Every finding on record at Concourse Rehabilitation and Nursing Center, Inc

Based on observation, record review, and interviews conducted during a Recertification and Abbreviated survey (NY00331425) from 4/6/2024 to 4/12/2024, the resident received inadequate supervision to prevent an accident. This was evident for one (Resident #80) of three residents reviewed for accidents out of 38 total sampled residents. Specifically, the plan of care did not clearly indicate Resident #80 required 2-person assistance with activities of daily living. Subsequently, Resident #80 fell and sustained a left distal femoral neck fracture (thigh bone broken at the knee) when Certified Nursing Assistant #1 rolled the resident on their side during care without a 2nd staff member's assistance. This resulted in actual harm to Resident #80 that was not immediate jeopardy. Finding is: The facility policy and procedure titled Fall Prevention and Management Program dated 8/2023 documented the staff will follow the resident fall prevention plan of care to ensure resident safety. Resident #80 had diagnoses of dementia and cerebrovascular accident (a stroke). The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #80 was rarely/never understood and exhibited moderate cognitive impairment. Resident #80 required substantial/maximal assistance where the helper does more than half of the effort when rolling in bed and performing personal hygiene. The Certified Nursing Assistant Accountability Record for 1/2024 documented Resident #80 was provided with bed mobility assistance a total of 30 times between 1/1/2024 and 1/10/2024. The record documented 10 out of the 30 times bed mobility was performed, Resident #80 scored a 4 in performance, indicating they were totally dependent, and a 3 in support provided, indicating 2-person assistance was required. In 8 out of the 30 times bed mobility was performed, Resident #80 scored a 3 in performance, indicating they required extensive assistance, and a 3 in support provided, indicating 2-person assistance was required. The facility Accident Report dated 1/10/24 documented Certified Nursing Assistant #1 notified Registered Nurse #1 that Resident #80 fell from the bed onto the floor during care. Certified Nursing Assistant #1 lost their grip on Resident #80 when they rolled the resident onto their right side and the resident fell . The Accident Report documented a risk management plan for staff to observe the care protocol for two staff to assist with total care residents. The facility Write-Up Form dated 1/11/2024 documented Certified Nursing Assistant #1 was suspended for 3 weeks due to Resident #80's fall during care resulting in a diagnosis of left femur fracture. The write-up form documented that Certified Nursing Assistant #1 must always follow the Certified Nursing Assistant records prior to giving care to any resident. A Nursing Note dated 1/10/2024 documented a left knee x-ray showed Resident #80 had a moderately displaced comminuted fracture of the distal femur supracondylar region (thigh bone broken at the knee). Resident #80 was transferred to the hospital for further evaluation. The Comprehensive Care Plan related to activities of daily living initiated 2/7/2024 documented reposition Resident #80 in bed with total assistance every 2-4 hours using a turning sheet. There was no documented evidence Certified Nursing Assistant #1 was provided with definitive instruction to provide Resident #80 with 2-person assistance when performing activities of daily living. This resulted in Resident #80's fall and fracture on 1/10/2024 when Certified Nursing Assistant #1 rolled the resident in bed without a 2nd person to assist. During an interview conducted on 4/10/2024 at 4:33 PM, Certified Nursing Assistant #1 stated they provided Resident #80 with care on 1/10/2024. Certified Nursing Assistant #1 rolled the resident to one side to provide care and lost their grasp on the resident, causing Resident #80 to fall on the floor. Certified Nursing Assistant #1 stated they were unaware Resident #80 required 2 people to assist with activities of daily living as they were regularly assigned to Resident #80 prior to the incident and provided one person assistance to perform hygiene and bed mobility. On 4/11/2024 at 3:21 PM, an interview conducted with the Acting Assistant Director of Nursing who stated Certified Nursing Assistants checked the task list in the medical record for their assigned residents prior to providing care. Any changes in resident condition and care required were discussed during report given to the Certified Nursing Assistants prior to the start of their shift. The Acting Assistant Director of Nursing stated they did not supervise Certified Nursing Assistants by observing the care they provided to residents. Supervision took place by discussing and reinforcing the Certified Nursing Assistant's tasks and responsibilities with them during report. During an interview on 4/11/2024 at 11:06 AM, Director of Nursing #1 stated Certified Nursing Assistants were in-serviced and performed competencies regarding their responsibility for checking the Accountability Record in the medical record prior to performing tasks with residents. Resident #80 required 2-person assistance at the time of the incident on 1/10/2024. Certified Nursing Assistant #1 did not follow protocol for performing activities of daily living and was taken off the schedule until the investigation was completed. During an interview on 4/12/2024 at 11:03 AM, the Rehabilitation Director stated Resident #80 required the extensive assistance of two people to perform activities of daily living prior to their fall on 1/10/2024. During an interview on 4/10/2024 at 2:41 PM, Medical Doctor #1 stated they were aware Resident #80 had a fall and fracture on 1/10/2024. Resident #80 was non-ambulatory prior to the fall incident and their activity of daily living status did not significantly change upon readmission from the hospital. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 4/6/2024 to 4/12/2024, the facility did not ensure the results of the most recent facility survey were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for 12 of 12 residents (Resident #s 5, 11, 41, 64, 77, 129, 146, 188, 203, 209, 215, and 295) during the Resident Council Meeting. Specifically, there were no observations of posted survey results in the facility. The findings are: During the Resident Council Meeting on 4/8/2024 at 10:30 AM, Resident #s 5, 11, 41, 64, 77, 129, 146, 188, 203, 209, 215, and 295 stated they were not aware of the location of the facility's posted survey results. On 4/8/2024 at 11:50 AM, the 6th Floor was observed with a posting documenting the New York State Department of Health survey results were located on the 1st Floor bulletin board outside the Admissions Office. There were no other observations of a posting providing the location of the facility's survey results. On 4/8/2024 at 11:53 AM, the 1st Floor Admissions Office was observed without a bulletin board in the vicinity. There were no observations of posted survey results readily accessible to residents, family members, and resident legal representatives throughout the 1st Floor and all other areas of the facility. On 4/10/2024 at 12:17 PM, the Director of Admissions was interviewed and stated the 1st Floor bulletin board was removed during renovations and was never replaced after the construction. They were not aware a sign was posted on the 6th Floor indicating the facility's survey results could be found on the bulletin board. The Director of Admission stated the posting needed to be updated and the survey results needed to be accessible to all residents. On 4/12/2024 at 1:25 PM, the Director of Nursing stated survey results used to be posted on the bulletin board outside of the Admissions Office until recently. The survey results were no longer posted on the bulletin board or anywhere else in the facility. 415.3 (d)(1)(v)

Based on observation, record review, and interviews conducted during a Recertification and Abbreviated (NY00331425) survey from 4/7/2024 to 4/12/2024, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health immediately or within 2 hours after the allegation was made. This was evident for 2 (Resident #80 and #119) of 38 total sampled residents. Specifically, 1) Resident #80 had a fall resulting in a fracture that was not reported to the New York State Department of Health, and 2) Resident #119 had an unwitnessed fall resulting in a fracture that was not reported to the New York State Department of Health. The findings are: The facility policy titled Prevention of Mistreatment, Neglect and Abuse and Misappropriation of Resident Property dated 10/4/2022 documented the Director of Nursing will report any accident or incident where there is reasonable cause to believe that resident abuse occurred to the New York State Department of Health. The facility policy titled Accident Prevention and Reporting dated 6/2023 documented the Director of Nursing reported any suspected incidence of abuse, neglect, or mistreatment to the New York State Department of Health. 1) Resident #80 had diagnoses of dementia and seizure disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #80 had moderately impaired cognition and required the assistance of 1 person for rolling in bed. The facility Accident Report dated 1/10/2024 documented Resident #80 fell out of bed during care when Certified Nursing Assistant #1 rolled the resident to one side and was unable to hold onto the resident. Resident #80 sustained a left femoral (thigh bone) fracture as a result of the fall. There was no documented evidence Resident #80's fall and fracture were reported to the New York State Department of Health. 2) Resident #119 had diagnoses of congestive heart failure and anxiety disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #119 was moderately cognitively impaired and required extensive assistance of 2 people for transfers and personal hygiene. The facility Accident Report dated 3/4/2024 documented staff heard a scream coming from Resident #119's room. Upon entering the room, Resident #119 was found on the floor with their left leg rotated inwards. Resident #119 was found to have a left fibula (ankle) and tibia (shin bone) fracture. There was no documented evidence Resident #119's fall and subsequent fracture was reported to the New York State Department of Health. On 4/11/2024 at 11:06 AM, an interview conducted with the Director of Nursing who stated allegations of abuse were reported immediately to the New York State Department of Health. The Director of Nursing stated they investigated abuse allegations within the first 2 hours of the occurrence and ruled out abuse before deciding if they needed to be reported to the New York State Department of Health. Resident #80's fall and fracture were not reported because it was a witnessed fall. Resident #119's fall and fracture were not reported because the resident was able to give an account of the incident that took place. 10 NYCRR 415.4(b)(2)

Based on record review and interviews conducted during a Recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure that the baseline care plan was developed within 48 hours of a resident's admission and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 10) of 38 total sampled residents. Specifically, the baseline care plan was not completed within 48 hours of Resident #10's admission to the facility and a copy was not provided to Resident #10. The findings are: The facility policy titled Baseline Care Plan dated 9/2023 documented a baseline care plan will be developed within 48 hours of resident's admission and the resident and their representative will be provided with a summary of the baseline care plan prior to the completion of the comprehensive care plan. Resident #10 was admitted to the facility on [DATE] with diagnoses of unspecified convulsions and acute osteomyelitis of the left ankle and foot. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #10 was moderately impaired in cognition participated in the assessment. On 4/07/2024 at 10:02 AM, Resident #10 was interviewed and stated they were not provided with a copy of their baseline care plan from admission to the facility approximately 4 months ago. The Baseline Care Plan for Resident #10 created on 11/21/2023 documented a completion date of 11/24/2023, more than 48 hours after the resident's admission to the facility on [DATE]. There was no documented evidence a copy of the baseline care plan was provided to Resident #10. On 4/10/2024 at 10:27 AM, Registered Nurse #1 was interviewed and stated they were responsible for creating and ensuring the completion of baseline care plans. Residents and their representatives were provided with a copy of the baseline care plan upon its completion. Registered Nurse #1 was not aware and was unable to provide an explanation for Resident #10 not receiving a copy of their baseline care plan. The baseline care plan for Resident #10 was completed 4 days after their admission to the facility. Registered Nurse #1 stated they provided a copy to Resident #10 but had no documented evidence that a copy had been provided. On 4/10/2024 at 12:35 PM, the Director of Nursing was interviewed and stated the unit nurse manager was responsible for overseeing the completion of baseline care plans within 48 hours of a resident's admission to the facility and documented in the medical record that a copy was provided to the resident and/or their representative. The Director of Nursing had no explanation for a copy of the baseline care plan not being provided to Resident #10. 10 NYCRR 415.11 (c)

Based on record review and interviews conducted during the Recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, a comprehensive care plan was not developed and implemented for Resident #24's use of antipsychotic medication. The findings are: The facility policy titled Comprehensive & Interim Care Plan dated 8/10/2023 documented that a care plan is developed for each resident's problem, with a measurable goal and interventions necessary to achieve the goal. Resident #24 had diagnoses of delusional disorder and bipolar disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident # 24 was moderately impaired in cognition and received antipsychotic medication. The Physician Order dated 3/10/2024 documented Resident #24 received Quetiapine 50 milligrams once daily. The Medication Administration Record for March 2024 Resident #24 received Quetiapine 50 milligrams daily in accordance with the Physician Order. There was no documented evidence a comprehensive care plan was developed for Resident #24's use of Quetiapine, an antipsychotic medication. On 4/09/2024 at 11:48 AM, Registered Nurse #2 was interviewed and stated they were responsible for developing, reviewing, and updating comprehensive care plans upon admission, quarterly, and as needed. Resident # 24 was prescribed and administered the antipsychotic medication Quetiapine to treat behavioral symptoms. Registered Nurse #2 stated there should be a care plan for Resident #24's antipsychotic medication use and it was an oversight that one was not developed and implemented. On 4/09/2024 at 12:23 PM, the Director of Nursing was interviewed and stated the unit nurse manager was responsible for developing, reviewing, and updating the comprehensive care plans for each resident upon admission, quarterly, and as needed. A care plan should be developed for residents taking antipsychotic medication. The Director of Nursing was unable to locate a care plan for Resident #24's antipsychotic medication use and was not aware that one had not been developed. 10 NYCRR 415.11(c)(1

Based on observation, record review and interviews conducted during the recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1 (Resident #27) of 6 residents reviewed for pressure ulcers out of 38 total sampled residents. Specifically, Resident #27 was observed without on multiple occasions resident #27 was observed without heel float boots, a pressure-relieving device, in accordance with the Physician's Order. The findings are: The facility policy titled Pressure Ulcers dated 10/2023 documented assistive devices were used to treat and prevent pressure ulcers. Bony prominences were protected as needed. Resident #27 had diagnoses of dementia and respiratory failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #27 was severely cognitively impaired and was dependent on staff to perform activities of daily living. On 4/08/2024 at 11:00 AM and 12:30 PM and 4/10/2024 at 10:55 AM and 12:45 PM, Resident #27 was observed out of bed to a recliner chair in the unit hallway. Resident #27 did not have bilateral heel float boots in place. The Braden Scale - Skin Breakdown Risk assessment dated [DATE] documented that the resident was at risk for pressure ulcers. The Physician's Order initiated 10/10/2023 and renewed 4/1/2024 documented Resident #27 was ordered to always wear bilateral heel float boots, only to be removed for hygiene care. The Comprehensive Care Plan related to skin integrity last reviewed 3/29/2024 documented off-load Resident #27's heels while the resident was in bed. On 4/10/2024 at 12:34 PM, an interview was conducted with Certified Nursing Assistant #2 who stated they were assigned to Resident #27 and applied bilateral heel float boots to the resident's feet when the resident was in bed. Resident #27's family requested the resident where shoes when out of bed and in the recliner. Certified Nursing Assistant #2 stated that their daily task list for Resident #27 did not include instruction on application of heel float boots. On 4/10/2024 at 12:50 PM, an interview was conducted with Licensed Practical Nurse #1 who stated Resident #27 was ordered to always wear bilateral heel float boots unless they were receiving skin hygiene checks during activities of daily living care. Resident #27's family brought in shoes for the resident to wear and Licensed Practical Nurse #1 informed the family the Medical Doctor needed to be informed before the resident could wear the shoes. Licensed Practical Nurse #1 stated they saw Resident #27 wearing the shoes yesterday and instructed Certified Nursing Assistant #2 to stop using the shoes and to apply the bilateral heel float boots. On 4/10/2024 at 3:24 PM, Registered Nurse #1 was interviewed and stated Resident #27 had previously had a sacral pressure ulcer that healed. Resident #27 was ordered to always wear bilateral heel float boots to prevent skin breakdown. Registered Nurse #1 could not explain the reason Certified Nursing Assistant #2 did not apply the bilateral heel float boots to Resident #27's feet in accordance with the Physician's Order. 4/11/2024 at 1:40 PM, the Director of Nursing was interviewed and stated Registered Nurses were responsible for monitoring the application of special devices, such as hell float boots. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and interviews conducted during the recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure dental services were provided from an outside resource to meet the needs of the resident. This was evident for 1 (Resident #203) of 38 total sampled residents. Specifically, the facility did not obtain outside dental services for Resident #203 when a tooth extraction was recommended. The findings are: The facility policy titled Dental Consultation dated 8/2023 documented residents were provided access to dental consultations as part of their comprehensive primary care. Resident #203 had diagnoses of diabetes mellitus and heart failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #203 was moderately cognitively impaired. On 4/10/2024 at 12:42 PM, Resident #203 was interviewed and stated a Dentist saw them in the facility a few months ago and recommended a tooth extraction. The facility did not assist with scheduling an appointment to have the tooth extraction and Resident #203's son coordinated with an outside dentist for an appointment. Resident #203 went to the outside dentist and the tooth extraction was not done because of an insurance issue. The facility has not assisted with any follow-up appointments with the dentist and the tooth extraction still was not addressed. The Comprehensive Care Plan related to dental care dated 1/13/2024 documented Resident #203 was at risk for a dental condition and should be referred for dental services. The Dental Consult dated 2/14/2024 documented Resident #203 complained of lower right mouth pain. Resident #203 had a broken tooth and the Dentist recommended Resident #203 have a tooth extraction. There was no documented evidence a Dental Consult for tooth extraction was ordered in response to the Dentist's recommendation on 2/14/2024. The Nursing Note dated 3/12/2024 documented Resident #203's son visited and informed the Nursing staff they made an appointment for Resident #203 to see an outside Dentist on 3/22/2024. The Physician's Order dated 3/12/2024 documented Resident had a Dentist appointment scheduled for 3/22/2024. The Nursing Note dated 3/22/2024 documented Resident #203 returned from their Dentist appointment and was not evaluated for tooth extraction because of an insurance issue. There was no documented evidence a follow-up Dentist appointment was scheduled when Resident #203 was not evaluated for tooth extraction on 3/22/2024. There was no documented evidence the facility assisted with alternative Dental arrangements or sources of payment for Resident #203 to receive a tooth extraction. On 4/10/2024 at 9:29 AM, Unit Clerk #1 was interviewed and stated they recall Resident #203's son made an appointment for the resident to be seen by a Dentist outside the facility. Resident #203 did go to the appointment on 3/22/2024 but was not seen by the Dentist due to an insurance issue. On 4/10/2024 at 12:59 PM, Registered Nurse #3 was interviewed and stated they were aware Resident #203 attempted to see an outside Dentist on 3/22/2024 but was not seen due to an insurance issue. Another Dental Consult was ordered for Resident #203, but Registered Nurse #3 did not know if the resident received any follow-up appointment yet. On 4/11/2024 at 11:56 AM, Medical Doctor #3 was interviewed and stated they were not aware Resident #203 had any dental pain until recently. Medical Doctor #3 stated Dental Consult recommendations were reviewed but they do not recall reviewing Resident #203's Dental Consult recommending tooth extraction due to pain from a broken tooth. 10 NYCRR 415.17(b)

Based on record review and interviews conducted during the Recertification survey from 4/7/2024 through 4/12/2024, the facility did not ensure the Binding Arbitration Agreement granted the resident or representative the right to rescind the agreement within 30 calendar days of signing it. This was evident for 1 (Resident #156) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Resident #156 did not grant the resident 30 calendar days to rescind the agreement. The findings are: The facility's sample Admission Agreement contained a Binding Arbitration Agreement that documented the agreement can be rescinded within 10 days of the resident's admission to the facility. Resident #156 signed a Binding Arbitration Agreement on 12/22/2021. There was no documented evidence Resident #156 was provided 30 calendar days to rescind the agreement. On 4/12/2024 at 12:51 PM, the Director of Social Service was interviewed and stated they were unaware that the resident or their representative should have the right to rescind the agreement within 30 days of signing it. The facility Binding Arbitration Agreement documents that it may be rescinded within 10 days from the date of the resident's admission to the facility. On 4/12/2024 at 1:10 PM, the Administrator was interviewed and stated the facility Binding Arbitration Agreement states it can be rescinded within 10 days of a resident's admission to the facility. The Administrator stated they were unaware residents had the right to rescind within 30 days of signing the agreement. 10 NYCRR 415.30

Based on observation and interview conducted during the recertification survey, the facility did not ensure a resident is free from physical restraint. Specifically, a resident was observed in the day room, sitting on a wheel chair with a lap tray attached to the resident's body, and the resident was unable to remove it. This was evident for 1 of the 1 resident reviewed for Physical Restraints out of a sample of 39 residents. (Resident # 302). The finding is: The facility policy on Physical Restraint dated (YEAR) documented the following: Residents being considered for restraints/Device will be evaluated by a team composed of a Licensed Nurse and a rehabilitation therapist and or a social worker. The policy also documented that, prior to instituting a device, a verbal or written order must be obtained from the resident or a designated representative, if at all possible. The policy further documented that the monitoring for continued need will be documented on the tracking sheet for each resident. In addition, the policy stated that the comprehensive care plan will reflect the quarterly review interventions. Resident #302 is [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) 3.0 dated 1/3/19 documented the resident's cognitive status is severely impaired, requires extensive assistance with one person assist and has impairment on one side of the upper extremity. On 8/01/19 at 11:56 AM, the resident was observed in the elevator, sitting on a wheel chair with a lap tray that was tied to the back of the wheel chair. The resident was later wheeled to the day room where the Certified Nursing Assistant (CNA) untied the lap tray from the back of the resident's wheel chair. The CNA stated that we only remove the tray before the lunch and put it back on after lunch. On 8/02/19 at 11:38 AM, the resident was observed in the day room, sitting in a wheel chair with a lap tray tied to the back of the wheel chair. The State Agent (SA) spoke to the resident and the resident responded in Spanish language. The SA then asked CNA #4 who speaks Spanish to interpret. CNA #4 instructed the resident to remove the tray 3 times. The resident made an attempt to remove the tray but was not able to do so. CNA#4 stated that the resident is confused. Registered Nurse Manager (RNM #2) was present. The Cognitive Care Plan dated 12/29/19 documented the resident had impaired judgement. The Social Service assessment dated [DATE] documented the resident is alert and confused with short and long term memory impaired. Review of the medical record was done on 8/5/19 and revealed no assessment was completed prior to the use of the lap tray. The physician's orders [REDACTED]. Resident can remove by will and by command. This order was discontinued (d/c) on 8/1/19. The physician's orders [REDACTED]. An Occupational Therapy Note dated 8/1/19 documented, Resident assessed for lab tray. Requires lab tray to support left upper ext, to prevent subluxation of the left shoulder. On 8/05/19 at 10:40 AM, the Occupational Therapy and Rehab Director (OTRD) was interviewed. The OTRD stated we assess the resident to determine why they need the device. He also stated that the resident was provided with a lap tray due to left [MEDICAL CONDITION] and the resident's muscle tone. An arm tray was tried prior but this was not effective. The OTRD further stated that there was no written assessment was done prior to the use of lap tray. The issue was discussed with nursing staff. The OTRD also stated that an assessment was conducted when the resident was first provided with the lap tray and the resident was able to remove it at that time. No additional assessments were done after the lab tray was started. On 8/01/19 at 2:00 PM, CNA #2 was interviewed. CNA#2 stated that she has worked with the resident for the past year and the resident is confused, unable to make his needs known and cannot follow instructions. CNA#2 also stated the resident has had the lap tray for a while and she places it on him after doing his morning care and removes it before lunch. CNA#2 further stated that she was instructed by the nurse manager a very long time ago to apply the tray as she stated. The lap tray was not included in her daily task but she is following the instructions from the Registered Nurse (RN)Manager. On 8/01/19 at 2:25 PM, RN #1 was interviewed. RN #1 stated that rehab, and not nursing, is responsible for assessing the resident's use of the lap tray. RN#1 also stated that the tray is only removed during feeding and ADL care. On 8/02/19 at 11:40 AM, Registered Nurse Manager (RNM) #2 was interviewed. RNM #2 was unable to describe the facility protocol for assessment of physical restraints. RNM #2 also stated that the resident is very confused and was able to remove the lap tray a few weeks ago. RNM#2 was not able to specify how often residents are evaluated and assessed to determine the ongoing need for the use of restraint. 415.4 (a)(2-7)

Based on observation and interview conducted during the recertification survey, the facility did not ensure a care plan was developed for a resident. Specifically, there was no care plan developed for a resident using a laptray. This was evident for 1 resident out of a sample of 39 residents. (Resident # 302) The finding is: The facility policy for Assessment and Care Process/Development dated 11/2018 documented the following that it is the responsibility of the facility to provide care necessary for each resident to reach his/ her highest practicable physical, mental and psychosocial well-being. The policy also documented that a care plan is developed for each resident in order to have a systematic blueprint of the resident's problems and interventions determined to be necessary to achieve the measurable specified and individualized. The policy further documented that the the Comprehensive Care Plan must reflect the residents specific problems, and also the basis guidelines for the Certified Nursing Assistant assignment sheet. Resident #302 is [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) 3.0 dated 1/3/19 documented the resident's cognitive status is severely impaired, requires extensive assistance with one person assist and has impairment on one side of the upper extremity. On 8/01/19 at 11:56 AM, the resident was observed in the elevator, sitting on a wheel chair with a lap tray that was tied to the back of the wheel chair. The resident was later wheeled to the day room where the Certified Nursing Assistant (CNA) untied the lap tray from the back of the resident's wheel chair. The CNA stated that we only remove the tray before the lunch and put it back on after lunch. On 8/02/19 at 11:38 AM, the resident was observed in the day room, sitting in a wheel chair with a lap tray tied to the back of the wheel chair. The State Agent (SA) spoke to the resident and the resident responded in Spanish language. The SA then asked CNA #4 who speaks Spanish to interpret. CNA #4 instructed the resident to remove the tray 3 times. The resident made an attempt to remove the tray but was not able to do so. CNA#4 stated that the resident is confused. Registered Nurse Manager (RNM #2) was present. The physician's orders [REDACTED]. Resident can remove by will and by command. This order was discontinued (d/c) on 8/1/19. Review of the medical record revealed that there was no care plan created for the use of a lap tray. On 8/01/19 at 2:00 PM, CNA #2 was interviewed. CNA#2 stated that she has worked with the resident for the past year and the resident is confused, unable to make his needs known and cannot follow instructions. CNA#2 also stated the resident has had the lap tray for a while and she places it on him after doing his morning care and removes it before lunch. CNA#2 further stated that she was instructed by the nurse manager a very long time ago to apply the tray as she stated. The lap tray was not included in her daily task but she is following the instructions from the Registered Nurse (RN)Manager. On 8/01/19 at 2:25 PM, the RN #1-Supervisor was interviewed. RN#1 stated there is no care plan for the use of the lab tray. The tray is used to position the resident due to [MEDICAL CONDITION]. RN #1 also stated that the RN charge nurse is responsible for care planning. RN#1 was unable to explain why the care plan for the use of lap tray was not developed. 415.11(c)(1)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident's total plan of care was reviewed by the Physician following readmission. Specifically, The family member of Resident #58 complained to SA that the resident was not walking post fall and was not receiving Physical Therapy/Occupational Therapy. Record reviews revealed that prior to having a fall in the facility and being hospitalized the resident was receiving PT/OT. The Nurse Practitioner (NP#9) assessed the resident upon the resident's readmission, however, the NP did not refer the resident to PT/OT for evaluation. The NP documented that they would confer with the resident's Medical Doctor (MD). There was no documented evidence that the NP conferred with the MD or that the MD evaluated the resident post fall and hospitalization . The resident was never referred to PT or OT for revaluation. This was evident for one of five residents reviewed for Unnecessary Medications and Dementia Care in a sample size of 39 residents. The finding is: On 8/01/19 at approximately 9:51 AM resident #58 was observed by this State Agent seated in a wheel chair, awake and alert and dressed appropriately for the weather. Speech is clear and appropriate. On 8/02/19 the resident returned from his activity at approximately 11:00 AM. At approximately 11:25 AM he went to lunch in the dining room. He is awake, alert and calm. He is dressed appropriately, wearing his black arm/wrist support. He has no complaints of pain in his right lower arm. He is quietly seated in his wheelchair. On 8/1/19 at approximately 2:30 PM the resident's daughter spoke briefly with this SA and stated she is content with care given to her father but doesn't know why he isn't walking. She stated she visits often and speaks with the nurse and NP. Resident #58 is [AGE] years old and was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set ((MDS) dated [DATE] was reviewed and documented that the resident's BIMS score was 11(moderately impaired). His Activities of Daily Living for Section G: subsection: C: does not walk in the room. Subsection D: does not walk in the corridor. A record review was conducted. The PT (Physical Therapy) Progress and Discharge (d/c) summary documented: 2/27/19. Diagnosis: [REDACTED]. [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Infarction affecting Right dominant side (12/12/18). History of falling (12/12/18). Short Term/Long Term goals set and worked on with resident. D/C plans and Instructions: resident was d/c to hospital due to medical complexity. To be re-evaluated upon re-admission. The Nurse Practitioner (NP) #9 note of 2/25/19, 4:25 PM was reviewed. She documented the resident returned from(NAME)Hospital. Assessment/Plan: monitor resident for pain, instruct him to use call bell at all times in order to prevent falls. Discussed with Medical Provider #8. There are no written notes by Medical Provider #8 since 1/12/19. The 1/12/19 note documented that the resident has Right Hip Open Reduction Internal Fixation (ORIF). No documentation of any therapy or follow up by Orthopedist. On 08/02/19 at approximately 11:27 AM the Physical Therapist #6 was interviewed and he stated that the resident was walking in Physical Therapy, became sick and was d/c from therapy. He (Physical Therapist #6) reviewed the orders from 2/20/19-3/1/19 in the resident's Electronic Medical Record (EMR) and there were no orders entered for re-evaluation by Physical Therapy. He reviewed the EMR and found that resident was sent to hospital and returned within 24 hours: 2/25/2019-2/26/19 at 12:08PM He stated that the resident was d/c from therapy and upon his return from the hospital he should have been referred back to therapy for re-evaluation. RN #4 was at the desk and he asked her if the resident was on FAP (Floor Ambulation Program) and she stated no. 0n 8/02/19 at 11:59 AM RN #1 was interviewed and stated that the resident was discharged (D/C) from Physical Therapy (PT) in Feb, 2019 and sent to the hospital. She continued to state that he was D/C from Occupational Therapy (OT) and PT because of d/c to hospital and then was transferred to the 4th floor. On 8/2/19 at approximately 3:40 PM RN #1 was interviewed and stated that the facility policy is when a resident returns from a hospital visit, they are re-evaluated by OT and PT. She does not know how the resident was not re-evaluated by PT. On 8/05/19 at approximately 10:02 AM RN #1 was re-interviewed and stated the resident was not seen by PT when he returned to the facility on [DATE]. The facility process is: all residents who are new admissions are screened by Rehab. This resident was sent to the hospital and returned. He was not referred to PT by the Physician. The NP #9, this NP is not working here any longer, signed the transfer form from the hospital. The physician, Medical Provider #8 is following this resident. On 8/05/19 at approximately 10:22 AM RN #4 was interviewed and stated NP #9 saw the resident and she wrote notes. She is responsible to write her orders for the resident. She stated that she did not notice that NP #9 did not order PT re-evaluation for the resident. She continued to state: My responsibility is to ensure that all of the nursing preparations are done in order for the resident to be seen by the NP, MD, Dietary or therapy. This includes taking Vital Signs (blood pressure, pulse, respirations and temperature), they are dressed appropriately and/or weighed. On 8/05/19 at approximately 11:30 AM the Rehab Clinical Supervisor #2 was interviewed. He stated that his department had a rehab director who left in beginning of Feb, 2019. There was no replacement until early March, 2019. He continued to state that he was responsible to attend the Morning Report but if he was busy, he did not attend the meeting. The Physical Therapist was preparing to discharge the resident the week that he had a fall because he reached his maximum potential. The resident was discharged to the hospital and upon his return, there was no referral made by Nurse Practitioner #9 or Medical Provider #8. On 8/05/19 at approximately 12:04 PM Physical Therapist #7 was interviewed and stated the resident was on Physical Therapy since (MONTH) 18, (YEAR). He was doing well-participating well, and motivated. Physical Therapist #7 continued to stated that a PT note was written on 2/20/19 and it stated the resident was reaching his maximum potential and was supposed to be discharged in a week. Then, he fell , and was discharged to the hospital on [DATE]. He was not placed on Floor Ambulation Program and we discharged him from our system. Physical Therapist #7 continued to stated that the resident came back to the facility and we did not receive an order from MD #8 or NP#9 to follow up. When the residents go and come back from the hospital there is usually a PT order to come, screen and evaluate the resident. If there was no significant decline in prior level of function there would be a referral for PT evaluation, and then he would receive therapy. He would be kept on PT until he reached prior level of function. Lastly, she stated we usually screen everyone who comes back from the hospital. On 8/5/19 the Medical Provider #8 was paged and called but did not return the calls per RN#1. On 08/05/19 at approximately 02:18 PM Medical Director #5 was interviewed. He stated that he is aware of this situation: the resident's medical provider did not evaluate the resident following return from the emergency room following a fall. The Medical Director #5 continued to state that NP #9 is no longer is working here. The Medical Director #5 stated the facility is working with the Rehabilitation Department (they are a separate company) to share the information. The Health Care Provider runs the ship. The buck stops with the Medical Provider and he will speak with him. He lastly stated that the resident fell through the cracks. Rehab will retool themselves and have a dedicated person attend Morning Report so things aren't missed. 415.15 (b)(2)(iii)

Based on observations and interviews conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a resident who continuously used oxygen was observed on multiple occasions to have oxygen tubing on the floor. (Resident #120) The findings are: The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #120 had moderately impaired cognition and a [DIAGNOSES REDACTED]. The resident was also documented as receiving suctioning, [MEDICAL CONDITION] care and oxygen therapy. The most recent Physician order [REDACTED]. On 07/31/19 at 10:28 AM, Resident #120 was observed in his room, out of bed, and in a wheelchair next to his bed. The oxygen tubing connecting the oxygen concentrator to the [MEDICAL CONDITION] collar was observed to be lying on the floor between the wheelchair and bed. On 07/31/19 at 11:56 AM, Resident #120 was observed to be in his room in the wheelchair in the same position as previously observed. The oxygen tubing was still lying on the floor in the same position. A Certified Nursing Assistant (CNA) was observed bringing the resident his lunch tray. The CNA placed the lunch tray on the resident's bedside table in front of his wheelchair and then left the room without addressing the oxygen tubing on the floor. On 08/05/19 at 11:09 AM, an interview was conducted with CNA #1, who was observed bringing the resident his meal tray. CNA #1 stated that she does recall coming into the resident room to provide him with lunch last week but the resident is not on her regular assignment. CNA #1 stated that she did not realize that the tubing was on the floor because of how the resident was positioned in the room. This resident is mobile and moves around a lot so even if the tubing is kept off the floor, sometimes it will end up on the floor again. CNA#1 further stated that if tubing is observed on the floor, she would let the nurse know so that the tubing can be changed. It is an infection control issue and that she has been trained on this previously. On 08/05/19 at 12:46 PM, the Director of Nursing(DNS) who is also responsible for Infection Control was interviewed. The DNS stated staff are inserviced during orientation, annually, and as necessary on infection control policies and procedures. Infection control inservices include care of oxygen tubing, labeling, and the fact that they are to be changed every 3 days. The DNS also stated he does rounds frequently to ensure that oxygen tubing is cared for properly. Sometimes there are patients that move around and this can cause the tubing to be on the floor. Once observed, new tubing should be provided to the resident. There are plastic bags that the facility provides to the residents. These plastic bags are used to ensure that excess oxygen tubing remains off the floor. 415.19(a)(1-3)

Based on record review and interviews during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, Quarterly MDS assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date. Specifically, 57 out of 57 residents reviewed for the Resident Assessment Facility Task had MDS Assessments submitted later than 14 days after completion. (Residents #14, 29, 44, 57, 130, 43, 48, 3, 51, 5, and 62). The findings included but are not limited to: The CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR)), Chapter 5 titled Submission and Correction of the MDS Assessments documented the MDS completion date must be no later than 14 days after the assessment reference date (ARD) for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. 1). Resident #14: The Quarterly MDS assessment with an ARD date of 5/16/19 was completed on 5/23/19 and submitted on 8/1/19 2). Resident #29: The Quarterly MDS assessment with an ARD date of 6/29/19 was completed on 7/06/19 and submitted on 8/1/19 3). Resident #44: The Quarterly MDS assessment with an ARD date of 06/04/19 was completed on 6/11/19 and submitted on 8/1/19 4). Resident #57: The Quarterly MDS assessment with an ARD date of 6/13/19 was completed on 6/20/19 and submitted on 8/1/19 5). Res #43: The Quarterly MDS assessment with an ARD of 6/1/19 was submitted on 8/1/19. 6). Res #48: The Quarterly MDS assessment with an ARD of 6/5/19 was submitted on 8/1/19. 7). Res #3: The Quarterly MDS assessment with an ARD of 5/10/19 was submitted on 8/1/19. 8). Resident # 51: The Quarterly MDS with an ARD of 6/10/2019 was submitted on 8/1/19. 9). Resident #5: The Quarterly MDS with an ARD of 5/12/2019 was submitted on 8/1/19. 10). Resident # 62: The Quarterly MDS with an ARD of 6/17/2019 was submitted on 8/1/19. On 08/05/19 at 12:53 PM, Registered Nurse (RN) #3, MDS Coordinator was interviewed. RN #3 stated that she is currently working part-time with 2 full time MDS Assessors. RN#3 also stated that she was not aware that the assessments were not submitted and maybe the assessments had not been saved. RN#3 further stated that the submission of the MDS is done by the Administrator. On 08/05/19 at 01:23 PM, an interview was conducted with the Facility Administrator. The Administrator stated that he is responsible for the submission of the completed Misstep Administrator also stated that once the assessments have been completed, the residents list will appear on my Electronic Medical Record dashboard indicating that they are ready to be submitted. The Administrator further stated that the assessments had been completed but were not saved and so did not show up on the dashboard and as a result were not submitted once they had been completed. 415.11(a)(1-5)

Based on staff interviews and record review during an abbreviated survey (NY 635), the facility did not ensure that the Office of the State Long Term Care Ombudsman was notified of residents' transfers/discharges. This was evident in 2 out of 4 residents sampled, (Resident #1 and #3). Specifically, Resident #1 and Resident #3 were transferred to the Hospital and the facility did not notify the Office of the State Long Term Care (LTC) Ombudsman of the transfers. Review of the following facility policy and procedures: Discharge Planning dated 05/2018; Patient Transfer Form dated 06/1997; The Discharge Plan dated 06/1997; and an undated Bed Retention Policy revealed no information that address notification of the Ombudsman. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 05/10/2018 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 15/15, associated with intact cognition (00-07 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Notice of Transfer /discharge date d 07/10/2018 documented Resident #1 was given a notice stating that she was being transferred/discharged to the hospital on [DATE] for noncompliance with treatment, wound management/prevention, worsening sacral; left calf and left heel ulcers. A review of the Patient Transfer Form dated 07/10/2018 documented that Resident #1's primary [DIAGNOSES REDACTED]. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 08/03/2018 documented that Resident #3's cognitive skills for decision making was severely impaired. A Notice of Transfer /discharge date d 08/29/2018 documented that Resident #3 was given a notice stating that she was being transferred/discharged to the hospital on [DATE], as her welfare and her needs could not be met in the facility. A review of the Patient Transfer Form dated 08/29/2018 documented Resident #3's primary [DIAGNOSES REDACTED]. There was no documentation that the facility sent a copy of the transfer/discharge notices to the Office of the State Long Term Care Ombudsman for Resident #1 and Resident #3. The Director of Social Services was interviewed on 09/13/2018 and stated that the Ombudsman was not notified of Resident #1 and Resident #3's transfers to the acute care facility. The Ombudsman is only notified if a resident was given a 30-day notice or when if the resident was discharged to home. The facility does not have a policy and procedure for Ombudsman notification of transfers/discharges. The Administrator was interviewed on 10/16/2018 at 12:50 PM. He stated that the facility only notifies the Ombudsman for discharges to home only. Social Service Department is responsible for updating the policy and reviewing it with the Administrator. He stated that the facility is in the process of updating the policy. 415.3(h)(1)(i)(iii) (a-c), 415.3(h)(1)(iv)(a-e)

Based on observation, record reviews and interviews, the facility did not ensure that medications were administered in accordance with the clinical standard of practice. Specifically, The physician orders [REDACTED]. During a Medication Pass Observation the Registered Nurse (RN) was observed administering the medications to the resident between the hours of 2:40PM and 3:00PM. This was evident for 3 of 25 medication opportunities observed during Medication Administration Observation performed by one (1) Registered Nurse. The findings are: The facility policy on Medication Administration (undated) documented that medication will be administered by licensed nurses on a timely manner at 9-1-5-9 schedule unless alternate time is indicated. It further documented the time schedule for medication administration as follows: Daily medications are to be administered: 9 AM. The Two times daily (BID) are to be administered: 9 AM and 5 PM, while the three times (TID) are: 9 AM, 1 PM, AND 5 PM. Every 12 hours medications are administered at 9 AM and 9 PM, unless alternate time is indicated. Resident #64 is an [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets 3.0 ((MDS) dated [DATE] documented that the resident's cognitive status is intact, no mood and behavioral problems identified. The MDS further documented that the resident required total assistance with all Activities of Daily Living (ADL). On 09/13/17 between the hours of 2:40PM and 3:00PM, the following was observed: The RN administered the following medications to the resident orally: [MEDICATION NAME] 25 Milligrams (mg) 1/2 (half) tablet (tab), [MEDICATION NAME] 100 mg 3 capsules, , Calcium [MEDICATION NAME]-Vitamin D3, 315 mg-250 Units 1 tab. The resident was also observed sitting on the wheel chair, alert and awake, bilateral lower legs [MEDICAL CONDITION], a left hand contracture, and unable to move arm. On 09/15/2017 10:58AM the resident was interviewed and stated that sometimes she gets medication late. The Physician orders [REDACTED]. The Medication Administration Record [REDACTED] On 09/13/2017 at 3:14 PM, RN#1 who administered the medications was interviewed. He stated that he has been working at the facility for approximately 6 months. The RN also stated that he began to work at 6:30 AM today and started to give medications shortly after the start of the shift. RN #1 further stated that he's fully aware that medications were being given late. RN #1 continued to say that he usually finishes administering medications that were ordered for the morning between 1:00PM and 2:00PM. He stated this is because he's not familiar with the residents. He stated that he never reported the delay of medications to anyone, including the supervisor. On 09/15/2017 at 11:27 AM RN#2 (RN Supervisor) was interviewed. RN#2 stated that the medication nurse is pretty new, and that he was not aware that the nurse was having problems in finishing on time and the nurse did not report any problems. The nursing progress note dated 9/13/17 documented the following: the resident missed all 9 AM medications. The Physician was notified, resident will be monitored closely. However, it was observed that the resident received the medications scheduled for 9:00AM later in the day between the hours of 2:40PM and 3:00PM. The physician progress notes [REDACTED]. On 09/15/2017 at 11:49 AM the Director of Nursing (DNS) was interviewed. The DNS stated that the medications can be given an hour before or after the designated time ordered, and any medication given after those parameters are considered errors. The DNS further stated that she was not aware that the nurse was having difficulty giving medications on time. On 09/18/2017 at 2:09 PM the resident's primary physician (MD) was interviewed. The MD stated that she was made aware that the resident received the medications late, and acknowledged that was delayed and not a good practice. The physician further stated that she assessed the resident and reviewed all the medications and found no significant problems. The resident will be closely monitored. 415.11(c)(3)(i)

Based on observation, record review and interview, the facility did not ensure that the Physician orders [REDACTED]. This was evident for 3 of 25 medication opportunities observed during Medication Administration Observation The Findings are: Resident #64 is an [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets 3.0 ((MDS) dated [DATE] documented that the resident cognitive status is intact, no mood and behavioral problems identified. The MDS further documented that the resident required total assistance with all Activities of Daily Living (ADL). On 09/13/17 between the hours of 2:40PM and 3:00PM, the following was observed: The RN administered the following medications to the resident orally: [MEDICATION NAME] 25 Milligrams (mg) 1/2 (half) tablet (tab) ,[MEDICATION NAME] 100 mg 3 capsules, Calcium [MEDICATION NAME]-Vitamin D3, 315 mg-250 Units 1 tab. The resident was observed sitting on the wheel chair, alert and awake, with bilateral lower legs [MEDICAL CONDITION], a left hand contracture, and unable to move arm. The resident stated that sometimes she gets medication late. The Physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED] On 09/13/2017 at 3:14 PM, the RN who administered the medications was interviewed and stated that he has been working at the facility for approximately 6 months. The RN also stated that he began work at 6:30AM today and started to give medications shortly after the start of the shift. The RN further stated that he's fully aware that medications were being giving late and is to be administered one hour before and one hour after the designated administration time. The RN continue to say that he usually finishes administering medications ordered for the morning between 1PM and 2 PM because he's not familiar with the residents, and did not report the delay of medication to the supervisor. On 09/15/2017 11:27 AM, the RN Charge Nurse was interviewed and stated that the medication RN nurse is pretty new, and he was not aware that the nurse is having problems finishing on time and the nurse did not report any problems as well. A review of the nursing progress note dated 9/13/17 documented the following: the resident missed all 9AM medications. The Physician was notified, resident will be monitored closely. On 09/15/2017 11:49 AM, the Director of Nursing (DNS) was interviewed. She stated that the medications were supposed to be given an hour before or after the designated time ordered, and any medication given after those parameters are considered errors. The DNS further stated that she was never aware that the nurse was having difficulty giving medications on time. On 09/18/2017 2:09 PM, the primary physician was interviewed that she understand that she was made aware that the resident received the medications late, and acknowledged that was delayed and not a good practices. The physician further stated that she assessed the resident and reviewed all the medications and found no significant problems. The resident will be closely monitored. The facility policy on Medication Administration (undated) documented that medication will be administered by licensed nurses on a timely manner at 9-1-5-9 schedule unless alternate time is indicated. It further documented the time schedule for medication administration as follows: Daily medications are to be administered: 9 AM. The Two times daily (BID) are to be administered: 9AM and 5PM, while the three times (TID) are: 9AM, 1PM, AND 5PM. Every 12 hours medications are administered at 9AM and 9PM, unless alternate time is indicated. 415.11(c)(3)(ii)

Based on observation, record reviews and staff interviews, the facility did not ensure that medication error rates were less than 5 percent. Specifically, during observation of the medication administration, the Registered Nurse (RN) was observed administering medications outside of the time that the medications were ordered. This was evident for 3 of 25 medication opportunities observed during Medication Administration Observation resulting in the medication error rate of 12 % (Resident # 64). The findings are: The facility policy on Medication Administration (undated) documented medication will be administered by licensed nurses or medical doctors. Nurses must be knowledgeable of expected outcomes and side effects of medications administered. The policy further documented that the medications will be administered in a timely manner at 9-1-5-9 schedule unless alternate time is indicated. The medication administration policy also documented that the time schedule for medication administration as follows: Daily medications are to be administered: 9 AM. The Two times daily (BID) are to be administered: 9AM and 5PM, while the three times (TID) are: 9AM, 1PM, AND 5PM. Every 12 hours medications are administered at 9AM and 9PM, unless alternate time is indicated. Resident #64 is an [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets 3.0 ((MDS) dated [DATE] documented that the resident cognitive status is intact, no mood and behavioral problems identified. The MDS further documented that the resident required a total assistance with Activity of Daily Livings (ADLS). The Physician orders [REDACTED]. On 09/13/17, the nurse was observed administering a first dose of the following medications at 2:53 PM: [MEDICATION NAME] 25 Milligrams 1/2 (half) tablet by mouth, [MEDICATION NAME] 100 Milligram 3 capsules by mouth, Calcium [MEDICATION NAME]-Vitamin D3, 315 miligrams-250 Units 1 tab by mouth. A review of the Medication Administration Records (MAR) dated 9/13/17 revealed that the above medications were administered between the hours of 2:28 PM and 3:00PM. A further review of the Medication Administration Records (MAR) dated from 9/06/17 to 9/12/17 also documented that the medication administration time were between the hours of 1:00PM to 2:30PM. The medications were adminstered out of frequencies. A review of the progress note 9/13/17 documented that the resident missed all 9AM medications. The Physician was notified, resident will be monitored closely. Physician note dated 9/13/17 documented that she received a telephone call from the nursing staff that the resident did not received all 9AM medications. The Physician further documented that the Tylenol will be changed to as needed (PRN), continue to monitor resident. On 09/13/2017 at 3:14 PM, an interview was conducted with the RN who stated that he had been working here for about 6 months. The RN also stated that he began work at 6:30AM today and started to give medications shortly after the start of the shift. The RN further stated that he's fully aware that medications were to be administered one hour before and one hour after the designated administration time. The RN continue to say that he usually finishes administering medications ordered for the morning between 1PM and 2 PM because he's not familiar with the residents. On 09/15/2017 10:58AM an interview conducted with the resident. The resident was sitting on the wheel chair, alert and awake, was noted with bilateral lower legs [MEDICAL CONDITION]. The resident was also noted with left hand contracture, unable to move arm. The resident stated that sometimes she gets medication late but have no concern about it, and that the nurse will call her when ready to give medications. The resident stated she look for the nurse sometimes when feeling pain. The resident further stated that she had arthritis, always feel pain. The resident also stated that, she has been taking antibiotics on and off. The resident further stated that her legs have always been like that, swelling reduce when wake up in the morning and get back up during the day. On 09/15/2017 11:27 AM, an interview was conducted with RN Charge Nurse, who stated he's been working here more than 2 years as a unit charge nurse. The unit charge nurse further stated that he's responsible to make sure that physician orders [REDACTED]. The charge nurse also stated that the medication RN nurse is pretty new, and he was not aware that the nurse is having problems finishing on time. On 09/15/2017 11:49 AM, an interview was conducted with the Director of Nursing (DNS) The DNS stated that the medications were supposed to be given an hour before or after the designated time and any medication given after those periods are considered errors. The DNS also stated that she was never aware that the nurse was having difficulty giving medication on time. On 09/18/2017 2:09 PM an interview was conducted with the primary physician (MD). The MD stated that she understand that the resident received medication late and acknowledged that was delayed , not a good practices but the resident was fine. The physician further stated that she assessed the resident and reviewed all the medications and found no significant problems. The resident will be closely monitored. 415.12(m)(l)

Based on observation, record review and staff interviews the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, the as needed order for the use of [REDACTED]. In addition the nursing staff did not document resident's behaviors prior to or after the administration of [MEDICATION NAME] (an antipsychotic medication) to justify as needed. This was evident for 1 of 5 residents reviewed for Unnecessary Medication Use (Resident # 239). The finding is: Resident # 239 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/29/16 at 12 noon, the resident was observed in bed, alert and awake, resident is non ambulatory, non verbal, unable to make needs known to others. Resident responds to his name by looking at you when being called. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognitive status is severe cognitive impaired with no mood and behavioral problems identified. The MDS further documnted that the resident unable to walk, and also required total assistance of two persons for activities of daily living. The Monthly Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence in the resident's medical record to justify the administration of [MEDICATION NAME] when given PRN. On 6/30/16 at 10:28 AM, an interview conducted with the Licensed Practical Nurse (LPN) who stated that the use of [MEDICATION NAME] is to alleviate the behaviors and is to be given every 6 hours as needed as per MD order. She further stated that on those days she administered the PRN [MEDICATION NAME] to the resident, she stated she observed the resident hitting himself and screaming, making noises, and attempting to grab her personal items. She also stated that she did not document the resident's behaviors because she did not know she was supposed to document his behaviors. There was no documented evidence that the nursing staff attempted the use of non-pharmacological Interventions prior to administering [MEDICATION NAME] to the resident. There is no documented evidence of the effectiveness of [MEDICATION NAME] after administration. The psychiatric progress note dated 3/14/16 documented the following Diagnosis: [REDACTED]. The notes further documented: there are no formal psychotic symptoms including hallucination or delusions. Resident hits his head and strikes out at nurses repeatedly. The Psychosocial note dated 6/16/16 documented resident remain stable, in psychosocial well being and continue to enjoy watching TV. Staff will continue to monitor. Review of the Drug Regimen Review Form dated 1/3/16 documented please note resident continues on PRN [MEDICATION NAME] by mouth and injectable. Please consider that this may be seen as a chemical restraint. Please consider that a care plan is available as well as non pharmacological interventions documented before use of [MEDICATION NAME] prn as well as outcome. There was no documented evidence that the attending physician, nursing staff, or psychiatrist reviewed the pharmacist's recommendation to use non-pharmcological interventions prior to the use of [MEDICATION NAME] PRN. On 6//30/16 at at 10:41 AM, an interview was conducted with the Charge Nurse/Registered Nurse (RN) who stated that resident has a history of pounding his chest, being agitated, and clapping hands. She further stated that the [MEDICATION NAME] is given as needed to address the resident's behavioral problems. The RN also stated that the nursing staff have not documented the reason for administering medication in the resident's medical record, but moving forward would begin to document appropriately. On 6/30/16 at 11:20am, an interview conducted with the Attending Physician who stated that the Klonopin, [MEDICATION NAME] and [MEDICATION NAME] are prescribed for [MEDICAL CONDITION] and [MEDICATION NAME] PRN is for self abusive behavior. He further stated the PRN medication is for when the resident has an increase in these behaviors, and that is when the resident will benefit from additional medication. He also stated he is responsible for documenting the purpose of the PRN order, and all staff know why the resident should be on it. On 6/30/16 at 12:14 PM, an interview was conducted with the Psychiatrist who stated that PRN order of [MEDICATION NAME] 3mg is for violent behavior and when the resident is abusive to self, and may cause injury to others. He further stated that he did not know why the order did not explain the indication for use of the medication as this information should have been included in the order. 415.12(l)(1)

Based on record review and interview, the facility did not ensure SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) were provided to 3 of the 3 eligible Medicare Beneficiaries reviewed. Specifically, there was no documented evident that resident #15, #16 and #33 received SNFABN. This resulted in no harm with potential for no more than minimal harm that is not immediate jeopardy. The findings are: 1) The medical record of Resident # 15 documented that the resident was admitted to the facility on [DATE], and discharged home on[DATE]. 2) The medical record of Resident # 16 documented that the resident admitted to the facility on [DATE], dischaged 0n 12/4/14, resident had a 60 days remaining out of 100 days..also discharged home. 3) The medical record of Resident # 33 documented that the resident was admitted to the facility on [DATE] and discharged home on[DATE]. These three discharged residents were reviewed for Liability Notice and Beneficiary Rights Appeals. There was no documented evidence that, prior to discharge from the facility, a SNFABN or denial letter was provided to the residents or their representatives to inform them of the date the facility determined termination of Medicare Part A Benefits would occur, the residents' potential liability for payment beyond that date and to inform them of their rights to appeal the decision. On 4/30/15 at approximately 1:00 PM, an interview was conducted with the Administrator who stated that the employee designated for providing the notice and keeping record of liability notices was not available at the time of survey. The Administrator further stated that the liability notices are kept away from the facility in a storage facility and were not available to the survey team. The MDS (Minimum Data Sets) coordinator stated that she prepares the liability notices and was familiar with the process. On 4/30/15 at 2:05pm, an interview was conducted with the MDSCoordinator, she stated that she prepares the liability notices and gives to the designated employee. She further stated that liability notices were not currently available in the facility. 415.3(g)(i)

Based on observations, record reviews and interviews the facility did not ensure that Residents were free from unneccessary medication. Specifically, the facility did not provide justificatin for the use of [MEDICAL CONDITION] medication with an appropriate diagnosis; in addition there was no attempt made to taper [MEDICAL CONDITION] medications for residents receiving [MEDICATION NAME] for over a year. This was evident for 2 of 5 residents reviewed for unnecessary medications (Resident # 55 and #130). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Resident #55 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment documents that resident is severely cognitively impaired and unable to make needs known with total dependence for all activities of daily living (ADL). On 4/27/15 at 12pm, the resident was observed seated in a Geri-chair in the hallway and was observed to be lethargic. On 4/28/15 at approximately 12:15 pm, the resident was observed seated in a Geri-chair while being fed lunch. Resident was noted to be lethargic and the Certified Nursing Assistant (CNA) called out to the resident on more than one occasion in an attempt to keep the resident awake. The Medication Administration Record [REDACTED]. On 4/9/15 [MEDICATION NAME] was decreased to 1.5 mg orally once daily. Review of Comprehensive Care Plan for Behavioral Symptoms dated 11/20/14 and 2/20/15 documented that the resident's behavior is controlled. Review of the physician's evaluation and nursing progress notes revealed no documented evidence to support behavioral problem or psychotic symptoms and there was no psychiatric [DIAGNOSES REDACTED]. On 4/28/15 at 12:40 PM, the Registered Nurse (RN) in charge of the unit was interviewed and stated that the resident is sometimes agitated and resistant to care. On 4/29/15 at 12:45 PM, the Attending Physician was interviewed via telephone and stated that the resident was prescribed 3 mg of [MEDICATION NAME] daily because of combative behavior, refusal of care and very resistant behavior. There is no evidence of combative behavior documented in the resident's medical record. There is no documented evidence of refusal of care or resistant behavior. The nurse's notes do not reveal any communication to the physician reporting this type of behavior. The physician's notes does not indicate notification of this type of behavior. On 4/30/15 at 12:30pm, the CNA assigned to the resident was interviewed and stated that she has no problem caring for the resident, and that there has been no inappropriate behavior displayed. On 4/30/15 at 12:50pm a second interview was conducted with the Attending Physician who stated that the resident has Dementia and a number of medical issues and she was eventually going to address the use of antipsychotic medication. 2) Resident # 130 is an [AGE] year old with [DIAGNOSES REDACTED]. The resident was observed on 4/24/15, 4/29/15 and 4/30/15 during the day, on the unit and in the dining room. She appeared calm and quiet. The MDS (Minimum Data Set) 3.0 dated 4/26/15 documented that the resident's cognition is severely impaired with long and short term memory problems. The Physicians orders dated 11/2/10-4/10/15 documented: [MEDICATION NAME] 0.5mg tablet one and one half tablet by mouth at bedtime . The Psychiatrist note dated 4/23/15 documented to discontinue [MEDICATION NAME]. The Physicians note dated 4/23/15 documented that the resident has periods of tearfulness and to continue [MEDICATION NAME]. On 4/29/15 at 10:22 am the RN (Registered Nurse) was interviewed and stated that the resident's behavior is reflected by her crying on and off for no reason. She stated that there is no aggression, no agitation and the resident was not displaying any signs of [MEDICAL CONDITION] such as talking to herself or seeing things that are not there. There is no documented evidence that the Physician attempted to discontinue or reduce the use of the [MEDICAL CONDITION] medication for this resident for over a year. There was also no documented evidence that non-pharmological interventions were used to address the resident's periods of tearfulness. On 4/29/15 at 10:30 am the Licensed Practical Nurse (LPN ) was interviewed and stated that the resident cries on and off. The resident does not talk to herself or see things. The nursing staff did not provide either through notes, care plan or interview evidence that non-pharmological interventions were being used to address the resident's periods of tearfulness prior to the use of an antipsychotic medication. On 4/29/15 at 11:00 am the Physician was interviewed and stated that the resident has been on [MEDICATION NAME] since 2010, that the resident cries for no reason and that she is being treated for [REDACTED]. The Physician stated that he did not discontinue the [MEDICATION NAME] as recommended because he did not want to risk the resident going into crying episodes. He stated that in retrospect he could have really tried to discontinue the [MEDICAL CONDITION] medication as recommend by the Psychiatrist. On 4/29/15 10: 20AM observed the resident in Catholic Service, no crying or combative behavior noted. 4/30/15 10:40 AM resident obs in the dining room, activty in progress, planting flowers. Resident sitting with several other residents. No behaviors observed. On 4/30/15 at 12:30pm the Director of Nursing was interviewed and stated that the facility did not have a written policy and procedure for management of the resident receiving [MEDICAL CONDITION] medications. 415.12(1)(1)