Every finding on record at Dr Susan Smith Mckinney Nursing and Rehabilitation

Based on observations, record review, and interviews conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility failed to ensure menus were followed. This was evident for 3 residents of 38 total sampled residents (Resident # 70, Resident # 193 and Resident # 247). Specifically, Residents # 70, #193 and #247 did not receive the key lime parfait in accordance with their menu. The findings include: The policy titled Food Preferences revised 09/2024 documented that resident's food and beverage preferences will be obtained upon admission and periodically as needed to assist the Food and Nutrition Services department in providing preferred food and beverages to enhance/maintain quality of life and nutritional status. In case a food item is not available, a substitute will be provided as an alternative. The resident will be made aware of the substitute using a peel and stick label which reads substitute. The sticker will be placed on the tray mat of the resident's meal tray. Resident #70 had diagnoses of hyperlipidemia unspecified, Disease of intestine unspecified, hypercalcemia, and vitamin D deficiency. The Quarterly Minimum Data Set 3.0 dated 6/21/2024 documented Resident #70 was cognitively intact. Resident #193 had diagnoses of Dysphagia oral phase, dysphagia following cerebral infarction and vitamin D deficiency, Vitamin B deficiency. The Quarterly Minimum Data Set 3.0 dated 09/06/2024 and The Annual Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #193 was moderately cognitively impaired. Resident # 247 had diagnoses of diabetes and hyperlipidemia and cerebral infarction. The Quarterly Minimum Data Set 3.0 dated 7/26/2024 documented Resident #247 was severely cognitively impaired. On 09/26/2024 at 11:44 AM - 12:24 PM dining was observed on the 5th floor. The dessert served for the residents included a key lime parfait dessert item. Three residents (resident #70, # 193 and #247 with pureed level 4 texture diets were served unsweetened applesauce on their lunch tray versus the 1/2 cup of key lime pie parfait on their tray ticket. The residents did not receive the Key Lime Parfait but was offered a 4-ounce cup of unsweetened applesauce instead. The menu substitution offered was not indicated on the resident's tray ticket and there was nothing on the resident tray to indicate a substitution was made for the item. On 09/26/2024 at 12:20 PM, Resident #106 was asked if they like their food preferences and they did not reply to the question and continued eating their food. Resident #106 tray contained an 8-ounce low fat milk, a can of ginger ale, unsweetened apple sauce, coffee, pureed pasta loaf, puree vegetable blend, puree chicken with gravy. Their tray ticket documented Regular Pureed 4 diet with thin liquids, Key lime Parfait 1/2 cup, 5-ounce coffee, 8-ounce carton of 1% milk, ginger ale, 3-ounce pureed chicken loaf, 1 ounce gravy. 1/2 cup pureed pasta loaf, 4-ounce pureed winter blend vegetable and 6-ounces of Carrot Ginger soup. Resident # 106 did not receive the key lime parfait but received unsweetened applesauce instead. On 09/26/2024 at 12:24 PM, Resident #247 was observed with their lunch tray which contained 4 ounce skim milk, 6 ounces of hot tea, applesauce cup, 3 ounces of pureed chicken loaf with 1 ounce gravy, 4 ounce pureed winter blend vegetables, 6 ounces of carrot ginger soup. The tray ticket menu delivered with the meal documented Resident #247 was to have 1/2 cup of key lime parfait on their meal tray and this item was not on the resident's tray. There were no observations of any corrections to the resident's tray ticket. On 09/26/2024 at 12:29 PM, Resident #193 was observed with their lunch tray which contained pureed thickened liquid tea, applesauce, 1 carton of thickened milk nectar consistency, pureed vegetables, puree pasta, puree chicken loaf, carrot ginger soup, 2 peanut butter and jelly sandwiches, salad, coffee, 4 oz fat free milk, and fruit cocktail. The tray ticket menu delivered with the meal documented Resident # 193 was to have 1/2 cup of key lime parfait on their meal tray and this item was not on the resident's tray. There were no observations of any corrections to the resident tray ticket. On 09/26/2024 at 12:39 PM, the Patient Care Technician #5 for Resident #106 stated that the resident was supposed to receive 8 ounces of milk on their tray but they milk they got is smaller and there was no substitute today. To make sure resident is eating the right food, resident could be allergic to a food item and to make sure the resident eats properly. On 09/26/2024 at 12:36PM, Patient Care Assistant #6 was interviewed and stated they check the Resident # 70 tray before feeding. The resident got applesauce they are missing key lime parfait and probably substitute it sometimes on menu board or ticket. In case a resident has a food allergy the tray ticket needs to be correct and since resident is on thickened liquids to make sure the consistency is correct. On 09/26/2024 at 12:48 PM, an interview was conducted with Licensed Practical Nurse # 1 who stated they monitor the dining room during lunch time for the residents in their rooms. They check the meal trays; nursing staff and dietary staff take the trays off the cart, and they check to make sure items on the tray match the tray ticket. They stated that they are not aware of any substitute of food for lunch. One goal is to prevent aspiration, allergic reaction and to make sure residents are eating what the dietitian set for their diet and consistency is correct to prevent aspirations. On 09/26/2024 at 12:51 PM, an interview was conducted with the Registered Dietitian who stated the key lime parfait and applesauce is for the puree texture diet. The key lime pie is todays special, and we introduce new food items to support residents' palates to be on the menu in the future. The residents should have received the food item that was on their tray ticket. On 10/02/2024 at 11:16 AM, an interview was conducted with Dietary Aide #2 who stated we had the key lime pie but the puree texture we got it late. It was replaced with applesauce for the puree. They stated they spoke to the manger to let them know there was not key lime pie for the puree, and we are supposed to put substitute tickets on the tray to show that we don't have the supply and the supervisors will have the diet ticket. On 10/02/2024 at 11:21 AM, an interview was conducted with the Assistant Coordinator Dietary Manager who stated the food item was a special item and they could not locate the dessert item for the puree soft bite size, puree and mince moist diet textures. They communicated with the Operations Dietary Manager, and applesauce was used as an alternative. They were informed that a substitution was needed for the item and staff were to implement a substitution card. The substitution card should have been placed on the cold side of the tray. The substitution card is the only source we use to notify the units of a change on the resident's tray. They did not put the substitution card on the units that day. Residents are paying for a service, and they are entitled to everything they are paying for. On 01/02/2024 at 11:31 AM, an interview was conducted with the Operations Dietary Manager who stated the dessert items was a special item and they were notified that the puree texture for the key lime pie was not available, and another food item had to be used. They were notified that applesauce would be the substitute and the Assistant Coordinator Dietary Manager notified Dietary Service Aide #2. At home we are allowed to make choices of what we want to receive and if residents are given the option for a food substitution. We want to be accurate for resident's dietary needs. On 10/02/2024 at 11:40 AM, an interview was conducted with the Food Service Director who stated they order food items 2 weeks in advance for the menus. They were informed by staff that the dessert item was missing for the puree texture and they triple checked to locate it. They instructed their staff to make the item and sent it upstairs. When dietary staff use a substitute food item on a meal they are suppose to place a substitute ticket on the resident's tray. The checker on the tray line and the loader, dessert person and Dietary Manager double check items on resident trays as part of the monitoring process. 415.11(c)(1-3)

Based on observations, record review, and interview conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility did not ensure that infection control practices were maintained. This was evident in 1 of 4 floors (5th Floor) observed for the Dining Task and Infection Control. Specifically, Patient Care Technician #5 did not perform hand hygiene while assisting multiple residents in the 5th Floor dining room. The facility policy titled Dining Room Policy reviewed 03/2020 documented residents must have hand hygiene before meals using hand wipes. Staff must perform hand hygiene between each resident during meal preparation (cleansing hands, setting up meal trays). The charge nurse or designee checks to see all residents have received their trays. The facility policy titled Hand Hygiene reviewed 03/06/2023 documented the facility considered hand hygiene the primary means to prevent the spread of infections and will comply with current Centers for Disease Control and Prevention hand hygiene guidelines. Hand hygiene is the most effective measure in the prevention and control of transmission of infection. Effective hand hygiene reduces the incidence of healthcare associated infections. Indications for hand hygiene using alcohol-based hand rub in the following clinical situations before having direct contact with patients and after contact with residents intact skin. During a dining observation on 09/26/2024 from 11:43 AM to 12:38 PM, Patient Care Technician #5 was observed assisting residents in performing hand hygiene with bare hands during dining. Patient Care Technician #5 was observed picking up the used hand wipe from Resident #45. Then Patient Care Technician #5 assisting Resident #247 to perform hand hygiene with their bare hands. No hand hygiene was observed by Patient Care Technician #5 after assisting Resident #247. On 10/01/2024 at 03:08 PM, an interview was conducted with Patient Care Technician # 5 who stated that when they sat down to feed Resident #247 they realized that they did not do hand hygiene between the residents. Hand hygiene is to be done to prevent contamination between residents. They have had a hand hygiene inservice this year. On 10/02/2024 at 03:28 PM, an interview was conducted with Assistant Director of Nursing who stated that they monitor the patient care technicians. They look to see if residents want an extra food item or want a change in their menu and they intervene if they see anything abnormal. They stated that when staff walk into the dining room/day room they should use the hand sanitizer. The main thing is hand washing to prevent cross contamination and it should be done before and after each resident. Inservice was done after the survey began and every 1 month or every 3 months and in-service is done when anything triggers on the unit. We do an in-service for all staff (nurses and patient care technicians). On 10/02/2024 at 3:33 PM, an interview was conducted with the Infection Preventionist who stated they do rounds on unit Monday to Friday when they look for infection control, hand hygiene during resident care, personal protective equipment use, properly changing of gloves. They do periodic rounds for dining mostly during lunch and during dinner rounds they observe hand hygiene. There have been no recent concerns and for the past day or two they have noticed that staff are not properly carrying out hand hygiene and staff were in-serviced. It was observed during meal pass that staff were not practicing hand hygiene and they were re-inserviced. Staff should be doing hand hygiene when in the dining room prior to preparing residents and between serving residents trays. If they touch a residents wheelchair staff should sanitize their hands before touching meal trays to prevent dirt from getting on their hands that may have germs. On 10/03/2024 at 12:50 PM, an interview was conducted with the Director of Nursing who stated that they do rounds daily when they get a chance and if they cannot make it to the unit they can observe virtually while in the office or from home. They observe if staff are cleaning resident's hands. During dining it is recommended that staff use hand sanitizer between residents. Staff should do hand hygiene to protect themselves and the residents and there is constant education. When they use sanitizer, they should use the same friction as hand hygiene and get the sanitizer between their fingers. The Infection Preventionist is involved in hand hygiene education and we stress it to staff. We also do spot checks where there are secret shoppers who observe hand hygiene from patient rooms and in the dining rooms. There are new staff coming from the hospital to the nursing home and hand hygiene education is ongoing. 415.19 (b)(4)

Based on observation, record review, and interview conducted during the COVID-19 Focused Infection Control Survey completed on 02/22/21, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. This was evident for 1 out of 8 units observed. (Unit 4-B) Specifically, a staff member was observed not donning (putting on) a gown prior to providing care to a resident on contact and droplet precautions. The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20 provides: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a (National Institute for Occupational Safety and Health) NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The CDC guidance titled, Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/20, documented HCP should use all recommended COVID-19 PPE (Personal Protective Equipment) for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. The New York State Department of Health (NYSDOH) Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/20 revised 7/10/20, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemask's/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility policy on Infection Control - Guidance and Management for COVID-19 in Long Term Care Facilities dated 03/12/20 and revised on 08/18/20 states: It is the policy of the facility to protect residents, employees, contractors , visitors , students and visitors from contracting or transmitting the [DIAGNOSES REDACTED]-CoV-2 virus within the facility premises. The facility shall develop strategies based on the latest recommendation from the governing bodies which the facility is required to follow. Strategies includes but not limited to: Minimize the transmission of COVID-19 within the facility. Isolation and use of personal protective equipment's and surveillance and compliance management. During entrance interview on 02/22/21 at 10:30 AM, the Assistant Director of Nursing (ADON) stated there were currently 5 residents located on the Red Zone Unit (1A) in the facility who tested positive for COVID -19. The ADON also stated there were 8 employees who tested positive for COVID-19 and 3 employees with known exposures and are currently furloughed. During a tour of Unit 4-B on 02/22/21 at 12:15 PM a sign was posted on the entrance door to the unit which read, CONTACT/DROPLET PRECAUTIONS. Stop signs with Red, Yellow and Green coloring with explanation of those colors read as follows: Red-gown, gloves, face shield, N-95 - unit with residents tested COVID-19 + (positive) Yellow - Gown, gloves, face shield and surgical mask - unit with resident who tested COVID-19 + and moved to red zone. The unit is on Contact / Droplet precautions as precautionary measures due to exposure. Green - Surgical mask and face shield. Unit with no exposure. There was no observed signage specifying which stop sign color applied to Unit 4-B. During an observation on 02/22/21 at 12:31 PM on Unit 4-B, revealed Patient Care Technician (PCT) #7 in room [ROOM NUMBER]B feeding a resident. The PCT was wearing a facemask, face shield and gloves. The PCT was not wearing a gown. During an interview on 02/22/21 at 12:35 PM the PCT was interviewed and stated, There are no issues with Personal Protective Equipment (PPE). I can take it from the isolation carts on the unit. I have had in- services on infection control and recall learning about handwashing and different zones and their meaning. I'm not sure what zone we are in. There has been some confusion between the nurses about what zone we are in. I think we are in the Green Zone. I am waiting for the nurse to tell me. In a Yellow Zone you are supposed to wear your gown, gloves, masks and face shield in a resident's room when giving direct care. I typically work on Unit 4-B. I did not work the weekend. My last day of work was on Friday 2/19/21 and this Unit was a Green Zone. The honest truth is, I was wearing a gown with all previous residents as a form of self-protection. I did not wear a gown with the resident in room [ROOM NUMBER]B because I was just feeding the resident. I was not certain that feeding was considered direct care. During an interview on 02/22/21 at 12:22 PM the charge nurse Registered Nurse (RN) stated, This unit is a Yellow Zone, and all staff are expected and must wear gowns, gloves, masks and face shields during direct care for all resident. All residents have been tested on this unit and are COVID-19 negative. She further stated, Staff are made aware of the color zones of each unit during the morning report. If there is any confusion regarding the zone, it is the responsibility of the staff member to ask. During an interview on 02/22/21 at 1:49 PM the Assistant Director of Nursing (ADNS)/Infection Control Preventionist (ICP) was interviewed. ADNS/ICP stated, Unit 4-A and Unit 4-B are in the Yellow Zone which means Contact Precautions. PPE includes gowns, gloves, face shields and masks. Gowns are required in all rooms, specifically, when providing care. Feeding a resident is considered direct care. If someone is spending 15 minutes or more in a room, they would need a gown also. During an interview on 02/22/21 at 3:03 PM Registered Nurse Unit Manager (RNUM) was interviewed and stated, Both units are in Yellow Zones. Eye protection, masks and gowns are to be worn for direct care. You do not need a gown for feeding a resident. If there is bathing, changing clothes or you are spending more than 30 minutes in the room you must wear a gown. Unit 4-B was a Green Zone last Friday. 415.19 (a)(1-2); 400.2

Based on interviews and record review, the facility did not ensure that residents were free from abuse. The facility did not ensure that its employees provided necessary services to residents to avoid physical pain, mental anguish or emotional distress. Specifically, 1) A Certified Nursing Assistant (CNA#10) tied Resident #154's left hand to the bed rails with a plastic bag, causing psycho social harm to a resident who was totally dependent on staff for all care needs, an unable to call for assistance or help. 2) While attempting to provide care, CNA#1 rough handled Resident #176. This deficient practice was evident for two (2) residents reviewed for allegations of abuse out of a sample of 37 residents. The facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property issued in (MONTH) 1997 and last reviewed in (MONTH) (YEAR) documented that each individual has the right to be free from verbal, sexual, physical, mental, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of property and or funds. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or any other individuals. The facility's policy documented that it has developed and implemented written policies and procedures that prevent, screen, investigate and report all allegations of resident abuse, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of resident property and finances. The facility policy further documented that all employees have an obligation to protect residents from abuse and to report any and all information related to abuse to their supervisor in a timely manner upon suspicion. The findings are: 1) Resident #154 is admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Safety Data Set ((MDS) dated [DATE] documented that Resident #154 cognitive status is severely impaired. On 02/08/19 at 10:40 AM The Director of Nursing (DNS) reported to the Survey Team that it was reported that on 02/07/19, Resident #154's left hand was discovered tied to the bed rail with a plastic bag. The DNS stated that RN # did not report the incident in a timely manner. The incident occured on 02/05/19. The DNS stated that RN #4 documented in the EMR that Resident #154 was assessed; and there were no bruises or injuries. She stated that the primary care physician and family members were notified. The DNS stated that CNA #10 admitted to tying the resident's left hand to the bed. The DNS also stated that CNA #10 was suspended pending investigation. The DNS stated that although the incident took place on the morning of 02/05/19; the incident was brought to her attention on the morning of 02/07/19. The DNS further stated that CNA #10 did not report to the nurse in charge that the resident was combative. Resident #154 has no documented history of being combative. The DNS stated that the incident has not been reported to NYSDOH . The incident would be reported to NYSDOH sometime on 02/08/19. The Comprehensive Care plan documented that Resident #154 is at risk for being abused by others due to frailty and inability to verbalize needs and concerns. Physician orders [REDACTED]. There were no doctor's orders for physical restraints. The interdisciplinary progress notes from (MONTH) 11, (YEAR) to (MONTH) 8, 2019 were reviewed. There were no behavior notes or incidents of resident acting aggressively towards staff. There are no notes documenting rejection of care or aggressive behaviors such as hitting, grabbing, etc. Nursing Assistant Accountability Records did not document that resident has a history of acting aggressively toward staff. physician progress notes [REDACTED]. Nursing Assignment and Accountability records for the periods (MONTH) and (MONTH) (YEAR) documented that the resident is confused and oriented, aphasic, has partial vision, has right arm paralysis. The Resident is to be repositioned every two hours. The initial physical therapy evaluation exam dated 6/12/18 documented that resident #154 has reduced ability to understand commands. Physical/Occupational Therapy screen dated 9/12/18 documented that Resident #154 does not have the ability to utilize the call bell. The evaluation further documented that Resident #154 is unable to ambulate, is constantly being assisted with most activities of daily living. The facility's Accident/Incident report dated 02/07/19 was reviewed. The incident report documented the date of the incident occurring on 02/05/19. Resident #154 condition before the incident was described as alert and oriented to person, disoriented to place and time. The summary of the occurrence documented that the Registered Nurse (RN#4) on duty was called to the room of Resident #154. RN #4 observed that resident's left hand was restricted to the bed with a plastic bag. No redness or swelling of left hand was noted. No indications of pain and no change in the mental status. Resident #154 left hand was released immediately. The report documented that the Primary Care Physician, Assistant Director of Nursing and Family members of resident #154 were notified. However, the DNS reported that RN#4 did not report the incident to facility administrative staff until 02/07/19. The 'Staff Assignment Sheets' for 2/5/19 to 2/8/19 were reviewed. The sheets revealed that CNA #10 was permitted to continue providing care to this resident from 02/05/19 to 02/07/19. On 02/11/19 at 01:29 PM the Surveyor reviewed the videotape of 3B-room [ROOM NUMBER]A in the presence of Employee #1 who is the Executive Senior Secretary. The video recording revealed that on 2/5/19 at 5:23 AM, CNA #10 observed in room moving floor mats and closes door. Again at 5:29 AM, CNA #10 observed moving floor mat and closed door. At 5:45 AM, CNA #10 exits the room and returns to room [ROOM NUMBER]B-16A with a plastic bag. CNA #10 Exits room at 5:47 AM. There is no video evidence of CNA #10 re-entering the resident's room. The video recording also revealed that on 2/5/19 At 7:41 AM, CNA #6 entered room [ROOM NUMBER]B-16A. At 7:42 AM, CNA #6 exits the room. Immediately after RN # 4 is observed entering room with CN #6 at 7:42 AM. The Assistant Director of Nursing (ADNS) documented on 02/08/19 that on 02/07/19 around 6:40 AM, RN # 4 reported that on 2/5/19 Resident #154's left hand was found bound to the bed rail with a plastic bag. The ADNS further documented that she immediately informed the Director of Nursing (DNS) via telephone of what occurred, and an investigation process was started. The facility's investigative summary dated 2/7/19 documented on 2/5/19, resident #154 was noted in bed with his left-hand restraints to the bed with a plastic bag. Upon investigation, CNA # 10 stated that she was giving care to resident #154 and the resident was fighting. As a result, the CNA restrained resident #154 left hand to the bed railing with a plastic bag. The CNA was counseled on resident abuse. The Facility documented that CNA #10 and RN #4 were relieved from duties. All the residents assigned to CNA # 10 were assessed for injuries and none were found. On 02/08/19 at 02:48 PM RN #4 was interviewed. RN #4 stated that resident #154 is disoriented and requires two people to assist with ADL care. RN #4 stated that she is not aware of resident # 154 being combative. The resident is usually calm. The resident is nonverbal and is totally dependent during ADL care. RN #4 stated that if a resident becomes combative, the CNA is directed to report it to the nurse. The resident would be assessed by the nurse and evaluated by the Primary Care Physician. RN #4 stated that she received training on abuse identification and prevention within the last twelve months. RN #4 further stated that on the morning of 02/05/19 morning, CNA #6 called her into the room of resident #154 and she observed resident's left hand tied to the bed with plastic bag. The resident was assessed, there were no bruises and no swelling. There was no sign of pain. RN # 4 stated that she did not report the incident to the ADNS on Tuesday 02/05/19. She reported the incident to the ADNS on the morning of Thursday 02/07/19. RN #4 stated that she should have reported the incident on the same day. RN # 4 stated that she was busy on the unit and did not get a chance to report the incident. RN #4 stated that she was overwhelmed and that is the reason why the incident was not reported right away. On 2/8/19 at 3:07 PM CNA #10 was interviewed. CNA #10 stated that she has been working in the unit for about seven years. CNA #10 stated that she was assigned to Resident #154 on 02/04/19 through 02/05/19 from 11 PM to 7 AM. CNA #10 stated that she continued to work with the resident up until 02/07/19. CNA # 10 stated that she provides ADL care to resident # 154. CNA #10 stated that she ensures the resident does not fall. CNA #10 stated that on the morning of 02/05/19 she was providing ADL care to Resident #154, and the resident had feces in his hands. CNA #10 stated that Resident #154 was combative, so she tied the resident left hand to the bed railing with a plastic bag. CNA #10 stated that she cleaned the resident's hands. CNA #10 further stated that she forgot to release the hand tie. CNA #10 stated that she did not report to the other staff that resident #154 was tied to the bed rails with a plastic bag. CNA #10 also stated that on the morning of 02/07/19 the RN Supervisor informed her that Resident #154 was found tied to side rails. CNA # 10 stated that she completed an incident report. CNA #10 further stated that the Director of Nursing suspended her until further notice. CNA #10 also stated that the facility provided abuse identification and reporting training about three to four months ago. CNA #10 stated that she did not mean to harm Resident #154. CNA # 10 stated that she wanted to clean the resident up and was rushing to complete ADL care. On 02/11/19 at 11:34 AM, CNA #6 stated that while conducting rounds around 7:10 AM on Tuesday 02/05/19, she went the room to check on Resident #154. Resident #154 was laying on his left side. Resident #154 was covered with a sheet. On Tuesday 02/05/19 around 7:45 AM, CNA #6 stated that she returned to resident #154 room to feed him. At that time, CNA #6 removed the sheet to turn the resident on his back. CNA #6 stated that she realized that the resident's left hand was tied to the bed with a plastic bag. CNA # 6 stated that she informed RN #4. CNA #6 stated that RN #4 removed the plastic bag and assessed the resident for any injuries. CNA #6 stated that the resident would try to hold her hand while she applied a hand brace to his right hand. CNA #6 further stated that Resident # 154 is usually calm. CNA #6 stated she received training on abuse identification and reporting. CNA #6 stated that abuse must be reported right away. On 02/08/19 at 12:45 PM the family member of Resident # 154 was interviewed. She stated that she visits the facility at least three times weekly. The family stated that the Facility did call to report that resident #154 had been restrained. The Resident #154 sister further stated that the resident has been in the facility for the past year and a half. The family member stated that Resident #154 may become resistant if the person caring for him is not the regular staff person. CNA #10 personnel and training records indicate that she was trained, and understood what constituted abuse and how to manage residents with behavioral issues. On 02/08/19 at 01:46 PM CNA #10's Employee File was reviewed. CNA #10 was hired on 8/25/97. CNA #10 was originally Certified as a CNA on 4/14/94. NYS Nurse Aide Registry Verification Report 4/20/18-Exp 4/30/20. No findings of resident abuse and no convictions. The last annual evaluation for CNA #10 was completed on 11/6/18, and employee's performance was rated satisfactory. The (YEAR) Mandatory In-service titled Prohibition, Neglect, Misappropriation, Reporting Behavior Management-non-medication was done on 5/30/18. There were no disciplinary actions related to abuse, mistreatment, neglect or misappropriation of resident's funds noted in the file. RN #4's personnel and training records indicate that she was trained and had knowledge of what constitutes abuse, when and whom to report abuse. On 02/08/19 at 02:29 PM, RN #4's Employee file was reviewed. RN #4 completed annual Mandatory In-service titled Prohibition, Neglect, Misappropriation, Reporting training on 10/17/18. The last annual evaluation for RN # 4 was completed on 04/25/18. RN # 4 was rated superior, conforms to policies governing or related to patient's rights including but not limited to Patient Abuse, communicates pertinent information to health team members in a timely manner. There were no disciplinary actions on record. 2) Resident #176 admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Safety Data Set ((MDS) dated [DATE] documented that Resident #176 cognitive status is severely impaired. An Accident or Incident Report dated 2/09/19 was reviewed. The incident report documented that on 02/09/19 Employee #2 reported that CNA#1 mistreated a resident in the dining room while providing care. Employee #2 stated that while Resident #176 sat in a Geriatric wheel chair, CNA#1 attempted to reposition the resident's leg. Employee #2 stated that while doing this CNA#1 was doing it roughly and with anger. No visible injuries noted. Skin is intact. No indication of discomfort. The resident is unable to state occurrence due to advanced dementia. Primary Care Physician was notified. Two (2) signatures were present: Primary Care Physician, signature of the Registered Nurse (RN) completing the form. Statements were taken from the staff involved, all data reviewed and completed on 2/11/19. The Comprehensive care plan documented that Resident # 176 is at risk for being abused by others due to frailty and inability to verbalize needs and concerns. Resident #176 is at risk for skin impairment secondary to disease process. Resident # 176 is noted with behavior problems secondary to [DIAGNOSES REDACTED].# 176 continues to exhibit some behavior problems at times, Resident # 176 is easily re-directed. The Physician's note dated 2/9/2019 documented that resident was being seen because it was alleged that a staff member pulled her leg and hand. Both legs were examined. No ecchymosis or swelling were noted. The physician didn't note any visible injuries on exam, no symptoms of pain on exam, resident on Tylenol twice a day due to right [MEDICAL CONDITION] treated conservatively, repeated. Physical therapy evaluation requested. The physician ordered X-ray of the right foot/knee, podiatry consult on 2/11/19 at 12:10 PM. Physician planned to discuss with staff safe and comfortable ways to position the resident's lower extremities. CNA #7 who was observed sitting next to the resident when the incident occured, documented on 2/11/19 that she did not observe staff handling resident #176 roughly. Activity therapist documented on 2/9/19 that CNA #1 was observed repositioning resident # 176 legs roughly on two occasions with anger. Nursing Progress note dated 2/9/19 documented alleged abuse was reported to risk management by the Activity therapist. Nursing note documented that CNA #1 mistreated resident# 176 by repositioning leg roughly on two occasions. Abuse identification and Reporting in-service sheets dated 2/9/19 reviewed. Review of in-service sheets revealed that CNA #1 was educated about abuse identification and reporting. Two Surveyors reviewed the video footage of the alleged abuse incident that occurred on 02/09/19. The video recording revealed that on 02/09/19 at 1:59 PM, the resident was in the dayroom, seated in the geriatric chair with the left leg dangling. CNA#1 came in the room and pulled Resident # 176's legs back into the chair. From 2:20 PM to 2:25 PM, the resident was observed sitting in a Geriatric chair in day room with two CNAs seated at the table. CNA #1 was observed pulling the resident's legs and repositioning the resident in the Geri chair. CNA #1 seemed aggressive while providing care to the resident. CNA # 1 was talking to the resident and appeared upset. CNA #1 then pulled the Geri chair against the table. CNA #7 was seated at the table and did not intervene. On 02/11/19 at 01:47 PM Employee #2 was interviewed. Employee #2 stated that he observed CNA # 1 pulling resident #176 back into the Geri chair in a manner that was rough, and the resident was screaming. Employee #2 stated that CNA #1 appeared angry and was talking over the resident and pointing her finger at the resident as if she was giving the resident a warning. Employee#1 stated that the incident lasted two minutes. Employee #2 stated that he was shocked to see this kind of incident, especially after staff were just in serviced that morning regarding Abuse and Restraints. Employee #2 further stated that he reported the incident to the Director of Risk Management and he wrote a statement. Employee #2 was asked if the abuse continued, what would he have done. He replied that he that he would have intervened immediately. He further stated that he has in the past seen staff talking loudly to residents who have behavioral issues, but not to the level of what he observed on 02/09/19. On 02/11/19 at 02:41 PM CNA #1 was interviewed. CNA #1 stated the Director of Nursing in serviced staff on Saturday 2/09/19, about abuse identification and reporting. CNA #1 stated that on 2/9/19 at approximately 2:00 PM in the day room of 2B, she was seated next to Resident #176, as there was a program going on at that time. She said Resident #176 was sitting in her Erica chair and appeared confused, the resident was sliding in the Erica chair and twisting herself. CNA #1 stated that Resident #176 has behavioral issues. CNA #1 said that she went to the resident and pulled the resident's upper back to reposition her in the geriatric chair. The resident's left leg was hanging over the chair and the right leg was also not well positioned. CNA #1 stated that she attempted to bring the left legs back to the chair; immediately the resident started screaming. CNA #1 stated that she was aware that the resident had a [MEDICAL CONDITION] in the past, and she never rough handled the resident. CNA #1 stated that she repositioned the resident's leg gently. CNA #1 further stated that maybe because the resident was screaming it made people think that the resident was handled roughly. CNA #1 stated that she was informed by her supervisor about the allegation and was told that she is suspended from work until further notice. On 02/11/19 at 03:36 PM CNA #7 was interviewed. CNA #7 stated that she was in the day room completing paperwork right before 2:00 PM. CNA #7 stated that the activity therapist came in into the day room gathering residents for group activity. CNA #7 also stated that she did not hear CNA #1 yelling at resident. CNA #7 stated that she left the day room around 2:00 PM. 415.4(b)(1)(i)

Based on interviews and record review, the facility did not ensure that residents are free from restraints imposed for discipline or staff convenience. The facility staff used physical restraints to unnecessarily inhibit a resident's freedom of movement. Specifically, A Certified Nurse's Assistant (CNA#10) tied Resident #154's left hand to the bed rail with a plastic bag. CNA#10 stated that she restrained the resident because he became resistive as she tried to clean feces from his hand. There were no orders to restrain this resident. CNA #10 was permitted to give care to this resident for two days after the incident. This was evident for one (1) resident reviewed for restraints out of a sample of 37 residents. The facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property issued in (MONTH) 1997 and last reviewed in (MONTH) (YEAR) documented that each individual has the right to be free from verbal, sexual, physical, mental, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of property and or funds. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or any other individuals. The facility's policy documented that it has developed and implemented written policies and procedures that prevent, screen, investigate and report all allegations of resident abuse, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of resident property and finances. (Policy on Restraints) The facility policy further documented that all employees have an obligation to protect residents from abuse and to report any and all information related to abuse to their supervisor in a timely manner upon suspicion. The Facility's policy also documented that placing resident on unreasonable restriction on a resident's mobility constitute restraint. The finding is: Resident #154 admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Safety Data Set ((MDS) dated [DATE] documented that Resident #154 cognitive status is severely impaired. and is totally dependent on staff for most activities of daily living. It is also documented that the resident requires the assist of one person with personal hygiene and dressing. The resident assessment did not document any mood or behavior indicators. The MDS did not document that physical restraints were being used for this resident. On 02/08/19 at 10:40 AM The Director of Nursing (DNS) reported to the Survey Team that on the morning of 02/07/19, RN #4 reported that on 02/05/19 Resident #154's left hand was discovered tied to the bed rail with a plastic bag. The DNS stated that RN #4 documented in the EMR that Resident #154 was assessed; and there were no bruises or injuries. She stated that the primary care physician and family members were notified. The DNS stated that CNA #10 admitted to tying the resident's left hand to the bed. The DNS also stated that CNA #10 was suspended pending investigation. The DNS stated that although the incident took place on the morning of 02/05/19; the incident was brought to her attention on the morning of 02/07/19. The DNS further stated that CNA #10 did not report to the nurse in charge that the resident was combative. Resident #154 has no documented history of being combative. The DNS stated that the incident has not being reported to DHS. The incident would be reported to DHS sometime on 02/08/19. The Comprehensive Care plan documented that Resident #154 is at risk for being abused by others due to frailty and inability to verbalize needs and concerns. CCP did not identify any behavioral issues or need for restraints for this resident. Physician orders [REDACTED]. There were no doctor's orders for physical restraints. The interdisciplinary progress notes from (MONTH) 11, (YEAR) to (MONTH) 8, 2019 were reviewed. There were no behavior notes or incidents of resident acting aggressively towards staff. There are no notes documenting rejection of care or aggressive behaviors such as hitting, grabbing, etc. Nursing Assistant Accountability Records up until 2/7/19 did not document that resident has a history of acting aggressively toward staff. physician progress notes [REDACTED]. Nursing Assignment and Accountability records for the periods (MONTH) and (MONTH) (YEAR) documented that the resident is confused and oriented, aphasic, has partial vision, has right arm paralysis. The Resident is to be repositioned every two hours. The initial physical therapy evaluation exam dated 6/12/18 documented that resident #154 has reduced ability to understand commands. Physical/Occupational Therapy screen dated 9/12/18 documented that Resident #154 does not have the ability to utilize the call bell. The evaluation further documented that Resident #154 is unable to ambulate, is constantly being assisted with most activities of daily living. The facility's Accident/Incident report dated 02/07/19 was reviewed. The incident report documented the date of the incident occurring on 02/05/19. Resident #154 condition before the incident was described as alert and oriented to person, disoriented to place and time. The summary of the occurrence documented that the Registered Nurse (RN#4) on duty was called to the room of Resident #154. RN #4 observed that resident's left hand was restricted to the bed with a plastic bag. No redness or swelling of left hand was noted. No indications of pain and no change in the mental status. Resident #154 left hand was released immediately. The report documented that the Primary Care Physician, Assistant Director of Nursing and Family members of resident #154 were notified. However, the DNS reported that RN#4 did not report the incident to facility administrative staff until 02/07/19. The 'Staff Assignment Sheets' for 2/5/19 to 2/8/19 were reviewed. The sheets revealed that CNA #10 was permitted to continue providing care to this resident from 02/05/19 to 02/07/19. On 02/11/19 at 01:29 PM the Surveyor reviewed the videotape of 3B-room [ROOM NUMBER]A in the presence of Employee #1 who is the Executive Senior Secretary. The video recording revealed that on 2/5/19 at 5:23 AM, CNA #10 observed in room moving floor mats and closes door. On 2/5/10 at 5:29 AM, CNA #10 observed moving floor mat and closed door. On 2/5/19 at 5:45 AM, CNA #10 exits the room and returns to room [ROOM NUMBER]B-16A with a plastic bag. CNA #10 Exits room at 5:47 AM. There is no video evidence of CNA #10 re-entering the resident's room. The video recording also revealed that on 2/5/19 At 7:41 AM, CNA #6 entered room [ROOM NUMBER]B-16A. At 7:42 AM, CNA #6 exits the room. CNA #6 then calls immediately calls for the nurse. RN # 4 is observed entering room at 7:42 AM. CNA #10 documented on 02/07/19 that on 02/05/19 Resident #154 was very agitated and attempted to scratch CNA #10. CNA #10 documented that a plastic bag was used to secure Resident #154 wrist. CNA #10 further documented that she forgot to release the plastic bag upon completion of morning care. CNA #6 documented on 2/7/19 that on 2/5/19 Resident #154 left hand was found tied to the bed with a plastic bag. The Assistant Director of Nursing (ADNS) documented on 02/08/19 that on 02/07/19 around 6:40 AM, RN #4 reported that on 2/5/19 Resident #154's left hand was found bound to the bed rail with a plastic bag. ADNS further documented that she immediately informed the Director of Nursing (DNS) via telephone of what occurred, and the investigation process was started. The facility's investigative summary dated 2/7/19 documented on 2/5/19, resident #154 was noted in bed with his left-hand restrainded to the bed with a plastic bag. During the investigation, CNA # 10 stated that she was giving care to resident #154 and the resident was fighting. As a result, the CNA #10 restrained resident #154's left hand to the bed railing with a plastic bag. CNA#10 was counseled on resident abuse. The Facility documented that CNA #10 and RN #4 were relieved from duties. All residents assigned to CNA # 10 were assessed for injuries and none were found. On 02/08/19 at 02:48 PM RN #4 was interviewed. RN #4 stated that resident #154 is disoriented and requires two people to assist with ADL care. RN #4 stated that she is not aware of resident # 154 being combative. The resident is usually calm. The resident is non-verbal and is totally dependent during ADL care. RN #4 stated that if a resident becomes combative, the CNA is directed to report it to the nurse. The resident would be assessed by the nurse and evaluated by the Primary Care Physician. RN #4 stated that she received training on abuse identification and prevention within the last twelve months. RN #4 further stated that on the morning of 02/05/19 morning, CNA #6 called her into the room of resident #154 and she observed resident's left hand tied to the bed with plastic bag. The resident was assessed, there were no bruises and no swelling. There was no sign of pain. RN # 4 stated that she did not report the incident to the ADNS on Tuesday 02/05/19. She reported the incident to the ADNS on the morning of Thursday 02/07/19. RN #4 stated that she should have reported the incident on the same day. RN #4 stated that she was busy on the unit and did not get a chance to report the incident. RN #4 stated that she was overwhelmed and that is the reason why the incident was not reported right away. On 2/8/19 at 3:07 PM CNA #10 was interviewed. CNA #10 stated that she has been working in the unit for about seven years. CNA #10 stated that she was assigned to Resident #154 on 02/04/19 through 02/05/19 from 11 PM to 7 AM. CNA #10 stated that she continued to work with the resident up until 02/07/19. CNA # 10 stated that she provides ADL care to resident # 154. CNA #10 stated that she ensures the resident does not fall. CNA # 10 stated that on the morning of 02/05/19 she was providing ADL care to Resident #154, and the resident had feces in his hands. CNA # 10 stated that Resident #154 was combative, so she tied the resident left hand to the bed railing with a plastic bag. CNA #10 stated that she cleaned the resident's hands. CNA #10 further stated that she forgot to release the hand tie. CNA #10 stated that she did not report to the other staff that resident #154 was tied to the bed rails with a plastic bag. CNA #10 also stated that on the morning of 02/07/19 the RN Supervisor informed her that Resident #154 was found tied to side rails. CNA # 10 stated that she completed an incident report. CNA #10 further stated that the Director of Nursing suspended her until further notice. CNA #10 also stated that the facility provided abuse identification and reporting training about three to four months ago. CNA #10 stated that she did not mean to harm Resident #154. CNA # 10 stated that she wanted to clean the resident up and was rushing to complete ADL care. On 02/11/19 at 11:34 AM, CNA #6 stated that while conducting rounds around 7:10 AM on Tuesday 02/05/19, she went the room to check on Resident #154. Resident #154 was laying on his left side. Resident #154 was covered with a sheet. On Tuesday 02/05/19 around 7:45 AM, CNA #6 stated that she returned to resident #154 room to feed him. At that time, CNA #6 removed the sheet to turn the resident on his back. CNA #6 stated that she realized that the resident's left hand was tied to the bed with a plastic bag. CNA # 6 stated that she informed RN #4. CNA #6 stated that RN #4 removed the plastic bag and assessed the resident for any injuries. CNA #6 stated that the resident would try to hold her hand while she applied a hand brace to his right hand. CNA #6 further stated that Resident # 154 is usually calm. CNA #6 stated she received training on abuse identification and reporting. CNA #6 stated that abuse must be reported right away. On 02/08/19 at 12:45 PM the family member of Resident #154 was interviewed. She stated that she visits the facility at least three times weekly. The family stated that the Facility did call to report that resident #154 had been restrained. The resident's family further stated that the resident has been in the facility for the past year and a half. The family member stated that Resident #154 may become resistant if the person caring for him is not the regular staff person. CNA #10 personnel and training records indicate that she was trained, and understood what constituted abuse, how to manage residents with behavioral issues. On 02/08/19 at 01:46 PM CNA #10's Employee File was reviewed. CNA #10 was hired on 8/25/97. CNA #10 was originally Certified as a CNA on 4/14/94. NYS Nurse Aide Registry Verification Report 4/20/18-Exp 4/30/20. No findings of resident abuse and no convictions. The last annual evaluation for CNA #10 was completed on 11/6/18, and employee's performance was rated satisfactory. The (YEAR) Mandatory In-service titled Prohibition, Neglect, Misappropriation, Reporting Behavior Management-Non-Medication was done on 5/30/18. There were no disciplinary actions related to abuse, mistreatment, neglect or misappropriation of resident's funds noted in the file. RN #4's personnel and training records indicate that she was trained and had knowledge of what constitutes, abuse, when and whom to report abuse. On 02/08/19 at 02:29 PM, RN #4's Employee file was reviewed. RN #4 completed annual Mandatory In-service titled Prohibition, Neglect, Misappropriation, Reporting training on 10/17/18. The last annual evaluation for RN # 4 was completed on 04/25/18. RN #4 was rated superior, conforms to policies governing or related to patient's rights including but not limited to Patient Abuse, communicates pertinent information to health team members in a timely manner. There were no disciplinary actions on record. 415.4(a)(2-7)

Based on observations and interviews found during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided for the residents. Specifically, dirty and stained floor mats next to resident's beds were observed in 3 rooms on one unit. (Rooms 203, 214, 218) The Finding is: During multiple environmental observations on 2/4/19-2/6/19 of the second floor B unit the following was observed: marks and stains on the floor mats in rooms [ROOM NUMBER]. On 02/06/19 at 10:09 AM CNA#1 was interviewed. CNA#1 stated that when she comes in the morning she makes rounds. CNA1 stated she looks to see if anything is out of the way and makes sure everything is where it is supposed to be- call bells are in place, bed in lowest position, and residents are positioned properly in bed. CNA#1 stated floor mats need to be in place and if they are not clean she will let the environmental staff know and it will be taken care. CNA#1 stated that sometimes overnight fluid from the feeding tube spills on the floor mats, getting them dirty. She stated she will tell the nurse or LPN know. CNA#1 was not aware of any current stains on floor mats in resident's rooms 02/06/19 10:19 AM LPN#1 was interviewed. LPN#1 stated she comes in the morning and does rounds- she makes sure residents are safe, makes sure those who are supposed to have floor mats have them, makes sure beds are low, check peg tubes have head above body, those who are risk for falls are safe. LPN#1 stated if there are any spills or hazards she will call the appropriate departments. LPN#1 stated the expectations is for aids to alert her or anyone of us immediately and keep the patients safe. LPN#1 stated aids make sure floor mats are there and residents are comfortable. LPN#1 stated if there is a spill on the floor or a floor mat we call housekeeping. LPN#1 stated no one reported that floor mats are currently dirty and stained. LPN#1 stated that there is no schedule for them to be cleaned. On 02/06/19 10:25 AM The unit housekeeper was interviewed. Housekeeper#1 stated his job is to sanitize the unit and keep it clean, make sure residents are comfortable. Housekeeper#1 stated he sweeps, mops, waxes, etc. Housekeeper#1 stated in the morning he will check the rooms to make sure there are no spills and then take the garbage out. Housekeeper#1 stated if he sees a spill or someone calls him about one he addresses it immediately. Housekeeper#1 stated the floor mats that are stained get cleaned and if the statins don't come out they may have been there for too long. Housekeeper#1 stated if he cannot get the stains out he will sanitize them, and they change them out as necessary. Housekeeper#1 stated he reports the stains to supervisors and managers. Housekeeper#1 stated that floor mats were cleaned yesterday (2/5/19). Housekeeper#1 stated he was not aware of dirty floor mats. 02/06/19 10:34 AM The Director of Housekeeping (DOH) was interviewed. DOH stated he oversees the overall cleaning of the facility- including resident's rooms, public space, corridors, etc. DOH stated he makes rounds and does quality assurance for improvements. DOH stated some of the things that were noticed was dirt in corners and dust on top of fixtures. DOH stated he does rounds on all the units daily. DOH stated he looks at floor mats and makes sure floor mats are sanitized daily. DOH stated some of the floor mats need to be replaced. DOH stated that if a floor mat is torn or has stains that are not readily coming out we want to replace. DOH stated housekeeping has swapped out mats in the past. DOH stated there were no recent orders for the second floor B unit regarding dirty and stained floor mats. 415.5(h)(2)

Based on interviews and record review, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility has written policies and procedures directing their staff on reporting allegations of abuse to facility Administration and the NYSDOH (New York State Department of Health.) 1) On one occasion a Registered Nurse (RN#4) identified an incident of Resident #154 being tied to the bed rail by a plastic bag by a staff member. RN #4 did not immediately report the incident to the facility's Administration. As a result, the staff member who was alleged to have committed the abuse was not immediately removed from having direct access to the alleged victim and other residents. In addition, the facility did not report the allegation of abuse to the NYSDOH for two days after the incident was reported to the facility. 2) Facility staff identified potential abuse of Resident #176 and immediately reported to facility Administration. The facility immediately started the investigation but did not report incident to the NYSDOH through the HERDS (Health Electronic Reporting System) within 24 hours of identification of alleged abuse. This was evident for two (2) residents reviewed for allegations of abuse out of a sample of 37 residents. The facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property issued in (MONTH) 1997 and last reviewed in (MONTH) (YEAR) documented that each individual has the right to be free from verbal, sexual, physical, mental, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of property and or funds. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or any other individuals. The facility's policy documented that it has developed and implemented written policies and procedures that prevent, screen, investigate and report all allegations of resident abuse, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of resident property and finances. The facility policy also documented that all employees have an obligation to protect residents from abuse and to report any and all information related to abuse to their supervisor in a timely manner upon suspicion. An occurrence report must be completed, and a physician assessment of the resident must be conducted. Upon completion, the occurrence report must be forwarded to the Risk Manager for review. The Facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property further documented that the Risk Manager will review compiled investigative information to determine if the incident meets NYSDOH reporting criteria and there is reasonable cause or sufficient evidence to support the abuse allegation. The findings from this meeting will be discussed with the CEO if reasonable cause or sufficient evidence is determined, the Risk Manager will report the incident to the NYS DOH via the electronic Health Commerce. A full investigation will be completed in five days. The facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property documented in all situations, the protection of the residents is paramount. The facility procedure is to protect resident from harm and further abuse while investigation is in progress. The Actions taken to ensure the safety of the residents can include the alleged perpetrator will be immediately removed and resident protected, Staff members accused of alleged abuse will be removed from the facility and remain removed pending the results of thorough investigation, supervised visits by family member/friend and devising an appropriate safety plan and assigning a specific staff member who will be responsible for follow through. The facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property also documented the facility reports all alleged violations and substantiated incidents to the New York State DOH as required and takes all necessary corrective actions depending on the results of the investigation within 24 hours of incident notification or next business day. The findings are: Details of alleged incidents can be found in F-Tag 600 and F-Tag 604 of this Statement of Deficiencies. 1) Resident #154 is a severely cognitively impaired resident. On 2/5/19 the resident was found tied to the bed rail by his left hand with a plastic bag. The staff member who found the resident immediately reported to the RN on duty. The RN failed to immediately report the incident the facility Administration for two days. During that time the alleged perpetrator was allowed to provide care to the resident and other residents in the facility. Review of employee assignment sheets, provided for employees from 2/05/19 through 02/08/19, revealed that the employee accused of the alleged abuse continue to work with resident # 154 from 2/5/19 to 2/7/19. Health electronic Response Data (HERDS) reviewed. The incident which occurred on 2/5/19 around 5:45AM was reported by the facility to HERDS on 2/8/19 at 12:56PM. The incident was reported 24 hours after the facility became aware of the incident. 2) On 02/09/19 a staff member reported to facility Administration that a CNA rough handled and spoke angrily at Resident #176 while providing care. Resident #176 is totally dependent on staff for ADL care. The facility immediately investigated the incident but did not report incident to NYSDOH until 02/11/19 when Surveyors returned onsite to continue recertification survey. The facility did not report incident via the NYSDOH HERDS until 02/13/19. Health electronic Response Data (HERDS) was reviewed by Surveyors during the recertification onsite survey. The facility did not report as of 02/11/19. The incident which occurred on 2/9/19 at approximately 04:40PM was not reported by the facility to HERDS until 2/13/19 at 12:47PM. The incident was not reported for more than 72 hours after the facility became aware of the incident On 02/11/19 at 04:30 PM, The Associate Director of Risk Management stated that abuse should be reported within 24 hours. 415.4(b)(1)(i)

Based on interviews and record review during the recertification survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported within time frames required by federal and state regulations. Specifically, 1) Upon immediate observation of alleged abuse (Resident #154's left hand tied to a bed rail by a plastic bag) CNA #6 reported this to RN#4. However, RN #4 observed the resident tied to the bed rail but did not report incident to facility Administration for two days. Incidents of abuse must be reported within 2 hours. The facility reported the incident to the State Surveyors conducting the onsite recertification survey the day RN#4 reported the incident to Administration. However, the facility Administration did not report incident through the NYSDOH HERDS incident reporting system until three (3) days after the knowledge of alleged allegation of abuse. The regulation requires the facility inform the State Agency no later than 2 hours if the events that cause the allegation involve abuse. 2) Employee #2 alleged to have witness CNA#1 rough handling and speaking angrily to Resident #176 while providing care to the resident. The employee immediately reported incident to facility Administrators. However, facility administrators failed to report allegation to State Agency within 2 hours. The alleged incident happened on a Saturday and the facility reported allegations to onsite Surveyors when they returned to facility on Monday that was 2 days after the incident. The facility did not report incident over the weekend to NYSDOH through the HERDS system until 4 days after allegation. This was evident for two (2) residents reviewed for allegations of abuse out of a sample of 37 residents. The facility's policy titled Prevention of Abuse, Neglect, Exploitation and Misappropriation of Property issued in (MONTH) 1997 and last reviewed in (MONTH) (YEAR) documented that each individual has the right to be free from verbal, sexual, physical, mental, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of property and or funds. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or any other individuals. The facility's policy documented that it has developed and implemented written policies and procedures that prevent, screen, investigate and report all allegations of resident abuse, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of resident property and finances. The facility policy further documented that all employees have an obligation to protect residents from abuse and to report any and all information related to abuse to their supervisor in a timely manner upon suspicion. An occurrence report must be completed, and a physician assessment of the resident must be conducted. Upon completion, the occurrence report must be forwarded to the Risk Manager for review. The Facility's policy further documented that the Risk Manager will review compiled investigative information to determine if the incident meets NYSDOH reporting criteria and there is reasonable cause or sufficient evidence to support the abuse allegation. The findings from this meeting will be discussed with the CEO if reasonable cause or sufficient evidence is determined, the Risk Manager will report the incident to the NYS DOH via the electronic Health Commerce. A full investigation will be completed in five days. The findings are: Details of the alleged abuse can be found at F-600 and F-604 of this Statement of Deficiencies. 1) Resident #154 is a severely cognitively impaired resident. On 2/5/19 the resident was found tied to the bed rail by his left hand with a plastic bag. The staff member who found the resident immediately reported to the RN on duty. The RN failed to immediately report the incident to the facility Administration for two days. During that timethe alleged perpetrator was allowed to provide care to the resident and other residents in the facility. Review of employee assignment sheets, provided for employees from 2/05/19 through 02/08/19, revealed that the employee accused of the alleged abuse continue to work with resident # 154 from 2/5/19 to 2/7/19. Health electronic Response Data (HERDS) reviewed. The incident which occurred on 2/5/19 around 5:45AM was reported by the facility to HERDS on 2/8/19 at 12:56PM. The incident was reported 24 hours after the facility became aware of the incident. 2) On 02/09/19 a staff member reported to facility Administration that a CNA rough handled and spoke angrily at Resident #176 while providing care. Resident #176 is totally dependent on staff for ADL care. The facility immediately investigated the incident but did not report incident to NYSDOH until 02/11/19 when Surveyors returned onsite to continue recertification survey. The facility did not report incident via the NYSDOH HERDS until 02/13/19. Health electronic Response Data (HERDS) was reviewed by Surveyors during the recertification onsite survey. The facility did not report as of 02/11/19. The incident which occurred on 2/9/19 at approximately 04:40PM was not reported by the facility to HERDS until 2/13/19 at 12:47PM. The incident was not reported for more than 72 hours after the facility became aware of the incident On 02/11/19 at 04:30 PM, The Associate Director of Risk Management stated that abuse should be reported within 24 hours. 415.4(a)

Based on record review and staff interviews conducted during the recertification survey, the facility did not ensure that residents were assessed using the CMS-specified quarterly review instrument, no less than once every 3 months, Specifically, Five (5) out of the eleven (11 residents reviewed for resident assessment did not have their quarterly assessment completed. (Residents #6, #7, #13, #22, and #285) Findings are: 1) Resident #6: On 02/07/19, a review of resident assessment was conducted. The quarterly MDS assessment with the ARD (Assessment Reference Date) date of was in progress status. The assessment was not in a complete status. 2) Resident #7: On 02/07/19, a review of resident assessment was conducted. The quarterly MDS assessment with the ARD (Assessment Reference Date) date of was in progress status. The assessment was not in a complete status. 3) Resident # 13: On 02/07/19, a review of resident assessment was conducted. The quarterly MDS assessment with the ARD (Assessment Reference Date) date of 12/21/18 was in progress status. The assessment was not in a complete status. 2) Resident # 22: On 02/07/19, the resident assessment review was conducted. It was revealed that the Quarterly MDS, with the ARD date of 12/3/18 was in progress status It was not in a complete status? 3) Resident # 285: The resident assessment review was conducted. It was revealed that the Quarterly MDS, with the ARD 1/2/2019 was not completed and submitted until 2/5/2019. On 02/07/19 at 12:59 PM, the RN #8 (MDS Director was interviewed. She stated that she started to oversee the MDS department in Nov (YEAR) after the facility realized there were problems with the MDS. Since then, she had been busy identifying the problems and making corrective plans of actions to address the problems. The RN # 8 further stated that there were multiple missing MDS assessment when she joined the facility, and she believed that the MDS staff needed more training on timely submission on the MDS. She acknowledged that they were behind on the completion of the MDS. The director also stated that the facility is trying to end the old way of completing the MDS. She stated that the MDS assessors are the only people completing the MDS for all the disciplines. For example, the MDS assessor will have to through the nutrition and social services notes and transcribed the information on the MDS. Thus, preventing them to complete MDS on a timely manner. The new approach right now is to On 02/07/19 at 03:37 PM, an interview conducted with the Director of Nursing. The DNS stated that she has been in the facility for over 4 years, she stated that she was not her responsibility to oversees the MDS dept., The MDS director retired and was assigned to oversee it. She stated, I did it for a few months and we hired someone to oversee the MDS. In (MONTH) (YEAR), the RN # 8 was hired as an MDS director. She stated that she was aware of those missing assessment, that happened before she came, she came and ran a report, and the head of post-acute of HHC, she came in (YEAR) before RN #8 came in an she is the one who identify problems. she stated that she stated that they have some more expertise. the issues were brought the QA and that is why they hired those staff. The following interviews were conducted of the MDS assessment Nursing Staff regarding the lateness of the assessments. On 02/07/19 at 12:10 PM, an interview was conducted with the RN # 5 (MDS assessor). She stated that she has been working in the facility since year 2000, as staff nurse. She also stated that she has been working as an MDS assessor for about 6 years. She stated that she took up the role on this unit since last years around sept (YEAR). She stated that she used to cover another floor 2A/B, she stated that she complete MDS assessment, you review chart and I assessed the resident, i collaborate with team, she stated that each discipline completes their assessment and the MDS assessor we must enter it on the MDS database. She stated that the MDS assessor is responsible for the completion, there is another coordinating manager does the remission. she stated that she's doing the HMO utilization and doing MDS in unit 3A. She stated that she's behind, they are trying to restructure the MDS procedures. On 02/08/19 at 10:49 AM an interview conducted with RN # 6. He stated that he started working here since 2006, he stated that he began as an MDS assessor in 2007. He also does case management for the HMO, and team coordination. He stated that he did MDS training a while back, i also went to seminars. He stated that they do not have anyone doing the schedule, we don't do the schedule. The previous MDS coordinator taught me how to do it prior to her leaving. The office coordinator will enter the book, we used to the write the MDS in paper, and the MDS coordinator will check it so the clerk will then enter it and submitted to the CMS. We lost coordinator, we lost another MDS nurse, there were changes in our assignments, he stated that there were time constraint doing the MDS assessment. we wasted a lot of time looking for records, sometime a document is not completed, or missing signature, if the signature is missing, they cannot file them, most of the documents are not easily accessed. those are the factors that affect the timely completion. He stated that the management is fully aware of this concern. He stated that the DNS at sometimes was the one doing the reassignment of the MDS On 02/08/19 at 11:21 AM an interview conducted with the RN #7, an MDS nurse who stated she has been doing MDS since (YEAR). She stated that she used to be a regular nurse on the unit until she started to be MDS assessor. She also stated that she never received any formal MDS training but recently we started to receive in-service when the new MDS director was hired. The RN # 7 stated that they used to have a coordinator who make the schedules, she stated that the assessment supposed to be completed within 14 days of the start date, but they are behind. She stated that the MDS director gives all discipline a monthly schedule, quarterly is 92 days from the last ARD. We started to do the schedule ourselves, we complete the MDS in paper and do it electrically. Up until now, we look for information from each discipline notes and this take a lot of time to complete them On 02/08/19 at 01:38 PM an interview was conducted with RN #9, who is the Director of Clinical Relinquishment. RN #9 stated that she joined the New York City Hospital and Health Corporation in (MONTH) (YEAR) and oversees the MDS dept in all the HHC Nursing home facilities. she Further stated that she discovered through a review of CASPER report that there were lot of missing incomplete MDS assessments. She then met with DNS and the Administrator. She acknowledged that they are out of compliant to the team. She also stated that the former MDS director was unable to explains now on vacation. One of the plans is to bring the MDS director in, and she started on 11/19/18. We started to do education, apparently the MDS staff because we identified some concerns regarding lack of knowledge with the MDS staff, we are planning to reassign them to the nursing floor. we are planning to bring new experienced in to the program. On 2/11/2019 at 9:12 AM RN# was interviewed. She stated: The work is too much for me to do, I am assigned to three units, one with twenty residents, plus the significant changes/admissions assessments mad and comprehensive are plan meetings. On 02/11/19 08:53 AM the MDS Director (RN#8) was again interviewed. She stated that there is a practice assessment being done late in the facility. RN # stated that the MDS nurse assessors don't have a reason. Per the RAI (Resident Assessment Instrument) a discharge Assessment must be completed on a resident discharge from the facility. Also, annual and quarterly review assessment were also not done on time. The MDS'S assessments were not completed because one of the MDS nurse assessors went on vacation and did not complete the assessment prior to her vacation. The director stated she was aware of the MDS'S not completed prior to the nurse going on vacation, and reminded all nurse assessors via e-mail, that the MDS assessments must be completed, but it was not done. The nurse returned from vacation on 12/07/2018 and did not complete the assessments. The director stated that on 2/5/2019 she spoke to the MDS nurse assessors about the lateness of the assessments. She acknowledged that the RNs have complained about the amount of assessments and other tasks that they must complete. The MDS director stated she check the MDS scheduler through 02/07/2019 and realized the lateness for resident # 6, annual assessment resident #7 and quarterly for resident #285 not done. The late MDS'S was completed 2/5-8/2019. On 02/08/19, a review of the QA MDS report dated 10/26/18 documented that concerns were identified. 1.) the facility's overdue MDS assessments, 2.) late submission of the MDS assessment, 3.) accuracy of the MDS assessment. The report further documented that that the facility had discharge MDS assessments that were not completed going back from (MONTH) 2014. Also, one comprehensive MDS assessment dated to (MONTH) 2013 was not completed. The report stated that the facility had a total of 167 missing MDS assessments. The report indicated that no discharge assessment was being completed but the discharge assessments were scheduled, however, the MDS clerk was completing the entry forms when the resident who were anticipated as being discharged , later returned to the facility. The reported also indicated that there were warning of inconsistent record sequence when entry was submitted. The report also stated that the MDS were not reflecting the accurate picture of residents' status. The QA corrective action documented that the assistant Director of MDS will conduct random audits by 1.) Reviewing the in progress MDS tab in PCC monthly to monitor the completion of the MDS assessment. 2.) 10% of the census discharge for 3 months for timely completion of discharge assessment, according to the RAI. 3.) 10% of the MDS assessment for 3 months for accuracy of MDS and timely completion according to RAI manual. The outcome will reported to the QA committee on a monthly follow up. The ongoing monitoring will be done until 100% compliance is achieved. 415.11)a)(4)

Based on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a resident's continued use of oxygen (O2) was not indicated on the MDS (Minimum Data Set 3.0) assessment. This was evident for 1 out of 11 sampled residents (Resident #619). Resident #619 was admitted to the facility on [DATE] with diagnoses, which include [MEDICAL CONDITION]. The Admission Minimum Data Set (MDS) 3.0 dated 01/25/18 documented intact cognition. Oxygen therapy was not documented while not a resident or while a resident at the facility. Nursing and Rehabilitation Center dated 01/18/19 documented the use of O2 2/L Nasal Cannula. Physician order [REDACTED]. Nursing progress notes dated 01/18/19 document Resident #169 was admitted on O2 sat 100% on 2/h O2 via N/C. Progress notes dated 01/22/18 document on MD note cont'd on O2 sat 90%, order on O2 2L/min, monitor. On 02/06/19 at 08:14 AM the resident was observe receiving O2. On 02/08/19, a review of the Quality Assurance MDS report dated 10/26/18 documented that concerns were identified. 1.) the facility's overdue MDS assessments, 2.) late submission of the MDS assessment, 3.) accuracy of the MDS assessment. The report further documented that that the facility had discharge MDS assessments that were not completed going back from (MONTH) 2014. Also, one comprehensive MDS assessment dated to (MONTH) 2013 was not completed. The report stated that the facility had a total of 167 missing MDS assessments. The report indicated that no discharge assessments were being completed but the discharge assessments were scheduled, however, the MDS clerk was completing the entry forms when the resident who were anticipated as being discharged , later returned to the facility. The reported also indicated that there were warning of inconsistent record sequence when entry was submitted. The report also stated that the MDS were not reflecting the accurate picture of resident's status. On 02/07/19 at 12:10 PM an interview was conducted with RN #5 (MDS Assessor). She stated that she has been working in the facility since year 2000, as a staff nurse. She also stated that she has been working as an MDS assessor for about 6 years. She stated that she took up the role on this unit since last years around sept (YEAR). She stated that she used to cover another floor 2A/B, she stated that she completes MDS assessment, you review chart and I assessed the resident, I collaborate with team, she stated that each discipline completes their assessment and the MDS assessor we must enter it on the MDS database. She stated that the MDS assessor is responsible for the completion, there is another coordinating manager that does the remission. She stated that she is also doing the HMO utilization and MDS assessments on unit 3A. She stated that she's behind, they are trying to restructure the MDS procedures. On 02/07/19 at 12:59 PM, RN #8 (MDS Director) was interviewed. She stated that she started overseeing the MDS department in (MONTH) (YEAR) after the facility realized there were problems with the MDS. Since then, she has been busy identifying the problems and making corrective plans of actions to address the problems. RN #8 further stated that there were multiple missing MDS assessment when she joined the facility, and she believed that the MDS staff needed more training on how to submit assessments timely. She acknowledges that they were behind on the completion of the MDS assessments. The director also stated that the facility is trying to end the old way of completing the assessments. She stated that the MDS assessors are the only people completing the MDS for all the disciplines. For example, the MDS assessor will have to through the nutrition and social services notes and transcribe the information on the MDS. Thus, preventing them to complete and submit the MDS assessments in a timely manner. On 07/19 at 03:37 PM, an interview was conducted with the Director of Nursing. She stated that she has worked in the facility for over 4 years, she stated that it was not her responsibility to oversee the MDS dept. The MDS director originally assigned to oversee that dept retired. She stated: I did it for a few months and then we hired someone to oversee the dept. In (MONTH) (YEAR), RN # 8 was hired as an MDS director. The DNS stated that she was aware of those missing assessments, it happened before she came. When she came she ran a report and gave it to the head of post-acute of HHC, who came in (YEAR). This was before RN #8 came onboard, now that is the person who identifies problems with the MDS. The DNS stated that that they have some more expertise in this area. The issues were brought to the QA and that is why they hired those staff members. On 02/08/19 at 10:49 AM an interview conducted with RN # 6, who is one of the MDS assessors. RN # 6 stated that he started working at the facility since 2006, he stated that he began as the MDS assessor since 2007. He also does case management for the HMO. He stated that he did MDS training a while back, also went to seminars. He stated that they do not have anyone doing the MDS schedule. He said: We don't do the schedule. The previous MDS coordinator taught me how to do it prior to her leaving. The office coordinator will enter the book, we used to the write the MDS on paper, and the MDS coordinator would check it, the clerk entered it and submitted to CMS. We lost the coordinator, we lost another MDS nurse, there were changes in our assignments. He further stated that there were time constraints in doing the MDS assessment. We wasted a lot of time looking for records, sometime a document is not completed, or missing signature, if the signature is missing, they cannot file them, most of the documents are not easily accessed. He stated that those are the factors that affect the timely completion. He stated that the management is fully aware of this concern. He stated that the DNS at sometimes was the one doing the reassignment of the MDS On 02/08/19 at 11:21 AM an interview was conducted with RN #7, an MDS assessor. RN #7 stated she has been doing MDS assessments since (YEAR). She stated that she used to be a regular nurse on the unit until she started to be the MDS assessor. She also stated that she never received any formal MDS training but recently started to receive in-service when the new MDS director was hired. RN #7 stated that they used to have a coordinator who made the schedules. Shestated that the assessments are supposed to be completed within 14 days of the start date, but they are behind. She stated that the MDS director gives all disciplines a monthly schedule, quarterly is 92 days from the last ARD. RN #7 stated: Wes started to do the schedule ourselves, we complete the MDS assessments on paper and do it electronically. Up until now, we look for information from each discipline notes and this take a lot of time to complete them. On 02/08/19 at 01:38 PM an interview was conducted with RN #9, who is the Director of Clinical Relinquishment. RN #9 stated that she joined the New York City Hospital and Health Corporation in (MONTH) (YEAR) and oversees the MDS dept in all the HHC Nursing home facilities. she Further stated that she discovered through a review of CASPER report that there were lot of missing incomplete MDS assessments. She then met with DNS and the Administrator. She acknowledged that they are out of compliant to the team. She also stated that the former MDS director was unable to explains now on vacation. One of the plans is to bring the MDS director in, and she started on 11/19/18. We started to do education, apparently the MDS staff because we identified some concerns regarding lack of knowledge with the MDS staff, we are planning to reassign them to the nursing floor. we are planning to bring new experienced in to the program. 415.11(b)

Based on records review and interview conducted during the recertification survey; the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, The facility conducted a comprehensive assessment of Resident # 5 on There was no documented evidence that a comprehensive care plan that included measurable goals and objectives and interventions was developed to address the resident's [DIAGNOSES REDACTED]. This was evident for 1 out of a sample of 37 residents reviewed. The finding is The facility policy Comprehensive Care Plan reviewed 1/2018 document the interdisciplinary team develops, documents, signs and date an individualized interdisciplinary comprehensive plan for care, treatment and services after comprehensive assessments are completed (according to regulatory required time frames and no later than 14 days post admission). Resident #5 was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with moderately impaired cognition and a [DIAGNOSES REDACTED]. An antidepressant was received for seven days. There was no documented evidence that a CCP (Comprehensive Care Plan) had been created to address the resident's medical [DIAGNOSES REDACTED]. However, the plan does not identify Depression as one of the problem areas and there are no measurable objectives, interventions, and time frames listed to meet the resident's mental, nursing, psychosocial needs as it pertains to the [DIAGNOSES REDACTED]. The same can be said for the CCP for medications. The resident is receiving multiple medications, however the measurable goals and timeframes are general and not specific for [MEDICAL CONDITION] medication and does not identify the clinical [DIAGNOSES REDACTED]. On 02/11/19 at 10:57 AM, the Assistant Director of Nursing Services (ADNS) was interviewed. After reviewing the resident's care plan stated there is no care plan for Depression. ADNS stated that the care plan should be initiated once the resident has a diagnosis, head to toe assessment and receive medication for that diagnosis. ADNS also stated review of the care plan occurs quarterly, when there is a change and a new [DIAGNOSES REDACTED]. 415.11(c)(1)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that a resident who use [MEDICAL CONDITION] drugs receive gradula dose reductions and behavioral interventions, unless clinically contraindicated. Specifically, Resident #5 has been prescribed and received ten (10) milligrams (mg) of [MEDICATION NAME] an antidepressant for over a year, without the attending physician attempting a gradual dose reduction. The attending physician did provide evidence that attempting to reduce medication would pose a greater risk than benefit to the resident. In addition the facility did not provide evidence that it consistently monitored resident's behavior and or moods. This was evidence by facility not developing a care plan that included; measurable goals and interventions that addressed the resident's [DIAGNOSES REDACTED]. (Resident #5). The findings are: The facility policy Antipsychotic Medications revised 9/2018 document within first year in which the resident is admitted on an antipsychotic/anxiolytic/antidepressant medication or after the facility has initiated one of these classes of medication, the facility must attempt a gradual dose reduction (GDR), in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. The GDR maybe considered clinically contraindicated if the resident's symptoms return or worsen after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. Contraindication means: the physicians has documented the clinical rationale for why any attempted dose reduction would likely to impair the resident function or cause psychiatric instability exacerbating an underlying psychiatric disorder. Resident #5 was originally admitted to the facility on [DATE]. The resident was readmitted to the facility after a brief discharge on 1/25/119 with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with moderately impaired cognition. An antidepressant was received for seven days. There was no documented evidence that a CCP had been created to address the resident's medical [DIAGNOSES REDACTED]. On 02/06/19 at 09:47 AM, Resident #5 was observed in bed and responded to the Surveyor's greetings. On 02/07/19 at 03:49 PM, Resident #5 stated she felt ok and did not feel sad or depressed. Resident #5 also stated she attends activities in the dayroom and likes to paint and listen to music. On 02/08/19, Resident#5 was observed moving through the hallway in her wheelchair and stated she felt ok. Previous Quarterly MDS dated [DATE], 6/2/18, 3/9/18, documented antidepressant medication was received for seven days prior to the assessment period. There is no documented evidence that during the quarterly MDS review the facility consistently or adequately evaluated the resident's mood function, behavior, and other domains that may be affected by medications. Physician order [REDACTED]. The most recent Physician order [REDACTED]. Pharmacy Medication Regimen Review dated 11/25/18 documented: this resident is currently receiving the following antidepressant: [MEDICATION NAME] 10mg place since 04/2017 and a review of the resident's chart does not reflect a worsening of depression - consider trial GDR. MD#8 documented a response which was not dated. MD #8 responded: the patient [MEDICAL CONDITION] history of Depression - I believe she is stable as she is on antidepressant. We will monitor. The physician did not order a dose reduction for the [MEDICATION NAME]. The Periodic Patient Assessments completed by the physician dated 2/2/18- 2/7/19 were reviewed. It documented that the patient is being seen because of medical, psychiatric or physical issues which have arisen and require evaluation and/or treatment at this time. The assessments are as follows: On 2/10/18 documented no behavioral or mood Indicators and no [MEDICAL CONDITION] drug reduction assessed. On 3/9/18 documented no behavioral or mood indicators, [MEDICATION NAME] GDR not possible and [MEDICAL CONDITION] drug reduction assessed is blank. It is important to note that after the 3/9/18 assessment, there was a Comprehensive Care Plan meeting held. According to the CCP note dated 3/21/18, which documented that the resident participates in recreation. There was no other evidence of a CCP meeting held for this resident. On 3/29/18 documented no behavioral or mood indicators and no [MEDICAL CONDITION] drug reduction assessed. On 4/25/18 documented no behavioral or mood indicators, yes to [MEDICAL CONDITION] drug reduction. Assessed. Patient not a candidate for GDR at this time still depressed, crying sometimes. Next of kin aware. On 6/4/18 documented no behavioral or mood indicators, no psych service NA, and yes to [MEDICAL CONDITION] drug reduction assessed. GDR not possible at this time. On 7/12/18 documented no behavioral or mood indicators. Yes, to [MEDICAL CONDITION] drug reduction assessed. Psychiatry recommendation patient is taking [MEDICATION NAME] for depression and [MEDICATION NAME] for her mood disorder. GDR is not possible at this time. On 8/1/18 document no behavioral or mood indicators. Patient taking [MEDICATION NAME] for mood disorder and stable on regimen. Not a candidate for GDR at this time. Discussed with caregiver. [MEDICAL CONDITION] drug reduction assessed is blank. However, there is a Therapeutic Recreation Quarterly note dated 8/24/18 which documented that the resident attends most group programs on/off unit. It further documented that she engages in socialization with peers/staff and family visitor who support her and spend quality time with her. On 9/13/18, 10/16/18, 11/20/18, and 12/18/18 documented no behavioral or mood indicators. [MEDICAL CONDITION] drug reduction assessment is blank. On 1/14/19 documented no behavioral or mood indicators and yes [MEDICAL CONDITION] drug reduction assessed. On 2/4/19 documented no behavioral or mood indicators and [MEDICAL CONDITION] drug reduction assessment is blank. The assessments do not document detail as to why the gradual dose reductions were not possible at the time of the assessment. The forms do not indicate evidence of interdisciplinary team discussion regarding this resident's plan of care. At no time after the assessments was the resident's identified problem of depression addressed. In addition, the CCP for medications were not updated to indicate that GDR was clinically contraindicated. The Mood/Behavioral log & Summary sheets from (MONTH) (YEAR)-February 2019 was reviewed. (MONTH) (YEAR) is blank. There is a documentation stating that resident exhibits no signs and symptoms (s/s) of behavioral or mood indicators. The logs are not complete, they do not clearly provide documented evidence that the resident's mood and behavior were being monitored daily. The following was revealed during the review: (MONTH) (YEAR) was blank. The following logs were not provided for (MONTH) (YEAR) and (MONTH) (YEAR). No evidence mood and behavior were being monitored during that time. On 04/07/18 in the summary box it is documented that resident exhibit signs or symptoms of behavioral problems. Will continue to monitor. There is no other note until 04/14/18 where it is documented again in the summary box that resident is alert and verbally responsive, noted wandering off unit. Staff had to redirect resident. Resident gets upset whenever she is being redirected currently on [MEDICATION NAME] 10 mg daily secondary to depression and [MEDICATION NAME] SOD DR 250 mg 2x daily secondary to Mood disorder. There were no other notes until 4/21/18. It was documented in the summary box that the resident was short tempered with staff when staff redirected resident from leaving unit. Writer reeducated her about her safety. The next note was not until 4/30/18 again documented in the summary box no behavior noted and will continue to monitor. The form for (MONTH) (YEAR) is blank. However, there is a therapeutic recreation quarterly note dated 5/29/18 which documented that the resident is active and participates in groups. It further documented that the resident participates in art, socials, games, trivia, discussions, and religious services. The note does not indicate that IDT (interdisciplinary team) discussed resident's behavior, mood or continued use of [MEDICAL CONDITION] medication. It does not indicate if physician was present or identified designee for medical. There are no notes again until 06/06/18. Documented in the summary box was a note that resident is alert and responsive verbally, noted trying to get on elevator without assistance of staff. When redirected by writer, resident started ssc4reaming and cursing at writer. Will continue to monitor. On 6/ 10/18 it was noted in summary box no behavior, noted, monitor ongoing, continue on [MEDICATION NAME] 10 mg secondary to depression. Will continue to monitor. The for (MONTH) (YEAR) form was blank. The form for (MONTH) (YEAR) was not provided, and thus there was no documented evidence that the residents mood and behavior were being monitored for this period. On 9/30/18 there is only one note in the summary box stating that no behavioral or mood indicators noted. The (MONTH) (YEAR) form has only one note which is not dated, in the summary box stating that no behavior problem exhibited at this time. The (MONTH) (YEAR) form was blank. However, there is a Nursing note dated 11/15/18 which documented that the resident displays no behavioral issues, is compliant with plan of care a cooperate with plan of care and cooperate with staff. It further documented that resident participate in all recreational activities and peer interaction. On 12/8/18 there is a note documented in the summary box that resident noted at time trying to get out of bed, when redirected by writer and staff, resident gets annoyed. Emotional support provided by staff, continue [MEDICATION NAME] secondary to depression. On 12/12/18 no behavioral or mood indicators noted, will continue to monitor was documented in the summary box. No other notes for (MONTH) (YEAR) documented. There are only three notes in the summary box for (MONTH) 2019. On 1/5/19 no behavioral or mood indicators noted, will continue to monitor; on 1/11/19 continue to monitor for behavioral problems, none witnessed. Safety Precautions monitored; on 1/20/19 resident noted screaming and trying to get out of bed. Redirect by staff. Emotional support provided. Thus far there were only two notes for (MONTH) 2019. On 2/2/19 resident noted screaming when caregiver redirected her from getting out of bed. Emotional support provided. No behavioral or mood indicators noted will continue to monitor. On 02/07/19 no behavioral problems noted was documented. On 02/07/19 at 04:44 PM, a telephone interview was conducted with the daughter of Resident #5 who stated her mother's mood is good especially when she visits. The daughter stated her mother is always in the day room participating in activities such as shopping and parties. The daughter stated Resident #5 would only stay in her room when she is feeling sick. The daughter of Resident #5 stated her mother only gets depressed when she told that she cannot go home to Jamaica, so she avoids that conversation. On 02/11/19 at 10:44 AM, an interview was conducted with Licensed Practical Nurse (LPN # 3) who stated Resident #5 has a history of depression and is on [MEDICATION NAME]. Resident #5 has outbursts about going to Jamaica and at times tries to get out of bed then is redirected. Resident # 5 is always happy. The daughter usually visits. Signs to observe that the resident is quiet/withdrawn includes when her daughter does not visit within 2 weeks or the resident realizes she is not going to Jamaica which has occurred maybe once for the month. LPN #3 looks for signs of depression such as resident is quiet, not eating, and going back her room during activities. The effectiveness of the drug is based on her behavior, the resident communicates, is happy, attends activities, and is not withdrawn. On 02/11/19 at 10:57 AM, an interview was conducted with Assistant Director of Nursing Services ADNS # 8 who reviewed the resident's care plan and stated there is no care plan for Depression. ADNS#8 stated that the care plan should be initiated once the resident has a diagnosis, head to toe assessment and receive medication for that diagnosis. ADNS #8 also stated review of the care plan occurs quarterly, when there is a change in condition, a new [DIAGNOSES REDACTED]. Assessing the efficacy of an antidepressant medication includes no sign/symptoms of withdrawal, change of appetite, and the resident is not crying. ADNS #8 stated resident participates in activities, resident goes out on pass with her daughter and does not see any signs of depression with the resident. ADNS #5 stated for antidepressant medication, the goal is to reduce the medication to the lowest dose without any harmful effects to the resident. On 02/11/19 at 12:09 PM, an interview was conducted with MD #8 who stated most of the patients that have experienced a stroke are depressed. MD #8 stated the decision not to attempt a gradual reduction was based on the way the resident behaves and carries herself. MD #8 stated based on staff the resident #5 sometimes gets angry and does not cooperate but this is not often. Due to her to her cognitive impairment sometimes is not able to verbalize her feeling such as stating life is not going well. Resident # 5 is depressed due to her circumstances of the stroke, dementia, DM retinopathy, wanting to go home, not being able to ambulate, uncontrolled DM and periods of crying. MD#8 stated [MEDICATION NAME] is an antidepressant not an antipsychotic medication. She stated that, 10 mg is not a high dosage and not as harmful as antipsychotic medications. MD#8 stated that the resident has [MEDICAL CONDITION] because of a stroke. MD#8 asserts that the medication should not be reduced. MD #8 stated the resident's clinical situation is not going to get better and the benefits such as being functional, not crying and being able to sleep outweighs the risk of the medication. There is no evidence that MD#8's followed the requirements underlying the guidance for gradual dose reduction for [MEDICAL CONDITION] medications. The MD's notes on the periodic assessment did not include specificity as to resident's response to the medication. As the behavioral notes indicate, the resident has several periods where her behavior and mood seemed to improve or stabilize. The therapeutic notes indicate that the activities care plan was beneficial to the resident. The notes from the therapeutic recreation do not refer to discussions with MD, or nursing. There is no documented evidence that the MD evaluated how the non-pharmacological approaches have benefited the resident when considering dose reduction. The facility also did not provide enough evidence that it evaluated the effectiveness of the behavioral interventions such as redirection and monitoring. The monitoring sheets were not completed, and it was not clear from the documentation if nursing staff was adequately and consistently monitoring the resident for signs and symptoms of depression or mood indicators. 415.12(1)(2)(i)(a-d)(ii)

Based on observation, record review and staff interviews the facility did not ensure that the Comprehensive Care Plan (Comprehensive Care Plan) was reviewed and revised to reflect preventative skin care measures for a resident identified at risk for pressure ulcer development. Specifically: the unit nurses did not identify and implement turning and positioning as preventative measures in a timely manner.This was evident for 1 of 3 residents reviewed for Pressure Ulcers. (Resident #142). The finding is: Resident # 142 a [AGE] years old female admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Quarterly MDS 3.0 assessment dated [DATE] documented: intact cognition, total assistance of one person for activities of daily living, range of motion limitation on one side of the upper and lower extremities, always incontinent of bowel and bladder, at risk for pressure ulcers, no healed or unhealed pressure ulcers and pressure relieving device for chair. The Quarterly MDS 3.0 assessment dated [DATE] documented: intact cognition, total dependence for activities of daily living, range of motion limitation on both sides of the upper and lower extremities, always incontinent of bowel and bladder and at risk for developing a pressure ulcer. The MDS further documented the two stage 3 pressure ulcers measuring .8 x .8 x .2 cm (centimeters) and slough- the most severe tissue that was not present on the prior assessment. No healed pressure ulcers present. The skin and ulcer treatment included turning and positioning. On 2/19/2016 at 10:10 AM, the resident was observed in bed during provision of care by the CNA ( Certified Nursing Assistant ). During the observation, the resident stated My doctor wants me to stay on my sides most of the time and not on my back. Sometimes nobody comes to do that especially in the afternoon and night. The CNA replied You are in your wheelchair most of the day. At 10:15 AM the SA (State Agency) observed wound care being performed by the nurse. After positioning the resident on her left lateral side and exposing the site, the old dressing was removed. There was minimal drainage. The wound bed was observed with tissue granulation, redness and no odor. The Comprehensive Care Plan (CCP) dated 7/2015 and revised 12/08/2015 identified the potential for skin breakdown with the following interventions: skin check every shift, provide incontinent care every shift as needed and apply moisture barrier cream after incontinent care, turn and position every two hours. Prior to 12/8/15, turning and positioning was not an identified intervention on the comprehensive care plan. The nursing progress note dated 12/08/2015 documented: Resident is alert and verbally responsive and able to make needs known. Noted with small reddened area mid buttock skin intact NAAR (Nurse Aide Accountability Record) updated to turn and position resident & (and) prn (as needed) to prevent pressure. Apply moisture barrier (after) incontinent care to prevent skin breakdown. The nursing progress note dated 12/13/2015 at 6:00 am documented: Resident noted with right sacral skin tear. Log in MD communication book. The nursing progress note dated 12/13/2015 at 12:25 PM documented: Resident noted this am with small skin break measuring 1.4 x 0.9 to right upper buttock.(name of Doctor) called and made aware. T.O (telephone order) given to writer for - cleanse skin break to right upper buttock (with) normal saline, pat dry, apply zinc oxide and cover with dry protective dressing daily and prn. Staff will continue with turning and positioning. The Weekly Pressure Ulcer and Wound Record dated 12/24/15 documented: Right buttock pressure ulcer-stage 3 measuring 3.3 x 1.6 x 0.3 cm. Preventative measures- Turn and Position and air mattress. The nursing progress note dated 12/17/2015 at 12:40 PM documented: Seen by wound care team today. Noted with stage 2 measuring 1.2 x 0.2 cm (pressure ulcer) to left buttock within close proximity to opening to right buttock. The Weekly Pressure Ulcer and Wound Record dated 12/24/15 documented: Left buttock pressure ulcer-stage 3 measuring 1.6 x 1.3 x 0.3 cm. Preventative measures- Turn and Position and air mattress. The Braden Scale For Predicting Pressure Sore Risk dated 7/12/2015 through 1/5/2016 identified the resident at moderate risk for pressure ulcer with scores of 14. The Braden Scale intervention Guide further documented- frequent Turning with a planned schedule for moderate risk (13-14). The NAAR for October and November 2015 documented: Position Every 2 Hours-Yes or No. For the months of October and November 2015, the boxes for positioning every 2 hours was left blank. There was no documented evidence that the resident was turned every two hours for the months of October and November 2015. The NAAR (Nursing Assignment & Accountability Record) for December 2015 and January 2016 documented: Position Every 2 Hours-Yes and dated 12/8/15. The Registered Nurse (RN) Charge Nurse was interviewed on 2/19/2016 at 11:20 AM and stated that the redness was observed and reported on 12/08/2015 and the physician was immediately contacted and orders obtained. A follow up interview was conducted on 2/22/2016 at 11:15 AM with the RN. The RN stated that the resident's Braden scale score was 14 indicating moderate risk for pressure ulcer development. The facility protocol includes turning and positioning every two hours. Filling out the resident care records is divided up between the day and night shifts. When I was informed on 12/08/2015 about the resident's skin redness, I immediately updated the care plan and noticed that the turning and positioning section (of the NAAR) had not been checked prior to December 2015. We should have been turning and positioning the resident because that is part of the facility skin care protocol. The CNA assigned to the resident was interviewed on 2/22/2016 at 11:30 AM and stated that after breakfast or before lunch she is transferred to her wheelchair and stays there until 3:00 PM. Review of the facility policy for Assessment of Pressure Sore-Potential-Preventive Plan documents: check all bony prominence's and other pressure areas, turn and positioning every two to four hours if unable to turn self, use turning and positioning clock as a guide for positioning. 415.11 (c)(1)

Based on observation, record review and staff interviews, the facility did not ensure that a resident received the treatment and services to promote healing of existing pressure ulcers and to prevent the development of new pressure sores. Specifically, the intervention of turning and positioning was not identified or implemented in a timely manner for a resident identified at risk for pressure ulcer development. This was evident for 1 of 3 residents reviewed for pressure Ulcers. (Resident # 142) The finding is: Resident # 142 a [AGE] years old female admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Quarterly MDS 3.0 assessment dated [DATE] documented: intact cognition, total assistance of one person for activities of daily living, range of motion limitation on one side of the upper and lower extremities, always incontinent of bowel and bladder, at risk for pressure ulcers, no healed or unhealed pressure ulcers and pressure relieving device for chair. The Quarterly MDS 3.0 assessment dated [DATE] documented: intact cognition, total dependence for activities of daily living, range of motion limitation on both sides of the upper and lower extremities, always incontinent of bowel and bladder and at risk for developing a pressure ulcer. The MDS further documented the two stage 3 pressure ulcers measuring .8 x .8 x .2 cm (centimeters) and slough- the most severe tissue that was not present on the prior assessment. No healed pressure ulcers present. The skin and ulcer treatment included turning and positioning. On 2/19/2016 at 10:10 AM, the resident was observed in bed during provision of care by the CNA ( Certified Nursing Assistant ). During the observation, the resident stated My doctor wants me to stay on my sides most of the time and not on my back. Sometimes nobody comes to do that especially in the afternoon and night. The CNA replied You are in your wheelchair most of the day. At 10:15 AM the SA (State Agency) observed wound care being performed by the nurse. After positioning the resident on her left lateral side and exposing the site, the old dressing was removed. There was minimal drainage. The wound bed was observed with tissue granulation, redness and no odor. The Comprehensive Care Plan (CCP) dated 7/2015 and revised 12/08/2015 identified the potential for skin breakdown with the following interventions: skin check every shift, provide incontinent care every shift as needed and apply moisture barrier cream after incontinent care, turn and position every two hours. Prior to 12/8/15, turning and positioning was not an identified intervention on the comprehensive care plan. The nursing progress note dated 12/08/2015 documented: Resident is alert and verbally responsive and able to make needs known. Noted with small reddened area mid buttock skin intact NAAR (Nurse Aide Accountability Record) updated to turn and position resident & (and) prn (as needed) to prevent pressure. Apply moisture barrier (after) incontinent care to prevent skin breakdown. The nursing progress note dated 12/13/2015 at 6:00 am documented: Resident noted with right sacral skin tear. Log in MD communication book. The nursing progress note dated 12/13/2015 at 12:25 PM documented: Resident noted this am with small skin break measuring 1.4 x 0.9 to right upper buttock.(name of Doctor) called and made aware. T.O (telephone order) given to writer for - cleanse skin break to right upper buttock (with) normal saline, pat dry, apply zinc oxide and cover with dry protective dressing daily and prn. Staff will continue with turning and positioning. Physician's order dated 12/13/2015 documented: Cleanse right upper buttocks with Normal Saline, pat dry, apply zinc oxide and cover with Dry Protective Dsg (Dressing) Daily & Prn till healed. Dx: Skin break. The Weekly Pressure Ulcer and Wound Record dated 12/24/15 documented: Right buttock pressure ulcer-stage 3 measuring 3.3 x 1.6 x 0.3 cm. Preventative measures- Turn and Position and air mattress. The nursing progress note dated 12/17/2015 at 12:40 PM documented: Seen by wound care team today. Noted with stage 2 measuring 1.2 x 0.2 cm (pressure ulcer) to left buttock within close proximity to opening to right buttock. The Weekly Pressure Ulcer and Wound Record dated 12/24/15 documented: Left buttock pressure ulcer-stage 3 measuring 1.6 x 1.3 x 0.3 cm. Preventative measures- Turn and Position and air mattress. Physician's order dated 1/15/16 documented: D/C (Discontinue) Tx (treatment) (R) (Right) (L) (left) buttocks-Clean (R) (L) Buttocks Daily (with) N/S (Normal Saline) -apply Dermagan cover (with) Dry Dressing-Stage III (3). The Braden Scale For Predicting Pressure Sore Risk dated 7/12/2015 through 1/5/2016 identified the resident at moderate risk for pressure ulcer with scores of 14. The Braden Scale intervention Guide further documented- frequent Turning with a planned schedule for moderate risk (13-14). The NAAR for October and November 2015 documented: Position Every 2 Hours-Yes or No. For the months of October and November 2015, the boxes for positioning every 2 hours was left blank. There was no documented evidence that the resident was turned every two hours for the months of October and November 2015. The NAAR (Nursing Assignment & Accountability Record) for December 2015 and January 2016 documented: Position Every 2 Hours-Yes and dated 12/8/15. The Registered Nurse (RN) Charge Nurse was interviewed on 2/19/2016 at 11:20 AM and stated that the redness was observed and reported on 12/08/2015 and the physician was immediately contacted and orders obtained. A follow up interview was conducted on 2/22/2016 at 11:15 AM with the RN. The RN stated that the resident's Braden scale score was 14 indicating moderate risk for pressure ulcer development. The facility protocol includes turning and positioning every two hours. Filling out the resident care records is divided up between the day and night shifts. When I was informed on 12/08/2015 about the resident's skin redness, I immediately updated the care plan and noticed that the turning and positioning section (of the NAAR) had not been checked prior to December 2015. We should have been turning and positioning the resident because that is part of the facility skin care protocol. The CNA assigned to the resident was interviewed on 2/22/2016 at 11:30 AM and stated that after breakfast or before lunch she is transferred to her wheelchair and stays there until 3:00 PM. On 2/22/2016 1:55 PM the DNS (Director of Nursing) was interviewed and stated that when a resident is admitted , the RN does a complete body check and uses the Braden scale assessment tool to determine pressure ulcer risk. Based on result of the assessment, interventions are put into place. The interventions should include a turning and positioning schedule, toileting, and an out of bed schedule. Ongoing assessment and monitoring are also important aspects of care for pressure ulcers to ensure that the wounds don't deteriorate. The care must be documented on the accountability records so that the CNA's know what kind of interventions are necessary for each resident. The CNA's are responsible for reporting any resident skin changes to the nurses immediately. Review of the facility policy for Assessment of Pressure Sore-Potential-Preventive Plan documents: check all bony prominence's and other pressure areas, turn and positioning every two to four hours if unable to turn self, use turning and positioning clock as a guide for positioning. 415.12(c)(1) (2)

Based on observation, record review and staff interviews, the facility did not ensure that: 1) drugs were stored at the proper temperature and that 2) narcotics were stored in separately locked permanently affixed compartments. This was evident on 2 of 8 nursing units during observations conducted for Medication Storage. (Units 4A and 4B) The findings are: Observations were conducted on 2/17/16 of medications stored on the 4th floor A & B unit medication rooms. The following was observed: 1)Controlled Substances were not stored in separately locked permanently affixed compartments. Both of the narcotic cabinet doors were opened with the same key. During the observation, the following controlled substances were stored inside the narcotic cabinet: Fentanyl patch 50 mcg (microgram) - 4 patches, Morphine sulfate 30 mg (milligram) ER tablet - 7 tablets, Tramadol 50 mg tablets - 88 tablets, Fentanyl patch 25 mcg - 6 patches, Percocet 5/325 mg tablets - 33 tablets, Oxycodone 5 mg tablets - 56 tablets and Oxycodone 10 mg tablets - 85 tablets. (Unit 4A) On unit 4B both of the narcotic cabinet doors were opened with the same key. During the observation, the following controlled substances were stored inside the narcotic cabinet: Tylenol Codeine #3 - 300/30 mg tablet - 96 tablets, Percocet 10/325 mg tablet - 33 tablets, Percocet 5/325 mg tablet - 28 tablets, Lyrica 25 mg capsule - 4 capsules. (Unit 4B) 2) Two boxes of Biscadyl suppositories containing a total of 16 suppositories were observed stored at 41 degrees F. The pre-printed manufacturer labeling on the boxes of suppositories documented a storage temperature between 68 to 77 degrees F (Fahrenheit). (Unit 4B) An interview was conducted with the 4A LPN (Licensed Practical Nurse) on 2/17/2016 at 9:22 AM. The LPN stated one key should open up the first lock on the outer door. The second key should open the lock on the inner door. I did not realize it was like this. The LPN further stated The refrigerator temperature is 41 degrees F. The box says it is supposed to be stored between 68 - 77 degrees F. I go into this refrigerator everyday. I just did not notice the fine print on the label. The 4B unit RN (Registered Nurse) was interviewed on 2/17/2016 at 9:49 AM. The RN stated that when she tried the key to the inner and outer doors, the one key opened both locks. The RN further stated that she was taught that you use a separate key to open the locks on each door and was not aware that one key could open both doors. The ADNS (Assistant Director of Nurses) was interviewed on 2/17/2016 at 10:03 AM. The ADNS stated that the narcotics are required to be stored behind two locked doors. There should be a separate key opening the lock on each door. The nurses access the narcotic cabinet on all three shifts and should have identified and reported the problem. The manufacturer labeled the box of suppositories to be stored at 68 to 77 degrees F. The refrigerator temperature of 41 degrees is too cold. An interview was conducted with the Pharmacist on 2/22/2016 at 9:40 AM. The Pharmacist stated that controlled substances should be stored in a double locked cabinet. The narcotic cabinet should have two doors and one lock on each door, with separate keys for each lock. The inspections of the narcotic boxes are the responsibility of the Pharmacists and are conducted monthly. The Pharmacist further stated that the temperature range for the medication refrigerators is 36 to 46 degrees F and added the boxes of Biscodyl suppositories should not have been stored in the refrigerator. When the stock medications are delivered to the units, the unit nurses put the delivered medications away in the cabinets or into the refrigerator. 415.18(d)

Based on record review and staff interviews, the facility did not ensure that clinical records were readily accessible, systematically organized and accurately documented. Specifically: 1) an order for [REDACTED].#110); 2) The daily and weekly weight records were not readily accessible or systematically organized (Resident #29). This was evident for 1 of 5 residents reviewed for Unnecessary Medications (Resident #110) and 1 of 5 residents reviewed for Nutrition. (Resident #29) The finding is: 1) Resident #110 is a [AGE] year old with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Review of Medication Administration Records (MAR) dated 1/26/16 documented transcription of both orders. The MAR further documented nurse initials for the [MEDICATION NAME] order and for the duplicate [MEDICATION NAME] ([MEDICATION NAME]) order that was preprinted onto the MAR. On 2/19/16 at 2:33 PM and on 2/22/16 at 10:00 AM the unit Licensed Practical Nurse (LPN) #1 was interviewed. The LPN stated that the pharmacy sends up a a unit dose of [MEDICATION NAME] to be administered daily. The LPN further stated that when there is a duplicate entry, the transcription should have been verified with the physician's orders [REDACTED]. On 2/19/16 at 3:21 PM, LPN #2 was interviewed. The LPN stated that she reads the medication record against the dispensed medication three times before administering the medication. The LPN further stated that sometimes there is a duplicate pharmacy transcription for the same medication on the MAR and added that she had overlooked the duplication prior to signing for the medication. On 2/22/16 at 9:43 AM, the Assistant Director of Nursing (ADND)/ Staff Development Coordinator was interviewed. The ADN stated that she is responsible for providing training for medication administration annually which also includes documentation. She further stated that nurse competencies are also conducted to ensure the nurses are administering and documenting medications properly. The lesson plan for Medication Administration: Safety Tips inservice (dated 11/12) was reviewed. .Document (timely and accurately) all medications administered . 2) Resident # 29 is an [AGE] year old admitted to the facility with [DIAGNOSES REDACTED]. The Annual MDS 3.0 assessment dated [DATE] documented: moderate cognitive impairment, extensive assistance for eating, total assistance for activities of daily living, therapeutic diet and diuretic medications received during the last seven days. The Comprehensive Care Plan (CCP) for risk for dehydration-receiving [MEDICATION NAME] (diuretic) dated 12/18/15 documented: Intervention: Monitor weight. Physician orders [REDACTED]. The CCP for weight monitoring did not accurately reflect the residents weight monitoring status. When the SA (State Agency) requested (on 2/19/16 at 11:30 am and at 4:00 PM) the residents weekly weight monitoring records, the unit nurses and nursing supervisor were unable to readily locate the consistent monitoring of the residents weight and repeatedly referred to the Unit Clerk as the staff person who knows where they are. An observation of the record storage area was conducted on 2/19/16 at 4:45 PM. The resident's medical record was stored in the clean utility room with other resident's filed documents. The weight records (of Resident #29) were rolled together with other resident documents, held together with a rubber band and stored in an unmarked box. Interviews were conducted with the Registered Dietician/Supervisor on 2/19/16 at 4:30 PM and on 2/22/16 at 9:45 AM. The Dietician stated that there is a daily wt (weight) sheet, a weekly weight sheet and a monthly sheet. The weekly weights can also be documented on the monthly weight sheets. I think the issue is the actual documentation on the multiple weight sheets and access to the multiple documents. There is a problem with consistent transcription of the weights throughout the facility. It can be very confusing for the staff to follow and adhere to documenting the weights on multiple pieces of paper. This has happened fairly regularly. We have monthly nutrition committee meetings and this (inconsistent documentation and access) has been discussed at the meetings. No written plan or change in policy has been developed. The filing system is also a problem. There is a filing system for depleted records but the system for the daily and monthly worksheets is inconsistent on each unit. The records are not well maintained in an organized fashion. An interview was conducted on 2/22/16 at 11:00 am with the RNS (Registered Nurse Supervisor). The RNS stated the filing system has been left for the unit clerks to develop on their own. We have to take responsibility for the delayed access to the medical records. The weight books were on the unit, I should have known where the documents were documented and stored. There are two weight books instead of one. I spot check the documentation of the wt's- but not consistently. The unit clerks are filing the worksheets in multiple binders that the nurses are not able to readily locate. The nurses and Dieticians are ultimately responsible for ensuring the complete and accurate transcription of the wt's into the medical record. Having two binders on the units for filing the wt's has made access chaotic at times. The facility Policy and procedure for Management of Information- Purging/Thinning of Active Charts dated 9/15 documented: Store thin charts in alphabetical order in a locked cabinet on the appropriate nursing unit to ensure the charts are accessible 24 hours a day .Arrangement of the clinical record- All forms must be filed in chronological order within each each section with the earliest date first 415.22(a)(1-4)

Based on record review and staff interviews, the facility did not ensure that the Quality Assessment and Assurance Committee identified and developed appropriate action plans to address discrepancies related to weight monitoring. Specifically, the QA&A committee did not identify the process, discrepancies and inconsistencies related to weight monitoring so that appropriate plans of action could be developed. The finding is: Refer to F514. On 02/22/2016 at 1:40 PM the facility Administrator was interviewed and stated. Yes. We have a committee and meet monthly. We have discussed weights in the past and the topic of weights is onging. As for clinical records,we have a Patient Care person who thins the records upstairs. We keep records on the units for 18 months. We have a medical records department that is located in a nearby building. An interview was conducted with the Registered Dietary /Supervisor on 2/22/16 at 9:45 AM. The Dietician stated that there is a daily wt (weight) sheet, a weekly weight sheet and a monthly sheet. The weekly weights can also be documented on the monthly weight sheets. I think the issue is the actual documentation on the multiple weight sheets. There is a problem in consistent transcription of the weights throughout the facility. It can be very confusing for the staff to follow and adhere to documenting the weights on multiple pieces of paper. This has happened fairly regularly. The nurses, doctor, Medical Director, Director of Nursing, and Administrator have monthly nutrition committee meetings. We have had the meetings every 4 to 6 months. This has been discussed at the meetings. A written plan or change in policy has not occurred. I'm on the QA committee but what I have discussed are individual residents nutrition concerns as opposed to system concerns related to identified inconsistencies with the weight monitoring on multiple units. One person cannot take ownership for the entire system. The filing system is a problem as well. There is a filing system for depleted records but the system for the daily and monthly worksheets is a problem. They are not well maintained in an organized fashion. Discussion of the entire weight monitoring process should have been discussed as a potential QA concern. 415.27(a-c)

Based on record review and staff interviews the facility did not ensure that the resident's family representative was invited to the resident's care planning meeting. Specifically, the resident's family representative was not invited to attend the comprehensive care plan meeting that was held on 1/23/15. This was evident for 1 of 3 Family Interviews conducted for review of Participation in Care Plan. (Resident # 323). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #323 is an [AGE] years old with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented: severe cognitive impairment. On 1/23/15 at 2:00 pm, an annual care plan meeting was held and there was no documented evidence that the resident's family representative was invited to attend or had attended. On 1/29/15 at 11:00 am a family interview was conducted. The family representative stated that she was not informed about the meeting or invited to attend the care-planning meeting. The representative further stated that if she is actively involved with her mother's care since she has been at the facility and would have attended had she been informed. On 1/30/15 at 10:00 am, Social Worker was interviewed and stated that when the annual meeting is to be held a letter is sent to the family representative 2-3 weeks prior and a follow-up phone call is made 2-3 days prior to the meeting. He further stated that he could not recall whether he had received a call from the family representative or whether a follow-up phone call had been placed as this is usually handled by the coordinator. On 1/30/15 at 10:15 am, Coordinating Manager for the Social Services Department was interviewed and stated that a letter was sent to the family at the beginning of January. She further stated that she is the person who makes the follow-up call to the family representative, she did not call this family member to confirm participation, and did not know why this call had not been made. 1/30/15 at 10:30 am, the Director of Social Work was interviewed and stated that letters are usually sent out by the Social Worker two weeks before the meeting is scheduled. She further stated that if no response is received from the family representative, the Coordinating Manager will do a follow-up call. In addition she stated that it is the responsibility of herself or the social worker to ensure that this was done however no follow-through had been done in this case. 415.11(c) (2) (i-iii)

Based on record review and staff interview, the facility did not ensure that a Medicare-covered resident received information about their right to an expedited appeal of service termination by the Quality Improvement Organization (QIO). This was evident for 1 of 3 resident reviewed for Liability Notices & Beneficiary Appeal Rights (Resident #393). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #393 was a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident received Medicare. The MDS further documented the resident had intact cognition and received Physical Therapy and Occupational Therapy services as of 10/10/13. A Nursing Note dated 10/24/13 documented the resident was discharged home to the community. There was no documented evidence in the medical record that the resident was provided with the Notice of Medicare Provider Non-coverage. On 1/24/14 at 2:22 pm, the Registered Nurse responsible for providing the information regarding the notices of Non-coverage, was interviewed and stated that residents are informed that they can appeal discharge decisions verbally during discharge planning, but the facility does not provide the notices in writing. He further stated that the notices will be provided to residents remaining in the facility. 415.3(g)(2)(i)

Based on record review and interview, the facility did not ensure that a resident's grievance about missing clothing was resolved. This was evident for 1 of 1 resident reviewed for Personal Property (Resident # 241). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #241 is a [AGE] year-old, readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had intact cognition (Brief Interview of Mental Status Score 15 out of 15). On 01/22/14 at 4:05 PM and 1/24/14 at 12:25 PM, the resident was interviewed and stated that when she went to the hospital, all of her clothing was packed in boxes for storage by the facility staff. The resident further stated that when she returned, they could not find a box of her clothing. She stated that she spoke to the Social Worker and a Housekeeper about it, but the box had not been located. The Resident stated she was not able to remember how many boxes were returned to her upon re-admission. She stated that several pieces of her church clothes were missing but was unable to remember the color or design of the clothing. The Personal Property List (PPL) in the medical record was blank. The Housekeeping Log entry dated 12/3/13 documented 9 boxes were sent to storage for the resident. The entry had a line through it. There was no entry documenting how many boxes were returned to the resident on the log. There was no documented evidence in the grievance log that the resident's grievance was documented so that it could be addressed. There was no documented evidence in the medical record that the resident's grievance was addressed. On 1/24/14 at 11:18 AM, the Registered Nurse (RN) Charge Nurse was interviewed and stated that when the resident went to the hospital, her clothing was packed in boxes and stored in another building. She further stated that after the resident told her that one box of clothing was missing, she informed the Social Worker and Housekeeping. She stated that Housekeeping searched for the box but could not find it. The RN also stated that the PPL should be completed upon admission and updated with new clothing and items as needed. On 1/24/14 at 11:24 AM, the Director of Social Work was interviewed and stated that the resident did not inform he of the missing box. She further stated that the RN told another Social Worker who is no longer employed at the facility. The Director stated that all complaints should be documented in the complaint log and followed-up within 5 days. She stated that no grievance form was filed for the resident's complaint. The Director also stated that after a search is done for the missing items, anything listed on the PPL is replaced. On 1/24/14 at 11:34 AM, the Senior Housekeeper was interviewed and stated that when the resident went to the hospital, 9 boxes were put into storage on 12/3/13. He further stated that all of the boxes were returned on 12/4/13. He also stated that he was informed of the missing box last week, and a search was completed. He stated that the box was not found. 415.3(c)(1)(ii)