01:13 PM, the resident was observed in the day room, alert and awake. The resident appeared confused and talked to herself non-stop. On 10/01/19 at 10:06 AM, the resident was observed sitting quietly in front of the nursing station. She appeared confused and was unable to respond when her name was called. The Admission physician's orders [REDACTED]. The physician's orders [REDACTED]. A physician's orders [REDACTED]. On 3/2/17, the physician order [REDACTED]. A Psychiatry Consult dated 07/5/18 documented the resident had Lewy Body [MEDICAL CONDITION] now managed on [MEDICATION NAME], and [MEDICATION NAME]. History of difficult agitation when medication was tapered, stable, controlled with no report of aggressive behavior. alert at this time , will continue observed, reviewed in 2 months. A Psychiatry Consult dated 01/24/19 documented the resident had LBD with [MEDICAL CONDITION] with a recent hx failed [MEDICATION NAME] GDR. The resident therefore remains on [MEDICATION NAME] with [MEDICATION NAME] and [MEDICATION NAME]. The resident had good control and was responsive with largely relevant replies, No Adverse Drug Reactions were noted. A Psychiatry note dated 01/31/19 documented the review of [MEDICATION NAME]. The resident was stable and had a prior failed attempted GDR of [MEDICATION NAME]. The resident had good control on the current regimen. The recommendation was to continue the same medication given the failed drug taper. The Comprehensive Care Plan for [MEDICAL CONDITION] drug use dated 7/18/19 documented the following interventions: Assess/record effectiveness of drug treatment, monitor and report signs of sedation, [MEDICATION NAME] and/or extrapyramidal symptoms, attempt to give the lowest dose possible, attempt a gradual dose reduction. A Psychiatry Note dated 05/13/19 documented the following: resident with stable and occasionally agitated during Activity of Daily Living (ADLS). The resident was on [MEDICAL CONDITION] medications of [MEDICATION NAME], and [MEDICATION NAME]. The resident had no symptoms of Adverse Drug reactions (ADR). The physician assessment dated [DATE] documented the following: Dementia: seen by psychiatrist 8/29/19 with no recommendation. Continue same regimen. The note also documented that the resident has a [DIAGNOSES REDACTED]. Continue [MEDICATION NAME] and [MEDICATION NAME]. Weekly behavioral note dated 3/18/19, 4/7/19, 4/17/19, 5/7/19, 5/17/19, 6/10/19, 6/13/19, 6/10/19, 7/1/19, 9/14/19, 9/29/19 consistently documented no physical behavioral symptoms directed toward others(e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no verbal behavioral symptoms directed toward others(e.g., threatening others, screaming at others, cursing at others) On 10/1/19, a review of current physician order [REDACTED]. [MEDICATION NAME] 3mg 1 tablet daily for Primary [MEDICAL CONDITION] started 7/23/18. No GDR of [MEDICATION NAME] 100mg was attempted since 03/2/17. In addition, no GDR was attempted for [MEDICATION NAME] 0.5mg 1 tab by mouth three times a day since 10/16/16. There were no behavioral issues with this resident, and the physician did not document the clinical rational for why a GDR would be contraindicated. There was no description of the targeted behaviors and why the risks outweigh the benefits. The Drug Regimen Review notes from 02/22/19 to 09/25/19 documented the medications were reviewed, and there were no irregularities identified. The Pharmacist did not identify that the resident was on [MEDICATION NAME] and [MEDICATION NAME] in the absence of behaviors over 2 years with no GDR. On 10/01/19 at 01:52 PM, an interview was conducted with the psychiatrist. He stated that [MEDICATION NAME] is used for anxiety, not for Dementia with behavioral disturbances. Dementia is not the correct indication for [MEDICATION NAME]. He stated [MEDICATION NAME] is an antipsychotic used for [MEDICAL CONDITION]. [MEDICATION NAME] should only be used for Dementia residents with [MEDICAL CONDITION] symptoms such as when the resident is delusional, afraid of everybody around her, and strikes out (ie, hitting). He stated that the resident had a GDR a while back and became psychotic. The Psychiatrist further stated that husband came to him and begged him not to reduce the medication dose again . He stated that in this case, he believed the husband who loves his wife very much. He stated that he is aware of the black box warning for using antipsychotic for Dementia residents, but the benefit outweigh the risks. He stated it would be inappropriate to reduce the dose. On 10/01/19 at 02:17 PM, an interview was conducted with the Consulting Pharmacist. She stated that she comes to the facility on ce a week. She stated that she look at the active orders, see if anything is discontinued, med orders, labs, consults, progress notes, etc. She stated she also reviewed the psychiatry evaluations. She stated the med supposed to be used for particular diagnosis. he stated that she question the mix matched diagnosis. She also stated she is aware of the black box warning because of an increased mortality rate. She stated that in her notes they did a trial GDR in 1/2017 that went badly, and she believed further GDRs were contraindicated. In 0ct (YEAR), the GDR of [MEDICATION NAME] and [MEDICATION NAME] was necessary. The behavior for resisting to care was noted on the progress note on 5/13/19. She stated that once she sees that the psychiatrist wrote continue current medications, it consider that no concerns

Based on observation, record reviews, and staff interviews conducted during the Recertification Survey, the facility did not ensure residents were from unnecessary [MEDICAL CONDITION] medications. Specifically, a resident with [DIAGNOSES REDACTED] received antipsychotic and anti-anxiety medications for over 2 years without an attempt at a Gradual Dose Reduction in the absence of behaviors. In addition, there was no documentation regarding the specific behaviors the antipsychotic medication was targeting. This was evident for 1 of 3 residents reviewed for Unnecessary Medications-Not Sampled out of a total sample of 37 residents. (Resident # 61). The finding is: The facility policy for [MEDICAL CONDITION] drug use dated 8/2017 documented the following: During the treatment with antipsychotic drugs, the Psychiatrist and or the attending physician will document in the medical record the clinical indication and rationale for the use. The medical rationale for the use of antipsychotic medication that is contraindicated or to be used under special consideration, and medical rationale why gradual dose reduction is contraindicated. Resident #61 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] documented that the resident has active [DIAGNOSES REDACTED]. The MDS also documented that the resident had severely impaired cognition, and the resident required total assistance with transfer, toilet use, bathing and personal hygiene. On 09/25/19 at 10:00 AM, during the initial tour of the unit, the resident was observed in bed. She had her eyes closed and appeared lethargic. On 09/26/19 at 11:28AM, the resident was observed in her room asleep in bed. Her husband was sitting by the door in the hallway. On 09/30/19 at 01:13 PM, the resident was observed in the day room, alert and awake. The resident appeared confused and talked to herself non-stop. On 10/01/19 at 10:06 AM, the resident was observed sitting quietly in front of the nursing station. She appeared confused and was unable to respond when her name was called. The Admission physician's orders [REDACTED]. The physician's orders [REDACTED]. A physician's orders [REDACTED]. On 3/2/17, the physician order [REDACTED]. A Psychiatry Consult dated 07/5/18 documented the resident had Lewy Body [MEDICAL CONDITION] now managed on [MEDICATION NAME], and [MEDICATION NAME]. History of difficult agitation when medication was tapered, stable, controlled with no report of aggressive behavior. alert at this time , will continue observed, reviewed in 2 months. A Psychiatry Consult dated 01/24/19 documented the resident had LBD with [MEDICAL CONDITION] with a recent hx failed [MEDICATION NAME] GDR. The resident therefore remains on [MEDICATION NAME] with [MEDICATION NAME] and [MEDICATION NAME]. The resident had good control and was responsive with largely relevant replies, No Adverse Drug Reactions were noted. A Psychiatry note dated 01/31/19 documented the review of [MEDICATION NAME]. The resident was stable and had a prior failed attempted GDR of [MEDICATION NAME]. The resident had good control on the current regimen. The recommendation was to continue the same medication given the failed drug taper. The Comprehensive Care Plan for [MEDICAL CONDITION] drug use dated 7/18/19 documented the following interventions: Assess/record effectiveness of drug treatment, monitor and report signs of sedation, [MEDICATION NAME] and/or extrapyramidal symptoms, attempt to give the lowest dose possible, attempt a gradual dose reduction. A Psychiatry Note dated 05/13/19 documented the following: resident with stable and occasionally agitated during Activity of Daily Living (ADLS). The resident was on [MEDICAL CONDITION] medications of [MEDICATION NAME], and [MEDICATION NAME]. The resident had no symptoms of Adverse Drug reactions (ADR). The physician assessment dated [DATE] documented the following: Dementia: seen by psychiatrist 8/29/19 with no recommendation. Continue same regimen. The note also documented that the resident has a [DIAGNOSES REDACTED]. Continue [MEDICATION NAME] and [MEDICATION NAME]. Weekly behavioral note dated 3/18/19, 4/7/19, 4/17/19, 5/7/19, 5/17/19, 6/10/19, 6/13/19, 6/10/19, 7/1/19, 9/14/19, 9/29/19 consistently documented no physical behavioral symptoms directed toward others(e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no verbal behavioral symptoms directed toward others(e.g., threatening others, screaming at others, cursing at others) On 10/1/19, a review of current physician order [REDACTED]. [MEDICATION NAME] 3mg 1 tablet daily for Primary [MEDICAL CONDITION] started 7/23/18. No GDR of [MEDICATION NAME] 100mg was attempted since 03/2/17. In addition, no GDR was attempted for [MEDICATION NAME] 0.5mg 1 tab by mouth three times a day since 10/16/16. There were no behavioral issues with this resident, and the physician did not document the clinical rational for why a GDR would be contraindicated. There was no description of the targeted behaviors and why the risks outweigh the benefits. The Drug Regimen Review notes from 02/22/19 to 09/25/19 documented the medications were reviewed, and there were no recommendations. On 10/01/19 at 10:29 AM, an interview conducted with Certified Nurse (CNA). She stated she has known the resident for over 3 years. She stated that when the resident came here, she used to talk and tell her about her family. The resident was stronger and used to stand and move around, but she was forgetful. Now the resident is more confused and talks a lot about things. Sometimes the resident holds onto herself and will not release herself when she is receiving care. The CNA stated the resident used to refuse care. She did not want staff to take her clothes off when she was first admitted . She stated that the resident was not combative. She stated that the resident only talked randomly. The CNA stated the resident was not hallucinating,and the resident does not say she sees things that are not there. On 10/01/19 at 10:40 AM, an interview conducted with the CN[NAME] She stated she came on the unit a month ago. She stated that the resident was always calm in the chair and talks to herself. On 10/01/19 at 11:47 AM, an interview was conducted with the Registered Nurse Manager (RNM). She stated the husband always comes and goes to activities with the resident. The resident is very calm, sometimes smiles, and always likes to talk. Sometimes the conversation is off and on. She stated the resident was not aggressive toward staff . She stated that the resident just talks with no hallucinations or delusions. On 10/01/19 at 01:52 PM, an interview was conducted with the psychiatrist. He stated that [MEDICATION NAME] is used for anxiety, not for Dementia with behavioral disturbances. Dementia is not the correct indication for [MEDICATION NAME]. He stated [MEDICATION NAME] is an antipsychotic used for [MEDICAL CONDITION]. [MEDICATION NAME] should only be used for Dementia residents with [MEDICAL CONDITION] symptoms such as when the resident is delusional, afraid of everybody around her, and strikes out (ie, hitting). He stated that the resident had a GDR a while back and became psychotic. The Psychiatrist further stated that husband came to him and begged him not to reduce the medication dose again . He stated that in this case, he believed the husband who loves his wife very much. He stated that he is aware of the black box warning for using antipsychotic for Dementia residents, but the benefit outweigh the risks. He stated it would be inappropriate to reduce the dose. On 10/01/19 at 02:17 PM, an interview was conducted with the Consulting Pharmacist. She stated that she comes to the facility on ce a week. She stated that she look at the active orders, see if anything is discontinued, med orders, labs, consults, progress notes, etc. She stated she also reviewed the psychiatry evaluations. She stated the med supposed to be used for particular diagnosis. he stated that she question the mix matched diagnosis. She also stated she is aware of the black box warning because of an increased mortality rate. She stated that in her notes they did a trial GDR in 1/2017 that went badly, and she believed further GDRs were contraindicated. In 0ct (YEAR), the GDR of [MEDICATION NAME] and [MEDICATION NAME] was necessary. The behavior for resisting to care was noted on the progress note on 5/13/19. She stated that once she sees that the psychiatrist wrote continue current medications, it consider that no concerns On 10/01/19 at 03:23 PM, an interview conducted wth the attending physician. He stated that he saw the resident last on 9/24/19. He stated that he has know the resident. He stated that whatever the psych recommends he confirms it. His field is medical and he is psych. He stated that he needs to follow the plan the pyshciatrist indicated. He trusts the psychiatrist, and his recommendations are okay. 415.18(c)(1)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 966), the facility failed to provide a safe and secure environment for a resident under its care. This was evident in 1 out of 5 residents sampled (Resident #2). Specifically, on [DATE] around 12:45AM, Resident #1 was observed in his room with his wheelchair leg rest in his hand, raised above Resident #2 (roommate). Resident #2 was observed in his room in bed with multiple lacerations and was covered with blood. He had lacerations to his scalp and left ear, and excoriations to his left shoulder and left upper arm. Resident #2 was transferred to the Hospital emergency room (ER) and returned to the facility with 20 staples to wounds on his scalp and sutures to his left ear. This resulted in actual harm that is not Immediate Jeopardy (IJ) for Resident #2. The Findings Include: Review of the Facility's Policy and Procedure on Abuse, Neglect, Mistreatment and Exploitation with a review date of ,[DATE] documented that it is, and always has been the primary intent of the facility to provide a safe and secure environment for its residents. The purpose of the abuse policy is to comply with the seven steps approach to abuse and neglect detection and prevention. Before a resident is accepted for admission, a review will determine if the facility has the capacity and capability to provide the necessary care and services for the resident. The facility provides identification, ongoing assessment, care planning for appropriate behaviors and monitoring of residents with needs and behaviors that might lead to conflict such as residents with cognitive deficits and aggressive behaviors. Resident #1 (the aggressor) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE], documented that Resident #1 had a Brief Interview for Mental Status (BIMS- used to determine attention, orientation and ability to recall information) score of ,[DATE], associated with moderately impaired cognition, (,[DATE] severe impairment, ,[DATE] moderate impairment &,[DATE] cognitively intact). The resident required extensive assistance of 1 person with walking in his room and most areas of his Activities of Daily Living (ADL). Review of Resident #1's physician's orders [REDACTED]. A Psychiatry Consult evaluation dated [DATE] and signed on [DATE] documented that Resident #1's judgement was mildly impaired with Mild Senile Dementia of Alzheimer's Type with Mild Depression features. Resident #1 had adequate capacity to determine his own advance care. Recommend [MEDICATION NAME] tablet 10mg orally daily and Psychology Consult. A physician's orders [REDACTED].#1 had an order for [REDACTED]. Record review of the Medication Administration Record [REDACTED]. A Mood State Care Plan (CP) initiated on [DATE] documented that Resident #1 had the potential to be victimized. The interventions included modify environmental stressors (avoid residents who promote agitation). A physician's orders [REDACTED].#1 had an order for [REDACTED]. Record review of the MAR indicated [REDACTED]. Review of Resident #1's Observation Sheet dated [DATE] documented that Resident #1 was observed in bed from 8:00PM to 12:30AM, as per staff initials. A Nursing Progress Note dated [DATE] at 2:36AM documented that the Registered Nurse Manager (RNM) was called to Resident #1's Room at approximately 12:45AM. Certified Nursing Assistant #1 (CNA #1) opened the residents room door during rounds and observed Resident #1 standing at Resident #2's bedside. Resident #1 had a bloody leg rest in his hand and was about to hit Resident #2. CNA #1 shouted stop to Resident #1. Resident #1 left Resident #2's bedside and charged at CNA #1. CNA #1 called for help and additional staff responded. Resident #1 stated that he was trying to protect staff from Resident #2. Staff provided emotional support and attempted to get the leg rest from Resident #1, but he was resistive. Resident #1 attempted to hit staff with the leg rest. Dr. Strong (used for violence) was activated and Security was able to direct Resident #1 to the Dining Room. Resident #1 continued to hold on to the leg rest. Resident #1 had blood on his pants, but no visible injury was noted. Resident #1 was transferred to the ER for evaluation. Review of the Facility's Notice of discharge date d [DATE], documented that Resident #1 was discharged on [DATE] with his son because the safety of individuals in the facility was endangered. Resident #2 (Victim) was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #2 had a BIMS score of ,[DATE]. The resident required extensive assistance of 1 person with most areas of his ADL. Review of Resident #2's CP included history of physical behavioral symptoms towards others which was initiated on [DATE]. The CP was last reviewed on [DATE]. The interventions documented: maintain a calm environment, keep resident at arm's length from others, administer medication as ordered and Psychiatry Consult. A Nursing Progress Note dated [DATE] at 1:45AM documented that Resident #2 was awake and sitting up in his bed. Resident #2 removed his blanket and sheets and tossed them on the floor. In addition, Resident #2 was verbally disruptive, he shouted random phrases and was not easily redirected. A Nursing Progress Note dated [DATE] at 7:50PM documented that Resident #2 was on [MEDICATION NAME] 10mg three times a day for Anxiety. A Nursing Progress Note dated [DATE] at 2:00AM documented that on assessment, Resident #2 was noted with multiple cuts to the middle of his head, left ear, left shoulder and his back. First aid was administered and Resident #2 was transferred to the ER via 911. The ER record dated [DATE] documented that Resident #2 was seen after assault with multiple ,[DATE] cm lacerations to the left side of his head and a laceration to his left ear. The ear was repaired with 2 sutures and the scalp lacerations were repaired with staples. Computed [NAME]ography (CT) scan of the head showed no acute intracranial disease and CT of the neck showed no acute fracture or dislocation. The left shoulder x-ray was negative for fracture. The resident had a hematoma to his forehead and reported headache. A Nursing Progress Note dated [DATE] at 11:46AM documented that Resident #2 returned from the ER. The resident was noted with swelling to his forehead and he had a total of 20 staples to various sites of his scalp with scant bleeding. The resident also had a superficial skin opening to his left shoulder. Review of the Facility Investigation dated [DATE] documented that on staff rounds approximately 12:45AM, Resident #2 was observed lying in bed on his right side with his head and upper body covered with blood. Resident #1 was standing at Resident #2's bedside with a bloody leg rest in his hand. 911 was activated and Resident #2 was assessed, Resident #2 was observed with multiple lacerations on his left side: head, ear, and superficial skin openings on his left shoulder and mid-back. Pressure dressing was applied to Resident #2's scalp. Resident #2 was responsive and stated that he didn't do anything and didn't know why he was hit by Resident #1. Resident #2 was transferred to the ER for evaluation. Resident #2 received 20 staples to his scalp and sutures to his left ear. Review of the Facility's Surveillance Video revealed that on [DATE] at 12:49AM, CNA #1 was seen pushing Resident #1 and Resident #2's room door open, she entered then backed out of the room. At 12:49AM, Resident #1 was seen standing in the doorway of his room with the wheelchair leg rest in his hand, pointing the leg rest at CNA #1. At 12:50AM, several staff members were seen at the residents' door. Licensed Practical Nurse #1 (LPN #1) unsuccessfully attempted to take the leg rest from Resident #1. At 12:51AM, Resident #1 raised the leg rest and attempted to hit staff then went back into the room. Several staff were seen entering and leaving the room between 12:51AM and 1:15AM. At 1:08AM, Security staff brought Resident #1 out of the room and walked him up the hallway out of camera view. Resident #1 was still holding the leg rest in his hand. Emergency Medical Technicians (EMT) arrived at 1:11AM and left with Resident #2 at 1:15AM. A telephone interview was conducted with LPN #1 on [DATE] at 6:29AM. He stated that he worked on [DATE] from 10:30PM-6:30AM and last saw Resident #1 in bed at about 11:45PM when he made rounds. He heard CNA #1 screaming and he responded and saw Resident #1 standing in front of his door with the wheelchair leg rest in his hand. He attempted to take the leg rest from Resident #1, but the resident resisted, and Security was called. LPN #1 went into the room to see Resident #2 and saw a lot of blood. CNA #2 was interviewed on [DATE] at 8:55AM and stated that she was assigned to Resident #1 and Resident #2 on [DATE] to [DATE] from 10:30PM -6:30AM. The residents were on half-hourly monitoring and she last saw both residents at 12:30AM. She was taking the residents' vital signs on the opposite side of the unit and she arrived at Resident #1 and Resident #2's room at about 12:30AM. Resident #2 was lying in bed, and she took his vital signs. Resident #1 was lying in bed in a fetal position and appeared miserable and she did not take Resident #1's vital signs. She stated that she never observed Resident #1 and Resident #2 with prior behavioral issues. A follow up telephone interview was conducted with CNA #2 on [DATE] at 8:39AM. She stated that she did not take Resident #1's vital signs because she did not want to wake him up. She further stated that Resident #1 would get miserable when he was awoken at times. Resident #1 would jump up and ask her what she wanted, but he never tried to hit her. She added that Resident #2 had episodes of singing at night. However, she did not hear him sing on [DATE] or yell while he was being hit by Resident #1. CNA #1 was interviewed by telephone on [DATE] at 12:42PM and stated that she was not familiar with Resident #1 and Resident #2. She stated that on [DATE] at around 12:45AM, she was performing her water rounds task. She pushed Resident #1 and Resident #2's room door open, the door was approximately three-quarter way closed. When she entered the room, she observed Resident #1 standing over Resident #2 at the right side of the bed. Resident #1 had a wheelchair leg rest in his hand over Resident #2's head. Resident #2 had blood all over him. Resident #1 was about to hit Resident #2 again and she yelled for Resident #1 to stop. Resident #1 charged towards her and she backed out of the room and shouted for help. She called out for the Charge Nurse/LPN #1 and he, the RNM and other staff responded. On inquiry, she stated that Resident #2 was able to speak, but she did not hear him cry out during the incident. The Director of Nursing (DON) was interviewed on [DATE] at 1:35PM and stated that Resident #1 was transferred to the facility from another Nursing Home. She reviewed Resident #1's paperwork from the previous facility on [DATE] and did not see any documentation or indication that Resident #1 had any behavioral problems. She saw that Resident #1 was on [MEDICATION NAME] 5mg at bedtime for Dementia. She further stated that Resident #1 was not care planned for any risk for aggressive behavior because he never exhibited such behavior. A follow up telephone interview was conducted with the DON on [DATE] at 11:18AM. She stated that prior to the incident on [DATE], Resident #2 was able to ambulate in his room to and from the bathroom. Since the incident, Resident #2's condition has deteriorated. Resident #2 had 2 hospital admissions, he is now totally dependent of staff with his ADL needs and he is not eating. A telephone interview was conducted with Resident #2's Primary Physician on [DATE] at 2:15PM. He stated that Resident #2 was relatively medically stable prior to the incident with Resident #1. He further stated that Resident #2's condition started to decline after the incident and his oral intake became poor. Resident #2 was transferred to and admitted to the Hospital in (MONTH) due to poor oral intake. He was transferred to the hospital again on [DATE] and expired in the facility on [DATE]. 415.4(b)(1)(i)

Based on observation and interviews, the facility did not ensure that all narcotic drugs are stored in locked compartments. Specifically, Marinol was observed not double locked in the narcotic compartment of the refrigerator. This was evident for 1 of 5 units reviewed for Medication Storage. (Mezzanine unit). The finding is: On 9/25/15 at 10:05 AM during the initial tour of the Mezzanine unit, the narcotic box inside the medication refrigerator in the medication room was observed to be un locked and contained a Marinol Blister Pack (3 Pills). On 9/25/15 at 10:05 AM, Registered Nurse (RN) was interviewed. The RN was unable to explain why the narcotic box left unlocked. On 9/25/15 at 10:07 AM, the Licensed Practical Nurse (LPN) was interviewed. The LPN stated she did not know why the narcotic box inside the medication refrigerator in the medication room was not locked. The LPN stated the compartment should be locked but sometimes the blister pack medications won't fit inside. On 9/30/15 at 12:41 PM, the Director of Nursing (DON) was interviewed and stated that narcotics should be double locked in the medication room refrigerator. The DON further stated that the nurses will be in-serviced. 415.18 (d)

Based on record review and interview, the facility did not ensure that residents received quarterly statements. This was evident for 2 of 3 residents reviewed for Personal Funds (Resident #198 and #59). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident #198 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 9/30/14 at 10:45 AM, the resident was interviewed and stated that she has never received her quarterly statement. She further stated that she told Social Worker (SW) that she never received her quarterly statements, but she kept stalling her and insisted that she was receiving them. The resident also stated that she does not receive any mail. On 9/30/14 at 11:07 AM, the SW was interviewed and stated that the resident should be receiving all quarterly statements. She further stated that the resident did speak to her about it and she informed Finance of the request. She also stated that the resident has no person listed on her face sheet responsible for billing, which indicates that she would get the quarterly statement. On 9/30/14 at 9:40 AM, the Finance Staff in charge of resident funds was interviewed and stated that resident is on the list to get quarterly statements mailed to her. She further stated that the statements are left with the resident mail and delivered by Recreation staff. She also stated that she had no documentation to show that the resident received her quarterly statements. On 9/30/14 at 11:28 AM, the Director of Recreation was interviewed and stated that residents do not sign for receipt of the quarterly statements. She also stated that Recreation staff deliver the mail to the residents' rooms, and the mail can be left at the bedside. 2) Resident #59 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and 8/23/14 documented resident had intact cognition. On 9/24/14 at 9:38 AM, the resident was interviewed and stated that the quarterly statements are sent to her brother, but she feels she should receive a copy also. The resident further stated that she is not told any information. She also stated that she asked for a copy of the quarterly statements, but never received it. The resident was unable to recall when she asked about the quarterly statements. On 9/30/14 at 9:40 AM, the Finance Staff in charge of resident funds was interviewed and stated that quarterly statements are automatically sent to the families. She further stated that she does not know which residents are capable of managing their funds, but she will send it to the residents that request it from the Social Worker. She stated that there are 5 residents who want to get statements sent to them, and the resident is not on the list. On 9/30/14 at 9:59 AM, the Social Worker was interviewed and stated that upon admission, which was years ago, resident was very confused and her brother was designated the responsible party for financial matters. She further stated that the resident is much better now and did ask about her quarterly statements a couple of weeks ago. The SW stated that she did provide a copy of the statement to the resident at the time and she went over it with the resident and the family. She also stated that she did not request ongoing quarterly statements to be sent to the resident because she never asked for it, but she will do so if that is what the resident wishes. The SW stated that resident does have periods of impaired cognition when she is sick. 415.26(h)(5)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accidents/Incidents (A/I's) were thoroughly investigated for 4 of 18 Stage 1 resident's reviewed for A/I's in a total sample of 30 records reviewed and, 2 of 2 out of sample residents reviewed as part of the abuse protocol. Specifically, Resident #'s 4, 5, 8, 9, 36 and 37 had documented injuries without comprehensive statements from all assigned staff. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is a repeat deficiency. The findings include but are not limited to: 1) Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident as having moderately impaired cognition. The MDS also documented that Resident #35 required extensive assistance of two people for transfer, toilet use and bathing. An A/I report dated 7/5/12 documented that the daughter of Resident #8 reported that the finger on the right hand had been injured and did not look right. Upon assessment the right 4 th finger was found to be discolored and inflamed. The A/I report dated 7/5/12 at 1:30 PM documented one statement from the Certified Nursing Assistant (CNA) giving care on the 11:00 PM-7:00 AM shift on 7/5/12. The A/I documented that the CNA provided PM and AM care to the resident. There was no additional information obtained from this employee. The A/I report dated 7/5/12 at 1:30 PM documented one statement from the Certified Nursing Assistant (CNA) giving care on the 3:00 PM-11:00 PM shift on 7/4/12. The A/I documented that the CNA provided total Activities of Daily Living (ADL) care to the resident. The statement also documented that the resident was in bed when she came on duty. There was no additional information obtained from this employee. 2) Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS assessment dated ,[DATE] documented that the residents cognition was severely impaired. The A/I report dated 3/6/12 documented that at 5:15 AM the CNA noted a discoloration on the top of left foot of Resident #36. The area had slight swelling, was painful to touch and measured 5 centimeters (cm) by 4 cm. The A/I report dated 3/6/12 documented a statement from the Certified Nursing Assistant (CNA) giving care on the 11:00 PM-7:00 AM shift on 3/6/12. The A/I documented that the CNA provided AM care to the resident. The 7:00 AM- 3:00 PM CNA documented that perineal care was provided and the resident was transferred to the chair. The 3:00 PM-11:00 PM CNA documented that PM care was provided. There was no additional information obtained from these employees. 3) Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident's cognition as moderately impaired. The MDS also documented that the resident was a two person physical assist for transfer. The A/I report dated 3/3/12 documented that at 12:00 AM the CNA observed a red discoloration to the right knee measuring 2.6 cm by 3 cm. The left knee was also observed with a 2 cm by 1 cm discoloration. The 11:00 PM-7:00 AM CNA statement documented that AM care had been provided with no additional comments. Additional statements contained no documentation from the CNA who had assisted in taking the resident out of bed on 3/3/12 or returned the resident to bed on 3/2/12. On 8/27/12 at 9:30 AM the Director of Nursing Services (DNS) was interviewed. The DNS stated that the Unit Manager or Charge Nurse assigned to the unit where a resident identification of a injury is made is responsible to notify the nursing supervisor immediately. The nursing supervisor then will observe the resident and obtain statements from staff. The A/I is forwarded to the DNS the following day, a review of the A/I is made by the DNS and the process continues until all statements are obtained. The DNS acknowledged that complete documentation was lacking on the A/I reports and stated that the form was being revised. The Policy/Procedure Titled Resident Incident Report Form last reviewed 11/2011 did not address staff interviews after an incident occurs. 415.4(b)(1)(ii)

Based on record review and staff interviews during a recertification survey, the facility did not ensure that acceptable parameters of nutritional status were maintained, such as body weight, unless the resident's clinical condition demonstrates that it is not possible. Specifically, one (Resident #8) of 16 residents, reviewed for weight loss, was identified with a significant weight loss and there was no documented evidence of further dietary intervention as the resident continued to lose weight. This resulted in no actual harm , with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #8 was [AGE] years of age with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented Resident #8's cognitive skills for daily decision making as moderately impaired. Interdisciplinary Progress notes written by Registered Dietician (RD) dated 5/10/12 at 12 noon documented weight loss of 13 lbs x 30 days. Reweigh and verification requested and 3 day plate study initiated. On 5/14/12 at 4:30 PM, the RD documented the resident's weight status, plate study findings, labs, skin status and plan which included Boost plus 8 oz twice a day, assist with feeding, weekly weight monitoring, and speech therapy evaluation. The Nutritional Annual or Interim assessment dated [DATE] documented that the resident was noted with a significant weight loss that month, which was confirmed by reweigh (April weight 130.6 and May weight 117). The resident was receiving healthshakes and prostat daily. New interventions implemented included Boost plus twice per day, weekly weight monitoring, 3 day plate study, speech evaluation and appetite stimulants. The Nutrition Plan of Care for nutritional deficiency dated 5/24/12 documented interventions including to monitor weights and lab values as ordered for ongoing detection of symptoms of nutritional decline, provide progressive increase in supplemental oral feedings, as tolerated, and monitor pattern of consumption of meals/supplements. The Nutrition Plan of Care for potential for nutritional deficit dated 12/18/09 with multiple review dates including 7/13/12 documented interventions as above and including provide assistance with feeding. The Nursing Policy and Procedure related to weight change notification revised 10/10 documented procedures including any resident who is on weekly weights and experiences a 2 pound loss will have a "weight change notification" form completed and forwarded to the Director of Nursing. Weekly weights schedule on all units every Wednesday. Resident #8's weight work sheet and weight record documented the resident's weekly weights from May to August 2012. May's week 4 weight was 113.8, June week 4 weight was 113.6, July's week 4 was 110.8, and August's week 2 was 109.4. The physician's medical evaluation dated 8/9/12 documented weight loss stabilizing, appetite improving on [MEDICATION NAME]. Weight change notification form dated 8/10/12 documented the resident's current weight on 8/5/12 as 109.8 and the resident's weight 6 months ago on 2/8/12 as 136.8. Review of the Interdisciplinary Progress Notes from 5/24/12-8/16/12 lacked documented evidence of further dietary documentation regarding Resident #8's weight or interventions. During an interview with the Registered Dietician (RD) on 8/22/12 at 10:35 AM, she stated that the resident had a significant weight loss in May. The resident was referred to speech, which found the diet consistency appropriate for the resident, Boost supplement twice a day was initiated, and physician ordered an appetite stimulate. The resident was receiving a health shake and prostat prior. A plate study was also done, which showed the resident's intake of 992 calories just enough to maintain her metabolic needs. The resident fed herself prior to weight loss but after May, she was spoon fed by staff. There were no reports of a poor appetite prior to weight loss. The resident required supervision at times and was redirected. The resident's intake is variable at this time. The dietician reviewed the resident's weight record and stated that there is a form used to notify the dietician of a significant weight loss. Other than that, the dietician will regularly review the weight book to monitor the resident's status. She added that the weight loss the resident experienced between June and July was approximately 2 pounds. She stated that during meals she would monitor the resident's meal intake periodically, which fluctuated. She would not document if the resident was stable. She stated that she last documented on the resident in May. She stated that she would "keep her eye" on the resident. She added that the resident is due for a quarterly evaluation and the resident will probably receive an increase in her supplement. The weight loss between June and August was not significant and the resident was stable. During a subsequent interview with the RD on 8/22/12 at 1:50 PM, she stated that there does not have to be a significant weight loss before an intervention is initiated. She stated that in "June the resident's weight was stable and because a supplement was added in May you have to give it time to work." The RD stated that in July, the resident started to trend down, the RD was away the first week of August and will now assess to possibly increase the supplement. The RD added that she did not like to bombard residents with supplements. The resident is not deteriorating rapidly. She will probably increase the Boost at this time to help stabilize her weight. During an interview with the Attending physician on 8/23/12 at 10:20 AM, he stated that he was aware of the resident's weight and monitored the same. The physician stated that he was giving the appetite stimulant time to take effect. Her weight has stabilized. The physician stated he will continue to monitor to see if he needs to suggest a peg to the family. The quarterly nutrition assessment dated [DATE] documented po (by mouth) intake continues to be fair-poor at times. Mild weight loss persists. Recommend increase Boost Plus to 8 oz three times per day. Continues on [MEDICATION NAME] and [MEDICATION NAME] for appetite. Interim physician's orders [REDACTED]. three times per day. 415.12(i )(1)

Based on record review and staff interview during the recertification survey, the facility did not accurately complete sections of the Minimum Data Set (MDS) assessments for three residents in a total sample of thirty. (Resident #3, #10 and #11) This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident #3 has [DIAGNOSES REDACTED]. The Resident-Specific Nursing Skin Assessment Record dated 5/29/12 revealed that the resident had a stage III sacral pressure ulcer measuring 0.5 by 0.2 by 0.2 centimeters. The quarterly MDS assessment dated [DATE] revealed that the resident had no pressure ulcers. The Registered Nurse (RN) MDS Coordinator was interviewed on 8/22/12 at 9:25 AM and stated that the information for that part of the MDS is generated by a Nursing Interim Assessment that is filled out in the facility's computer system. The RN who completed the Nursing Interim Assessment did not fill it out correctly. The RN who filled out the Nursing Interim Assessment was on vacation and not available for interview. 2) Resident #10 has [DIAGNOSES REDACTED]. The July 2012 Medication Sheet documented that the resident received [MEDICATION NAME] (an antidepressant medication) 10 milligrams (mg) tablet by mouth once daily for Depression from 7/7/12 through 7/26/12, [MEDICATION NAME] (an antipsychotic medication) 0.5 mg tablet 1 tablet by mouth three times daily as needed for Agitation from 7/12/12 through 7/15/12 and on 7/18/12, and [MEDICATION NAME] (an antipsychotic medication) 25 mg by mouth twice daily and at bedtime for Agitation from 7/21/12 through 7/26/12. In addition, the July 2012 Medication Sheet also documented that the resident received [MEDICATION NAME] (an insulin) 50 units subcutaneously (SQ) every morning and [MEDICATION NAME] 30 units SQ at bedtime for Diabetes Mellitus from 7/6/12 through 7/26/12. The 5-day Admission MDS assessment dated [DATE] revealed under Section N0410: Medications Received that the resident only received an antidepressant medication ([MEDICATION NAME]) for 7 days during the last 7 days. There was no documentation that the resident had received an antipsychotic medication ([MEDICATION NAME]) 2 days during the last 7 days. In addition, under Section N0350: Insulin that the resident received only one day of insulin injections during the last 7 days, when the resident had received daily insulin injections during the last 7 days. The Discharge MDS assessment dated [DATE] revealed under Section N0410: Medications Received that the resident only received an antipsychotic medication ([MEDICATION NAME]) for 5 days during the last 7 days. There was no documentation that the resident received an antidepressant medication ([MEDICATION NAME]) for 7 days during the last 7 days. The RN MDS Coordinator was interviewed on 8/22/12 at 9:25 AM and stated that she had filled out both sections of the Medications Received and it was a mistake on her part for not documenting the antipsychotic medication on the 5-day Admission MDS assessment dated [DATE] and for not documenting the antidepressant medication on the Discharge MDS assessment dated [DATE]. The Director of Nursing (DON) was interviewed on 8/23/12 at 3:00 PM and stated that the 5-day Admission MDS assessment dated [DATE] should have indicated that the resident received an insulin injection for 7 days during the last 7 days. 3) Resident #11 has [DIAGNOSES REDACTED]. The Interdisciplinary Progress Notes dated 7/17/12 documented that the resident was observed on the east wing lying on the floor on her left side in the hallway in front of her gerichair. The significant change MDS assessment dated [DATE] revealed that the resident had no falls. The RN MDS Coordinator was interviewed on 8/23/12 at 9:30 AM and stated that she had completed the Falls section of the MDS and did not indicated the resident's fall on 7/17/12 in error. 415.11(b)

Based on observation, record review, and staff interviews during a recertification survey, the facility did not ensure that each resident was provided adequate supervision to prevent accidents. Specifically, one (Resident #9) of 9 residents reviewed for falls did not have implementation of interventions for supervision to prevent falls. Resident #9 fell on 3 occasions sustaining injury to the shoulder, head, and right hip, which required hospitalization . This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The finding is: Resident #9 was [AGE] years old with [DIAGNOSES REDACTED]. The Fall Risk Status dated 8/23/11 and 7/22/12 documented the resident as a moderate risk. The Fall Risk Status dated 1/30/12 and 5/17/12 documented the resident as a low risk. The Minimum Data Set ((MDS) dated [DATE] documented Resident #9's cognitive skills for daily decision making as severely impaired. The Nursing Plan of Care for falls dated 8/23/11 with multiple updates including 8/21/12 documented interventions including neurocheck every 2 hours for 24 hours, bed alarm to alarm at nursing station (6/18/12 and d/c 6/23/12), room change for closer observation (6/28/12), transfer to hospital (6/28/12), place chair in anteroom so resident does not sit on hamper (7/3/12), out of bed to regular chair with assist of 1, ambulate with hand held assistance of 1 on unit, wheelchair as needed on unit, personal monitor in bed, bolster mattress and bed alarm (8/21/12). The Comprehensive Plan of Care for potential for falls dated 9/6/11 with multiple updates including 8/12/12 documented to provide supervision to direct/redirect during ambulation. The Nursing Plan of Care for at risk for Unsafe Wandering dated 8/23/11 with multiple updates including 6/4/12 documented interventions to ascertain whereabouts periodically during course of shift. There were no new interventions documented. The Incident Report dated 12/9/11 at 11:45 AM documented that the resident ambulates independently on the unit, known to be confused at times. The resident came to the nurse's station with blood on the right side of her head, stated that she fell in her room. The resident was noted with a small skin tear approximately 1 ? cm on the right side of her head and a hematoma, bluish in color. The physician ordered a transfer to hospital, which was discontinued after discussion with family member. Neurological checks were done. The Interdisciplinary Progress Notes written by the Rehabilitation Nurse on 12/12/11 at 6:40 PM documented that the staff is to observe resident closely to prevent any avoidable injury and to continue with the POC (plan of care) for the resident at this time. The Interdisciplinary Progress Notes written by the Physical Therapist (PT) on 12/14/11 (no time given) documented a follow up after the fall. The resident presents with decreased balance, unsteady gait, requiring assistance. Resident is to begin Restorative PT, out of bed to regular chair with assistance of 1 person, and ambulate to all unit activities with assist of 1. The Incident Report dated 2/22/12 at 11:45 AM documented that the resident is known to ambulate independently on and off unit. The resident reported to family members who came to visit that she had tripped and fell a few minutes before. Cold compresses were applied to resident's right knee and physician evaluated. The Accident Report and Incident Report dated 6/11/12 at 21:20 (9:20 PM) documented that the resident stated she was going to sit on the chair, slipped, and fell on her left shoulder. A Certified Nursing Assistant (CNA) passing in the hallway observed the resident lying on the floor and alerted the nurse. Chair was observed to be overturned. The resident sustained [REDACTED]. Nursing Care Plan for non compliance of out of bed status dated 6/15/12 documented interventions including redirect resident and encourage resident to follow directions, call for assistance when needed and to provide information, offer alternatives when possible, and to monitor reaction related to non compliance. The Incident Report dated 6/28/12 at 21:45 (9:45 PM) documented that a nurse was passing in the hallway and heard the resident yelling, "help, help." The resident was observed lying on the right side on the floor and stated that she was putting on her shoes, twisted and fell over and hit her head. The resident was transferred to the hospital. The Accident Report dated 8/8/12 at 6:55 documented that the resident was witnessed to stumble and fall forward exiting her room and going towards the hallway. The resident sustained [REDACTED]. The conclusion documented that the "resident was hand held assist for ambulation but secondary to cognition deficit and self determination she refuses assistance and is continually being redirected to need for assistance but refused same." The resident's medical record lacked documented evidence that interventions related to supervision were added to the resident's plan of care after her falls. During an interview with the Registered Nurse (RN) unit manager on 8/24/12 at 10:10 AM, he stated that the resident was ambulatory prior to hip fracture and did not like anyone to tell her what to do, she was non compliant. He reviewed the comprehensive and nursing care plans and noted that the resident's room was moved closer to the nursing station after the fall on 6/11/12. He stated that the resident refused to be assisted with ambulation. The RN stated that alarms and supervision interventions do not require a physician's orders [REDACTED]. She is in the dining room if there are no activities or therapy. After hip fracture a bed alarm and self releasing belt alarm were put into place and resident can release. The self releasing seat belt was not noted on any care plan or CNA accountability and the RN unit manager added the seat belt to the care plan and CNA accountability during the interview. The RN unit manager did not give any other examples of resident supervision prior to the fracture in August. During an interview with the Physical Therapist on 8/27/12 at 10:05 AM, she stated that the resident was high functioning and was supervised with ambulation prior. Prior to last fall, attempted to place the resident on physical therapy but she refused. The social worker and daughter were notified. A walker and cane were offered to the resident in the past but she refused. The resident then had a one person to ambulate on the unit. The resident fell and hurt her shoulder, wheelchair and cane was attempted but resident refused. The resident was left with one person on unit ambulation. The last fall she had the resident fractured her hip. The resident now comes to therapy and is in a wheelchair. She participates in therapy with encouragement. During an interview with 7 AM-3 PM Float CNA on 8/27/12 at 10:40 AM, she stated that she is assigned to the resident today, not the regular CNA. However, she has cared for the resident a few times in the past few months. A couple of months ago, the resident was independent in her ambulation. She is now in a wheelchair and is placed in the dining room with other residents to be monitored. During an interview with the ADON on 8/27/12 at 11:20 AM, she stated that the resident had falls on 12/9/11, 2/22/12, 6/11/12, 6/28/12, and 8/8/12. She added that the resident was self directing, very difficult to offer hand held assistance, to work with, and not compliant with direction. "It is difficult to have her do what you would like her to do." Therapy suggested hand held assistance but the resident would not let you. If she got up and staff tried to intervene she would say "don't bother me." There was supervision of the resident. Staff on unit knew she was difficulty, they knew to observe and check on her. Staff were aware to observe her closely and to know her whereabouts. The resident liked to go back to her room and staff had to redirect. The ADON stated that observation means to be aware of where the resident is and to ensure her safety. 415.12 (h)(1)(2)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that three of fourteen residents reviewed for [MEDICAL CONDITION] medications in a total sample of thirty had documentation that non-pharmacological interventions were attempted prior to the administration of an antipsychotic medication. (Resident #14, #10 and #4) Specifically, there was no documented evidence that non-pharmacological interventions were attempted prior to the administration of 1) [MEDICATION NAME] (an antianxiety drug) thirteen times to Resident #14, 2) [MEDICATION NAME] (an antipsychotic medication) five times to Resident #10, and 3)[MEDICATION NAME](a medication for [MEDICAL CONDITION]) 42 times to Resident #4. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is a repeat deficiency. The findings are: 1) Resident #14 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had a Gastrostomy Tube (GT) for nutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition as moderately impaired. An Interim physician's orders [REDACTED]. The current physician's orders [REDACTED]. The resident was still receiving [MEDICATION NAME] 0.5 mg (milligram) tablet every 6 hours via the GT (gastrostomy tube) as needed (prn) for Anxiety. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was documentation on the back of the MAR for three of those occasions that the [MEDICATION NAME] was effective. The MAR indicated [REDACTED]. There was documentation on the back of the MAR for five of the administrations addressing the result. The Nurses notes dated 4/20/12 through 8/16/12 were reviewed. On 4/27/12 at 10:30 PM the licensed nurse documented that the resident continued to be restless, [MEDICATION NAME] given positive effect. Again on 5/27/12 on the 11:00 PM-7:00 AM shift the licensed nurse documented that the resident was very agitated this tour refused to stay in bed "stated she has to take care of business [MEDICATION NAME] given with short term effect". There was no further documentation in the nurses notes of the [MEDICATION NAME] being administered. Additionally, there was no documentation in the medical record of any nonpharmacological interventions attempted prior to the administration of the [MEDICATION NAME]. The Comprehensive Care Plan (CCP) dated 5/8/12 documented that the resident had the potential for adverse drug effects. The interventions included observing for: 1) adverse signs and symptoms from use of medications and 2) frequent review with MD/psych for continued need of medications and possible downward titration. A review of the medical record revealed that no psych consult had been ordered for this resident to date. On 8/23/12 at 11:45 AM the Registered Nurse (RN) Unit Manager where Resident #14 resided was interviewed. The RN stated that it is not necessary to document a behavior in a nurses notes prior to the administration of antianxiety medication . The RN stated that it is sufficient to document on the back of the MAR. The RN confirmed that there was no psych consult completed for this resident. On 8/23/12 at 12:00 PM the Director of Nursing Services was interviewed. The (DNS) acknowledged that a CCP should have been developed for a resident with abnormal behavior. 2) Resident #10 has [DIAGNOSES REDACTED]. The Interim physician's orders [REDACTED]. Review of the July 2012 Medication Sheet revealed that the resident received the [MEDICATION NAME] once on 7/12/12, 7/13/12, 7/14/12, 7/15/12, and 7/18/12. Review of the Interdisciplinary Progress Notes (IPNs) dated 7/12/12 through 7/18/12 revealed only one note on 7/12/12 addressing the administration of the [MEDICATION NAME] to the resident. There was no documented evidence for any of the five times that specific behavioral interventions were attempted to reduce or alleviate the agitated behavior prior to the administration of the prn [MEDICATION NAME] medication. The Licensed Practical Nurse (LPN) Medication Nurse who administered the prn [MEDICATION NAME] medication to the resident on three occasions was interviewed on 8/23/12 at 3:00 PM and stated she had reported to her Registered Nurse (RN) Charge Nurse when she had administered the [MEDICATION NAME] and hoped that she had written a note documenting it. The LPN stated that it was not her responsibility to write a note, it was the responsibility of the RN Charge Nurse. The RN Charge Nurse was on vacation and was not available to be interviewed. The Director of Nursing (DON) was interviewed on 8/23/12 at 3:05 PM and stated that just because behavioral interventions were not documented did not mean that they were not done. The DON also stated that it was not just Nursing's responsibility to provide and document behavioral interventions prior to the administration of an antipsychotic medication, but that any discipline, such as Social Services or Recreation, could document as well. 3) Resident #4, [AGE] years old, was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Sets (MDS) assessment dated [DATE] documented that the resident had long and short term memory problems and had modified independence in cognitive skills for daily decision making. A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the back of the MAR for 35 of those occasions and for 7 of those occasions the MAR indicated effective" or the resident had "some relief". The Nurse's Notes dated 5/16/12 through 8/21/12 were reviewed. On 5/19/12 at 9:30 AM, a Nurse's Note (N/N)documented that the resident continued to [MEDICATION NAME] bedtime as needed for [MEDICAL CONDITION]. On 7/16/12 at 10:00 AM, the N/N documented that the resident still slept on and off at night and still made noise at times. A Psychiatry/Behavior N/N on 8/18/12 documented that the [MEDICATION NAME] not been used this period due to sleepiness during the day. There was no further documentation in the N/Ns of [MEDICATION NAME] administered. Additionally, there was no documentation in the medical record of any non-pharmacological interventions attempted prior to the administration of the Ambien. The Comprehensive Care Plan (CCP) dated 7/25/09 and updated on 7/2/12 titled Potential for adverse drug effects as evidenced by use of psychoactive medication related to dementia-depression-[MEDICAL CONDITION] documented interventions which included monitor medication for effectiveness and for adverse signs and symptoms. On 8/27/12 at 9:10 AM the Director of Nursing (DON) was interviewed and stated that non-pharmacological interventions were attempted for Resident #4, but were not documented. The DON further stated that it was "old school nursing" that if something is not documented, it is assumed that it was not done. The DON further stated that the interpretive guidelines of the regulations document that non-pharmacological interventions need only be considered. On 8/23/12 at 1:30 PM the Medical Director (MD) was interviewed and stated that he had completed an inservice for licensed staff on 7/26/12 with regard to the protocol for residents presenting with agitation. The MD stated that the inservice included that if [MEDICAL CONDITION] medications are prescribed, a psychiatric evaluation will be ordered. The MD further stated that if prn (as needed) psychopharmacologic medications are ordered, it is necessary to convey to the Physician and document the exact behavior requiring sedative medications and attempts to redirect the resident and/or use other interventions. 415.12(1)(i)