Every finding on record at Eden Rehabilitation Nursing Center

Based on observation, interview, and record review conducted during the Standard survey completed on 01/09/2025, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse and do not result in serious bodily injury, to the administrator of the facility for one (1) (Resident #12) of one (1) resident reviewed. Specifically, Resident #12 was found to have an injury of unknown origin that was not reported to the administrator. The finding is:The policy titled Abuse - Investigation, Protection and Reporting, dated 10/24/2022 documented an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source) would be reported immediately, but not later than: A. two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or B. twenty-four (24) hours if the violation did not involve abuse and had not resulted in serious bodily injury. Any injury that was explained and appeared to be a result of abuse must be reported. An injury should be classified as an injury of unknown source when ALL the following criteria were met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury was suspicious due to: the extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time, or the incident of injuries over time.The undated policy titled Weekly Skin Evaluation documented weekly skin evaluations were completed on each resident in the electronic medical record (point click care). Best practice was to do skin check on a shower day. The licensed nursed would examine the skin of each resident weekly on specified day, paying close attention to common areas of pressure. Each abnormality, e.g., skin tear, rash, excoriation, abrasion, bruise, and surgical wound would be checked on list. Color such as red and purple were late signs. If an abnormality was found then a weekly wound form was initiated based on facility would round protocol and the physician, Director of Nursing, and family were notified.Resident #12 had diagnoses including dementia without behavioral disturbances, depression, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (a resident assessment tool) dated 11/07/2025 documented Resident #12 was moderately cognitively impaired, was usually understood, and understands.The Kardex (a guide used by staff providing care) dated 01/04/2025 documented Resident #12 received their shower on Tuesday evening.The comprehensive care plan, dated 01/28/2025 documented Resident #12 was dependent on two (2) staff members for upper body dressing and transferring, requiring a mechanical lift, and a substantial/maximal assist of one (1) person for personal hygiene. Resident #12 had impaired skin integrity with interventions to evaluate skin integrity, provide skin care per facility guidelines, and for Resident #12 to wear long sleeve protectors when out of bed as tolerated.During an observation and interview on 01/05/2026 at 10:00 AM, Resident #12 was seated in their wheelchair sleeping, their sleeves were slightly pulled up and a large purple area was observed on their left forearm. When Resident #12 woke up, they stated they did not know where the purple area came from.During an observation on 01/06/2026 at 8:40 AM, Resident #12 was sitting up in their bed eating breakfast, the large purple area remained on their left forearm.Review of Resident #12s accident and incident reports from 08/01/2025 to 01/06/2026 revealed no reported incidents or findings regarding their left forearm.Review of nursing progress notes dated 12/31/2025 to 01/06/2026 revealed no documented evidence that Resident #12s injury of unknown origin was reported to administration.The Daily Unit Management Sheet dated 01/06/2026 2:00 PM to 10:00 PM shift, documented Resident #12 received a shower from Certified Nurse Aide #1 and Licensed Practical Nurse #1 was their assigned nurse.Review of Weekly Skin Check form dated 01/06/2026 at 7:35 PM, documented Resident #6s skin was intact with no new findings.Review of the nursing progress note dated 01/07/2026 at 9:45 AM, revealed the Regional Quality Improvement Nurse documented there was an area of discoloration to Resident #12s left forearm, purple in color, measuring 6.5 centimeters by 6.4 centimeters, they denied having any pain.Review of facility undated Internal Investigation Report documented on the morning of January 7th, 2026; a New York State Department of Health (DOH) surveyor notified a facility employee that they observed a purple discoloration on Resident #12s wrist. The surveyor further stated the discoloration had been observed previously on Monday January 5th, 2026. A weekly skin assessment completed on January 6th, 2026, documented no skin impairment. The nurse who completed the assessment was interviewed and stated they performed a thorough head to toe assessment on 01/06/2026 and the area was likely obscured by the resident's wrist band.During an interview on 01/07/2026 at 9:18 AM, Certified Nurse Aide #2 stated they were Resident #12 assigned nurse's aide, but Resident #12 had been dressed already when they came in for their shift that morning, they had not provided any hands-on care including dressing yet that morning.During an observation and interview on 01/07/2026 at 9:19 AM, Licensed Practical Nurse #1 observed Resident #12 and stated the resident had a purple area on their left forearm. Licensed Practical Nurse #1 stated they were not aware of Resident #12 having any new injuries, and if they were they would have reported it to administration so the area could be monitored, and an investigation could be started.During an observation and interview on 01/07/2026 at 9:25 AM, the Assistant Director of Nursing stated they were not aware of any new skin issues with Resident #12. They reviewed Resident #12s electronic medical record and stated there was only a new order for a fungal rash from 01/06/2026. The Assistant Director of Nursing observed Resident #12s left arm and stated they would have expected whoever found the area to have reported it, and any staff caring for Resident #12 could have.During an interview on 01/08/2026 at 1:07 PM, Licensed Practical Nurse #1 stated Resident #12 had received a shower from Certified Nurse Aide #1 on the evening of 01/06/2026, when they were called in to do a skin check they did not see the purple area on Resident #12s left forearm, but they should have.During a telephone interview on 01/08/2026 at 12:13 PM, Certified Nurse Aide #3, who was Resident #12s assigned aide on the over night shift (10:00 PM to 6:00 AM) on 01/05/2026, stated they do not turn the lights on when they complete care in that room because one of the roommates complains about the light being turned on at night, so they did not see any purple area on Resident #12.During a telephone interview on 01/08/2025 at 12:53 PM, Certified Nurse Aide #1 stated they assisted with giving Resident #12 a shower on 01/06/2026 on the evening shift (2:00 PM to 10:00 PM) and did not see any purple areas on their left forearm. They stated they did observe the area on 01/07/2026 when they worked next, and it was quite large. Certified Nurse Aide #1 stated if they saw a new skin issue with a resident, they would report it right away to figure out how it occurred. They would report any discoloration of the skin, whether it was a suspected bruise or suspected purpura.During an interview on 01/09/2026 at 10:01 AM, in the presence of the Regional Quality Improvement Nurse, the Director of Nursing stated they expected any staff caring for a resident to report any new skin issues, including a bruise, to their superior, so that it could be reported to administration. They would have expected staff to have been more observant when caring for Resident #12 and have noticed the purple area on their left forearm and reported it. During an interview on 01/09/2026 at 11:25 AM, the Administrator stated they monitor all reportable incidents in the facility, and discuss the findings in their Quality Assurance meetings, there had not been any issues identified with reporting in the facility.During a telephone interview on 01/09/2026 at 1:40 PM, the Medical Director stated the facility was supposed to report any injury of unknown origin, including a bruise, to administration, it was the facility policy. They would have expected the nursing staff providing hands on care to Resident #12 to have noticed the purple area and reported it so that a decision could be made about the next steps.10 NYCRR 415.4(b)(4)

Based on interview and record review the facility did not ensure that services being provided met professional standards of quality for one (1) (Resident #6) of one (1) resident reviewed. Specifically, an order for an antiviral medication was not continued upon readmission to the facility for an influenza (viral infection) positive resident. Additionally, there was a physician order placed to test/swab residents for influenza on [DATE], the testing supplies were not available until [DATE].The findings are: The policy titled Admission/readmission procedure, dated [DATE], documented the purpose of the policy was to establish a clear procedure for the admission and re-admission of residents to ensure compliance with federal and state regulations, including Centers for Medicare and Medicaid (CMS) Requirements of Participation as outlined in Appendix PP, and to promote quality and continuity for each resident. Upon residents' admission the charge nurse would familiarize themselves with the records accompanying the resident, review hospital medical record, discharge medications, and discharge summary. The Nursing Supervisor would review orders with the provider and enter/review medication orders. The policy titled Reconciliation of Medications on Admission/Re-Admission, dated [DATE], documented a complete medication reconciliation for all residents upon admission and readmission was completed to ensure accurate, safe, and continuous medication management. All medications, including prescription, over the counter, and supplements, shall be reviewed for accuracy, appropriateness, and potential interactions, and discrepancies shall be resolved and documented to support resident safety and continuity of care. If there was a discrepancy or conflict in medications, dose, route, or frequency, determine the appropriate action to resolve the discrepancy, such as contacting the physician from the referring facility or admitting physician. Resident #6 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (loss of use of left extremities following stroke), anxiety, and dementia without behavioral disturbances. The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #6 was moderately cognitively impaired, understands, and was usually understood by others. The comprehensive care plan dated [DATE] (current) documented that Resident #6 on [DATE] had an altered respiratory status related to a recent hospitalization for Influenza A and was to have oxygen on via nasal cannula at two (2) liters per minute as needed. Review of Order Recap Report dated with a printout date of [DATE] revealed an order for Resident #6 initiated on [DATE] to be swabbed for the flu. The order was discontinued on [DATE] because Resident #26 was transferred to the hospital. Review of nursing progress notes dated [DATE] to [DATE] revealed the following: On [DATE] at 4:43 PM Registered Nurse #1 documented Nurse Practitioner #1 saw Resident #6 and ordered them to be swabbed for influenza (flu). On [DATE] at 14:50 PM, Assistant Director of Nursing documented Resident #6 continued with cold symptoms, had not eaten anything that day, and remained in bed. Family was made aware of resident's sickness. Resident was afebrile (no fever) but very lethargic (lack of energy, drowsiness, reduced mental alertness). On [DATE] at 2:04 PM, Assistant Director of Nursing documented Resident #6 continued with cold symptoms and not feeling well, had not eaten that day. On [DATE] at 2:57 PM, the Assistant Director of Nursing documented the flu swabs were received from lab, they spoke with Nurse Practitioner #1 and informed them the flu swabs were received. Assistant Director of Nursing documented Nurse Practitioner #1 stated to not swab at that time and treat upper respiratory symptoms conservatively. Review of provider progress note dated [DATE], Nurse Practitioner #1 documented Resident #6 recently had an upper respiratory infection, suspected to be influenza due to exposure in facility. Was not tested due to no respiratory cultures available. Patient was managing symptoms with supportive care, has had decline today. Nursing reported not eating or drinking well, difficulty taking medications, appeared to have decreased mentation, pupils pinpoint, on supplemental oxygen. Recommended initiating antibiotics and obtaining chest x-ray to rule out pneumonia. Family requests Resident #6 be sent to the emergency room for further evaluation. Review of the Hospital History and Physical dated [DATE] revealed Resident #6's medications to include but not limited to the following: [COMPLETED]: oseltamivir (Tamiflu) capsule 75 milligram once on [DATE] at 8:41 PM. **FOLLOWED BY** [START ON [DATE]] oseltamivir (Tamiflu-antiviral medication used to treat and prevent the flu) capsule 30 milligrams, oral twice a day (BID). Review of the hospital Discharge summary dated [DATE] documented Resident #6 was admitted to the hospital with shortness of breath and productive cough, was found to be positive for Influenza A. The discharge summary did document Resident #6 completed oseltamivir (Tamiflu) therapy in the hospital course. Further down the discharge summary documented: Issues requiring follow-up included to follow up with primary care and continue Tamiflu. The After Visit Summary, with a print date of [DATE] at 1:46 PM documented Resident #6's medications had changed. The medication list revealed: START taking Tamiflu, guaifenesin (expectorant medication used to relieve chest congestion and loosens mucous in the airways), and Benzonate (cough suppressant). In the medications listed on the after-visit summary, oseltamivir (Tamiflu) was listed to start one (1) 75 milligram capsule by mouth in the morning and one (1) 75 milligram capsule before bedtime. Last time was given: 30 milligrams on [DATE] at 8:41 AM. Medications to be picked up at the pharmacy were listed at the bottom, Tamiflu included. Review of nursing progress notes dated [DATE] to [DATE] revealed Resident #6 had an occasional nonproductive cough and complaints of not feeling well. Review of provider progress note dated [DATE], Nurse Practitioner #1 documented Resident #6 was readmitted from the hospital on [DATE] after hospitalization due to Influenza A and dehydration. Resident #6 was able to be weaned off oxygen, received intravenous fluids, and was started on Tamiflu. Resident #6 seen that day and appeared stable, complains of continued cough, sore throat and body aches. Reviewed hospital course and discharge summary with recommendations. Completed course of Tamiflu. Supportive care with Tylenol for fevers and aches. During a telephone interview on [DATE] at 1:58 PM, Resident #6's family stated Resident #6 had gone to the hospital on [DATE], was diagnosed with Influenza, and was started on the standard course of antivirals while there. During an observation and interview on [DATE] at 8:23 AM, Resident #6 was sitting up in their bed eating breakfast and had a wet occasional cough. Resident #6 stated they were feeling crummy. During an interview on [DATE] at 2:56 PM, Registered Nurse #2 Infection Preventionist stated they reviewed Resident #6's After Visit Summary upon re-admission to the facility on [DATE], which did document they were supposed to continue a course of Tamiflu and thought they had been continued on it upon return from the hospital. Registered Nurse #2 reviewed Resident #6's Medication Administration Record and stated they did not see an order for the Tamiflu, active or discontinued, and there should have been one. They stated whoever the admitting nurse was should have called the facility provider to clarify the discrepancies or reached out to the hospital provider. Registered Nurse #2 Infection Preventionist stated they thought that the Assistant Director of Nursing completed the admission orders for Resident #6, but being the Infection Preventionist, they should have caught the missing order. Additionally, Registered Nurse #2 Infection Preventionist stated the order for Resident #6 to be swabbed for the flu was placed on [DATE], but the facility did not have proper supplies in the building, as they were expired. They stated Nurse Practitioner #1 was made aware they did not have swabs available, and on [DATE] when they came from the lab, Nurse Practitioner #1 was again made aware. Nurse Practitioner #1 said to not swab Resident #6 and just treat for an upper respiratory infection. On [DATE] antibiotics were recommended by Nurse Practitioner #1 due to Resident #6's continuing symptoms, but the family requested Resident #6 be sent out to the hospital. During an interview on [DATE] at 9:30 AM, Assistant Director of Nursing stated when a readmission came into the facility, the admitting nurse would review all their paperwork and review the orders with whatever provider was on call. Assistant Director of Nursing stated they did not enter Resident #6's order on [DATE] upon readmission, Registered Nurse #2 Infection Preventionist did. Additionally, Assistant Director of Nursing reviewed Resident #6's discharge summary and after visit summary with this writer and stated, I'm going to assume the hospital had Resident #6 on Tamiflu 75 milligrams for one day then started them on 30 milligrams on [DATE] and wanted them to continue the course upon discharge. During a telephone interview on [DATE] at 12:58 PM, Pharmacy Consultant stated they review all documents available in a resident's electronic medical record upon admission/ readmission, review medications, look for discrepancies, and report any if found. Pharmacy Consultant stated they reviewed Resident #6's after visit summary, discharge summary and medication list on [DATE] upon readmission from the hospital and did not note any discrepancies. Pharmacy Consultant reviewed all medications listed on after visit summary with this writer and identified Tamiflu as being a medication listed for Resident #6 upon discharge from the hospital, reviewed the residents medications ordered upon admission to the facility and stated there was no record of Resident #6 being on Tamiflu in the facility, they do not know what their exact mindset was when they completed the review, but should have noticed the discrepancy and reported it. They stated they read Nurse Practitioner #1's note on [DATE] when they did their next review that day and determined based on what was documented in the note and the order not being in Resident #6's current physician orders that they had completed the course. During an interview on [DATE] at 1:29 PM, Nurse Practitioner #1 stated they reviewed all the paperwork sent with Resident #6 upon readmission to the facility when they did their review on [DATE]. The discharge summary documented Tamiflu had been completed in the hospital. The typical course for Tamiflu was three (3) to five (5) days, the blister pack was preset, so they assumed it was just a three-day course that was completed. Additionally, Nurse Practitioner #1 stated they were made aware on [DATE] after they ordered the flu swab for Resident #6 that it was not available and then was updated on [DATE] that they were not available, told nursing staff to treat symptoms as they arouse. During a follow up interview on [DATE] at 11:13 AM, Assistant Director of Nursing stated they worked on [DATE] when the flu swabs arrived at the facility, contacted Nurse Practitioner #1 who instructed to not swab Resident #6, and just treat conservatively based on their symptoms. Assistant Director of Nursing stated there should have been documentation that Nurse Practitioner #1 was made aware on [DATE] that the swabs were not available other than the 24-hour report because the 24-hour report was not a part of Resident #6's medical record. It was important to document pertinent things in the resident's electronic medical record so that there could be follow through with the issues. During a telephone interview on [DATE] at 10:47 AM, Medical Director stated they would have expected the admitting nurse to review all documents sent with Resident #6 upon readmission to the facility and follow the recommendations for Tamiflu. If there was a discrepancy, to follow up with whatever provider was on call that day. It was the facilities policy. During a follow up interview on [DATE] at 1:44 PM, Nurse Practitioner #1 reviewed Resident #6's discharge summary with this writer, reviewed where it was documented under issues requiring follow up: to continue Tamiflu and stated they would have expected the admitting nurse to clarify with the hospital the discrepancies between the documents sent with Resident #6 regarding the Tamiflu order. If they could not reach that hospital provider, then clarify with the provider on call in the facility. During a telephone interview on [DATE] at 10:29 PM, Registered Nurse #1 stated they received a verbal order from Nurse Practitioner #1 on [DATE] to swab Resident #6 for influenza, they let Nurse Practitioner #1 know right then that they did not think they had swabs available. They stated they should have documented that in Resident #6's electronic medical record. Registered Nurse #1 stated they placed an order with the lab via fax that on [DATE], but the swabs had still not arrived by [DATE]. They stated they made the Director of Nursing aware. During an interview on [DATE] at 10:01 AM, the Director of Nursing and Regional Quality Improvement Nurse stated whatever nurse admitted Resident #6 was responsible for ensuring that the documents and medications were reviewed and discussed with the on-call provider. The Director of Nursing reviewed Resident #6's discharge summary and stated the summary read for Resident #6 to complete Tamiflu. They would have expected the admitting nurse to have read all paperwork pertinent to the resident and clarified the orders with a provider. They stated it was important to ensure continuity of care and that all residents were getting the treatment they needed. Additionally, Director of Nursing stated swabs were delivered from their lab whenever requested, and it was a collaborative effort by the facility to ensure they had proper supplies. Director of Nursing stated ideally there should not be expired items in the supply room. Director of Nursing stated they were made aware on [DATE] by Registered Nurse #1 that flu swabs were ordered for Resident #6, but the swabs in the facility were expired, and an order was placed for new ones. On [DATE] when Registered Nurse #1 updated them that the swabs had not arrived, they placed a call to the lab to see why. They were told the swabs were on back order. They had not documented that anywhere. During a follow up telephone interview on [DATE] at 11:43 AM, the Medical Director stated they had not had a chance to review Resident #6's documents from the hospital yet, and did not recall speaking to anyone about Resident #6's medications. Medical Director stated they would have expected all recommendations to have been followed for Resident #6 from the hospital, and if any discrepancies, to have them clarified with themself or another provider in the facility. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with residents' wishes for one (Resident #8) of one resident reviewed for advanced directives. Specifically, the facility did not ensure Resident #8's advanced directives identifier was consistent with the resident's wishes and provider's orders. The finding is: The policy and procedure titled Advanced Directives effective [DATE] documented advanced directives will be respected in accordance with state law and facility policy. The facility will verify the presence of advance directives or the resident's wishes regarding CPR (cardio-pulmonary resuscitation - artificial ventilation and chest compressions). Additionally, the policy and procedure documented, each resident's advanced directives will be distinguished using at least two resuscitative identifiers; identifiers will be maintained up to date and consistent. The policy and procedure documented the facility will utilize the following resuscitative identifiers to ensure resident's wishes are honored: arm band (red: do not resuscitate, blue: full code (the provision of emergency measures including artificial ventilation and chest compression in the absence of breathing and/or heart rate), electronic medical record order, and MOLST (medical orders for live saving treatment) book. Resident #8 had diagnoses including fracture of the sixth cervical vertebra (a bone in the neck), dementia, and intracerebral hemorrhage (bleeding within the brain). The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #8 was severely cognitively impaired, was always understood, always understands and their advanced directives included do not resuscitate. The comprehensive care plan initiated on [DATE] documented Resident #8 wished for advanced directives: full code. Interventions included check for name/code status band placement every shift, full code band on wheelchair, MOLST (medical orders for live saving treatment) in place. Review of the Medication Review Report (physicians) dated [DATE] documented Resident #8 had an order initiated on [DATE] for a full code. Review of the facility's advanced directives binder located at the nurse's station on [DATE] revealed there was no MOLST (medical orders for live saving treatment) for Resident #8. Review of interdisciplinary Progress Notes dated [DATE] through [DATE] revealed no documentation regarding advanced directives and code status. Review of the physician discharge summary note dated [DATE] documented there were no advanced directives currently available. During an observation on [DATE] at 9:00 AM, Resident #8 was sitting in their wheelchair. The wheelchair had a red band attached to it, labeled with Resident #8's name. During an interview on [DATE] at 10:01 AM, Certified Nurse Aide #3 stated a red bracelet indicated do not resuscitate and a blue bracelet indicated to resuscitate a resident. Certified Nurse Aide #3 stated they would notify a nurse if they found a resident was unresponsive. During a telephone interview on [DATE] at 10:02 AM, Resident #8's family member stated Resident #8 wished to be a full code. Resident #8's family member stated Resident #8's MOLST (medical orders for live saving treatment) was at home, and they forgot to bring it to the facility. During an interview on [DATE] at 10:10 AM, Licensed Practical Nurse #2 stated a resident's code status could be found in the electronic medical record provider's order, a sheet in the narcotic count book, the MOLST (medical orders for live saving treatment) form located in the advanced directive binder, or the arm band either worn by the resident or located on their wheelchair or walker. Licensed Practical Nurse #2 stated blue bands indicated full code status requiring CPR (cardio-pulmonary resuscitation) and red bands indicated do not resuscitate code status. Licensed Practical Nurse #2 stated upon admission the code status band was placed on the resident or their wheelchair by the admitting nurse or sometimes the social worker. Licensed Practical Nurse #2 stated if they had found a resident unresponsive, they would have first looked at the code status band and if it was a blue band, they would have begun CPR (cardio-pulmonary resuscitation). Licensed Practical Nurse #2 stated they would then call for assistance of another staff member to check another location regarding the code status. Licensed Practical Nurse #2 stated if the code status band was red when they found an unresponsive resident, then they would not begin CPR (cardio-pulmonary resuscitation), but they would then double check in another place. During an observation and interview on [DATE] at 10:19 AM, Registered Nurse #1 stated there was a red code status band on Resident #8's wheelchair which indicated Resident #8 would not be resuscitated, if needed. Registered Nurse #1 checked the advance directives binder and stated there was no MOLST (medical orders for live saving treatment) in the advanced directive binder for Resident #8. Registered Nurse #1 checked the electronic medical record and stated Resident #8 had an order for full code which meant CPR (cardio-pulmonary resuscitation) should be performed. Registered Nurse #1 stated the code status band on the wheelchair should be blue to match the order because that was Resident #8's life saving measure that they wanted. Registered Nurse #1 stated if the resident was found unresponsive, staff would not have started CPR (cardio-pulmonary resuscitation) and they would have wasted time looking for the MOLST (medical orders for live saving treatment) and then the order. Registered Nurse #1 stated this could have delayed Resident #8 from receiving CPR (cardio-pulmonary resuscitation) if they needed it. During an interview on [DATE] at 1:45 PM, the Social Worker stated they ensured new admissions had a MOLST (medical orders for live saving treatment) in the advanced directive binder unless they wished to remain a full code. The Social Worker stated they or the Registered Nurse Resident Care Coordinator put the code status bands on the resident or their wheelchairs. The Social Worker stated they thought they could rely on a Registered Nurse to place the correct code status band on a resident, but they should have double checked Resident #8's code status band. The Social Worker stated it was important for the code status band to match the orders and the MOLST (medical orders for live saving treatment) because that was the resident's wishes. The Social Worker stated this type of mistake could result in a resident receiving CPR (cardio-pulmonary resuscitation) when they did not want it, or they might not receive CPR (cardio-pulmonary resuscitation) when they wanted it. During an interview on [DATE] at 3:04 PM, the Director of Nursing stated the Registered Nurse Resident Care Coordinator received residents advanced directives upon admission. The Director of Nursing stated both the Registered Nurse Resident Care Coordinator and the Social Worker checked code bands weekly and documented it on an audit sheet. The Director of Nursing stated it was expected that Resident #8's code status band matched Resident #8's order for full code. 10 NYCRR 400.21

Based on observation, interview, and record review conducted during the Standard survey completed on 5/8/24, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for one (Resident #3) of one resident reviewed for positioning. Specifically, a resident who required extensive assist of two for bed mobility was not provided with their planned positioning devices. The findings are: The policy and procedure titled Quality of Care dated 2/2024 documented that residents will have an individualized plan of care that is consistent with their needs. The plan will be implemented upon admission and revised when indicated. It will include interventions that are to be furnished to attain, maintain, or improve the residents highest practicable physical, mental, and psychosocial well-being. The policy and procedure titled Turning & Positioning dated 10/2022 documented ensure to place any adaptive devises after turning and positioning resident. Some devices may be ordered/care planned strictly based upon as needed of resident as they can tolerate. Some devices may be implemented strictly for resident preference/at their request. Additionally, the policy and procedure documented the following information should be noted in the resident's chart: If resident refuses device/positioning care and why. The policy and procedure titled Edema dated 1/13/2022 documented for chronic edema-the care plan may include interventions such as elevation of affected extremities. Nurse staff will monitor residents with edema regularly to observe the effectiveness of interventions. Additionally, the policy and procedure documented nursing staff will implement preventative measures to reduce the risk of edema development and exacerbation. Resident #3 was admitted with diagnoses of unspecified fracture of right lower leg, periprosthetic fracture around internal prosthetic left knee joint, and congestive heart failure. The Minimum Data Set, dated dated dated [DATE] documented Resident #3 understood/understands and had no cognitive impairments. The Comprehensive Care Plan dated 4/16/24 documented Resident #3 had self-care performance and physical mobility deficits. Interventions included the resident was non ambulatory, required extensive assist of two staff members for bed mobility, and a positioning wedge placed beneath their feet while in bed as tolerated (initiated on 4/22/24). The care plan documented the resident was on diuretic therapy (medication used to help remove excess fluid) therapy and had a history of pressure ulcers. The Kardex (guide used by staff to provide care) dated 4/16/24 documented under Equipment/Safety: Positioning wedge beneath feet while in bed as tolerated. Review of interdisciplinary progress notes dated 4/15/24 to 5/6/24 revealed there was no documented evidence Resident #3 refused and did not tolerate the use of the positioning wedges. Review of an interdisciplinary progress note dated 4/21/24 completed by RN RCC documented the resident had 2 (+) plus pitting edema to both thighs and 1 (+) plus pitting to their left ankle, the medical doctor was advised, and the resident's Bumex (diuretic) was increased. During an observation on 5/3/24 at 9:18 AM Resident #3 was lying in bed, their left leg had 2 (+) plus pitting edema and the bottom of their left foot was pressed firmly up against the footboard. Resident #3 stated it was extremely painful when their feet were pressed up against the foot board. During an observation and interview on 5/7/24 at 9:37 AM, Resident #3 was lying in bed, the head of bed was elevated approximately 50 degrees, the bottom of their left foot was pressed firmly up against the footboard. Resident #3's left lower extremity had pitting edema, and resident was unable to move their left leg independently. Resident #3 stated staff had not asked or placed the wedges under their feet while they were in bed. During an interview and continuous observation on 5/7/24 at 10:50 AM to 11:06 AM, Resident #3's stated they had not been out of bed, and it was noted their left foot was still pressed up against the footboard. Resident #3 was unable to reposition themself to move their left leg from against the footboard. As Resident #3 attempted to reposition themself they grimaced and stated their leg and foot were really bothering them. During an interview on 5/7/24 at 11:11 AM, Certified Nursing Assistant #1 stated they noticed Resident #3's feet were low (against foot board), so they asked Licensed Practical Nurse #1 to assist with boosting resident. They stated Resident #3 can't sit up at a 90-degree angle in bed because of their fractures and boot, so the resident slides down in bed. Certified Nursing Assistant #1 also stated Resident #3 could get sores on their heels or feet from pressing against the footboard of the bed. During an observation and interview on 5/7/24 at 11:45 AM, in the presence of Certified Nursing Assistant #1 there was no wedge positioned under the resident's lower legs and feet. Certified Nursing Assistant #1 was asked if the resident had any care plan interventions to aide in their positioning. Certified Nursing Assistant #1 stated they would have to look through the Kardex. At this time Certified Nursing Assistant #1 reviewed the Kardex and stated, Oh I see that they are supposed to have a wedge under their feet as tolerated. Resident #3 stated they would allow the wedge to be placed under their feet. Certified Nursing Assistant #1 placed wedge, allowing the residents heels to float. Resident #3 stated they were able to tolerate the wedge. During an interview on 5/7/24 at 1:41 PM, Registered Nurse #1 stated Resident #3 slides down in bed and they try to reposition them. Registered Nurse #1 stated Resident #3 had an intervention to place a positioning wedge under their feet to tolerance. Registered Nurse #1 stated it was important to keep their feet elevated off the footboard because it could cause pain or skin breakdown. During an interview on 5/7/24 at 1:55 PM, the Director of Physical Therapy stated Resident #3 had a lot of swelling and they were working on reducing it with nursing. The Director of Physical Therapy stated they were trying to make sure the resident had adequate pressure relief and Resident #3 had no skin issues at the time, but noticed there was one possibly starting with the left heel. The Director of Physical Therapy stated Resident #3's family had brought in wedges and the wedges were added to the resident's care plan to address pressure relief and the family's request. During an interview on 5/8/24 at 9:57 AM, the Director of Nursing stated if Resident #3 was in pain from their feet against the foot board they would expect staff to attempt to alleviate the pressure and that stated repositioning would help. 10 NYCRR 415.11 (c)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY00329363) completed on 12/13/23 the facility did not ensure the resident had the right to be free from abuse for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was witnessed to being pushed through a door by Certified Nurse Aide #3. The finding is: The policy and procedure titled, Abuse - Investigation, Protection, and Reporting dated 11/24/22 documented that each resident has the right to be free from verbal, sexual, physical/mental abuse, involuntary seclusion, exploitation in any form, or any misappropriation of their property in accordance with state and federal regulations. Each resident has the right to be free from the willful infliction of physical harm, pain, or mental anguish in the form of corporal punishment or involuntary seclusion and shall not be physically or chemically restrained for any other reason than that they are required to treat a resident's symptoms. 1. Resident #1 had diagnoses that include dementia, dysphagia (difficulty in swallowing with food and liquid) and anxiety. Review of the Minimum Data Set (a resident assessment tool) dated 11/22/23 documented Resident #1 was severely cognitively impaired; usually understood and understands others; and required supervision or touch assistance to walk 150 feet. Review of the Nursing Progress note dated 12/5/23 documented that an incident was witnessed by four employees of a Certified Nurse Aide being unkind or inappropriate towards Resident #1. Review of the Investigation Statement dated 12/5/23 written by Licensed Practical Nurse #1 revealed Certified Nurse Aide #3 had the resident in a bear hug and walked the resident towards the dining room entrance. Certified Nurse Aide #3 placed both hands on Resident #1's back and pushed the resident through the doorway. Review of the Investigation Statement dated 12/5/23 written by Certified Nurse Aide #1 revealed they witnessed the resident being pushed by Certified Nurse Aide #3. Certified Nurse Aide #1 watched as the resident stumbled and stood by Resident #1 to make sure they didn't fall. Review of the Investigation Statement dated 12/5/23 written by Dietary Aide #1 revealed they witnessed Resident #1 was shoved out of the dining room by Certified Nurse Aide #3 with both hands. Resident #1 appeared to stumble after being shoved. Review of the Investigation Statement dated 12/5/23 written by Housekeeper #1 revealed they witnessed Certified Nurse Aide #3 push the resident out of the dining room with both hands. Review of the unsigned Investigation Statement dated 12/7/23 with a telephone interview with Certified Nurse Aide #3 revealed that Certified Nurse Aide #3 came behind Resident #1. Certified Nurse Aide #3 stated that they put their arms underneath Resident #1's armpit to lead the resident out of the dining room. Review of the Mandatory Inservice and General Orientation Education dated 7/11/23 revealed that Certified Nurse Aide #3 received education on abuse, resident rights, and eldercare. Review of an Inservice Record/Summary Report dated 8/2023 with subject covered Elder Abuse and Neglect revealed Certified Nurse Aide #3 signature of attendance. Review of Inservice Record/Summary Report dated 10/3/23 with subject de-escalation tactics to be used in a skilled nurse facility setting and responding to behaviors, good communication strategies, and managing your own emotions revealed that Certified Nurse Aide #3 had signed the attendance sheet that they received the education. During an interview on 12/7/23 at 8:59 AM, Licensed Practical Nurse #1 stated they heard a noise and looked up and saw Certified Nurse Aide #3 put Resident #1 in a bear hug or maybe hugged them. They stated they were facing Certified Nurse Aide #3 and Resident #1 from behind and could see their backs and observed Certified Nurse Aide #3 do a pushing motion to Resident #1's back. They stated Resident #1 stumbled and kept walking and Certified Nurse Aide #3 did not follow the resident out. They stated they told Certified Nurse Aide #3 you can go to jail for that and told Registered Nurse Supervisor #1 right away about the incident. They stated they also told the Director of Nursing about the incident while Registered Nurse Supervisor #1 obtained witness statements. During an interview on 12/7/23 at 9:27 AM, Registered Nurse Supervisor #1 stated they assessed Resident #1 after the incident and the resident did not have any injuries and was at their baseline. Registered Nurse Supervisor #1 stated that they obtained witness statements from staff who witnessed Resident #1 being pushed. During an interview on 12/7/23 at 11:21 AM, Housekeeper #1 stated they witnessed Certified Nurse Aide #3 hands on Resident #1's back and said to the resident let's get the hell out of here. They stated Resident #1 did not fall when they were pushed out of the dining room. During an interview on 12/7/23 at 1:04 PM, Certified Nurse Aide #1 stated they were at a bookshelf next to the dining room doorway and witnessed Certified Nurse Aide #3 push the resident with both hands out of the dining room entrance. Certified Nurse Aide #1 stated staff get abuse training every year and if they witness abuse, they are to report it right away. During an interview on 12/11/23 at 9:57 AM, Certified Nurse Aide #3 stated they did not push Resident #1 and attempted to remove the resident from the dining room and the resident grabbed onto their arm. They stated that Resident #1 kept repeating no, no, no and pushed up against them. They stated it looked like Resident #1 was going to fall so they put their arms underneath the resident's armpits to stop them from falling. They stated they did not learn that technique from the facility and did not learn that technique to prevent a fall from their Certified Nurse Aide training. During an interview on 12/19/23 at 2:43 PM, the Director of Nursing stated they believe it was abuse. They stated that was the reason why they reported the incident quickly. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review during the Standard survey started on 8/11/22 and completed on 8/17/22, the facility did not maintain an effective pest control program so that the facility was free from insects. Observations of one of one kitchen, main dining room, and the resident unit revealed flies in the facility. The findings are: Review of the facility policy and procedure titled, Pest Control, dated 1/20/21, revealed the facility shall maintain an effective pest control program to prevent entry of insects and rodents into the facility, reduce the threat of infection and disease, provide a safe and sanitary environment, and to maintain the appearance and cleanliness of the facility. 1a. Observations in the kitchen, during the initial kitchen tour on 8/11/22 from 8:45 AM until 9:15 AM revealed the following: -two live house flies at the coffee station, which was near the wall-mounted insect light trap (ILT - an insect control device that employs ultraviolet light to attract insects with glue boards to trap and kill them) -three live fruit flies under and around the soda/juice dispensing gun -two live house flies at the puree station -five live house flies under and around the automatic dishwashing machine -four fruit flies at the entrance to the walk-in cooler -one dead fruit fly inside the walk-in cooler, on a tray that also contained wrapped lunchmeat and cheeses -two live house flies on the shelving of the dry storage area, near the cake mixes and jelly During an interview at the time of the initial kitchen tour, Dietary Aide #1 stated an exterminator came to the facility about two weeks ago, but the flies were coming back. Dietary Aide #1 was shown the dead fruit fly in the walk-in cooler and stated it was a dead fly and flies do not normally enter the walk-in cooler. Dietary Aide #1 disposed of the fly at this time. 1b. Observation in Resident #23's room on 8/11/22 at 9:44 AM revealed two fruit flies and two house flies were flying around Resident #23. At the time of the observation, Resident #23 stated the flies bothered them, so they kept their arms under the covers. 1c. Observation in Resident #20's room on 8/11/22 at 10:07 AM revealed flies were on Resident #20's shirt and tray table. At the time of the observation, Resident #20 stated, Flies are always buzzing around the room, it bothers me, it is noticeable that they are here. 1d. Observation in Resident #34's room on 8/11/22 at 10:38 AM revealed one fly was flying around the room near Resident #34. Resident #34 had a fly swatter in their hand. At the time of the observation, Resident #34 stated the flies bothered them, they had killed two flies so far today, and flies had been around for about a week or more. 1e. During the Resident Council Meeting held on 8/11/22 at 1:23 PM, Resident #31 (Resident Council President) stated there were flies and fruit flies throughout the facility. The exterminator treated the flies in July but did not solve the problem. Resident #31 also stated, One resident uses a fly swatter at the dining room table during meals, it's disgusting, we lose our appetites. Residents #18,19,12, 25, and 29 were in attendance and agreed with Resident #31. 1f. Review of the 6/30/22 Resident Council meeting minutes, documented in the Resident Council Report revealed the list of new concerns included bugs everywhere. 1g. Observation in the kitchen during preparation of pureed foods on 8/12/22 at 12:00 PM revealed one fly was flying in the area next to the oven near the food and two additional flies were flying around the general area near the oven. 1h. Observations in the main dining room during the lunch meal on 8/12/22 from 12:20 PM until 12:45 PM revealed the following: -One house fly was observed on Resident #26's clothing protector and two more house flies were observed hovering above Resident #26's full and uncovered lunch plate. Certified Nurse Aide (CNA) #1 was feeding Resident #26 at this time and was observed making a swatting motion around Resident #26. CNA #1 stated they were trying to swat flies away from Resident #26. -Resident #5 was observed making swatting motions with their hand and stated loudly, Damn flies are driving me crazy. Resident #5 additionally stated, All night long, I couldn't sleep because a fly was around me and kept waking me up. At the time of Resident #5's statement, one house fly was observed on their blanket, which was on Resident #5's chest. -One house fly was observed on Resident #35's full and uncovered lunch plate. Additional observation revealed one house fly was on Resident #35's shoulder and one on their clothing protector, and two fruit flies were on the rim of Resident #35's full and uncovered drink cup. CNA #2 was feeding Resident #35 at this time and stated they had seen flies in the facility once in a while, and they were not sure how long it had been an issue. CNA #2 stated they imagined it would be like this (flies present) at every meal, not just lunch. Resident #35 was unable to comment. -Registered Nurse (RN) #1 was feeding Resident #16 and was observed swatting at Resident #16's hand. During an interview at this time, RN #1 stated they were trying to swat a fly away from Resident #16. RN #1 additionally stated every place has flies in farm country, and possibly the flies entered the facility when a door was opened for a delivery. Resident #16 was unable to comment. -Resident #29 was eating their lunch and a fruit fly was observed flying around their uncovered food plate and drink cup. At this time, Resident #29 stated, No one likes flies. I've seen them everywhere in the building, in my room, and here in the dining room. -Resident #34 had left hand elevated with napkin in hand, and stated there was a fly around them and they were going to get it with the napkin. 1i. Observation in the main dining room during the breakfast meal on 8/15/22 at 8:45 AM revealed a live fly was on the edge of Resident #29's uncovered oatmeal cup. At the time of the observation, Resident #29 stated, They are everywhere and Resident #31 added, The files are everywhere, including in our rooms. 1j. Observation in Resident #23's room on 8/15/22 at 10:28 AM revealed CNAs # 2 and 3 were providing morning care to Resident #23. During morning care, CNAs #2 and 3 were observed swatting a fly away from the resident. At the time of the observation, Resident #23 stated flies had been a problem lately and they just swat them away. 1k. Observation in Resident 34's room on 8/15/22 at 1:36 PM revealed a fly was on Resident #34's left pant leg. At the time of the observation, Resident #34 stated, The flies are driving me nuts, I can't find my fly swatter, they are looking for it, but I might need to have my niece bring me in a couple more. 1l. Observation of the ILT in the kitchen on 8/15/22 at 2:40 PM revealed it had one live bee on the grate, one live house fly and one live fruit fly flying in and around it, and one dead house fly on the glue paper. Further observation revealed there was a piece of glue paper on the back wall of the ILT that measured six inches wide by three inches high. During an interview at the time of the observation, the Interim Food Service Director/Diet Technician stated the ILT used to be very effective at reducing flies when the former exterminator used longer sheets of glue paper, which were about eighteen inches wide by four inches high. The Interim Food Service Director/Diet Technician further stated they were not sure whether the exterminator or the facility's maintenance staff was responsible for maintaining the ILTs. Additionally, they stated the flies in the kitchen had improved since the hole in the disposal pipe, which produced drain flies, was recently repaired. 1m. Observation in Resident Room #18 on 8/16/22 at 7:28 AM revealed duct tape and cardboard were against the window and the air conditioning unit installed in the window. Further observation revealed the cardboard had fallen away and left an open space approximately four inches long by one inch wide. On 8/16/22 at 1:52 PM, the Director of Nursing observed the cardboard in the window of Resident Room #18 and stated that it was a concern, and Maintenance staff should have made sure it was adhered properly to prevent flies from coming in. The Director of Nursing also stated this may be the source of the flies. 1m. Observation in Resident #34's room on 8/16/22 at 10:29 AM revealed a fruit fly was flying around the room. At the time of the observation, Resident #34 stated the flies still bothered them and they still did not have their fly swatter, but had killed two flies today using the box of tissues on their tray table. 1o. Observation of the ILT in the main dining room on 8/16/22 at 10:30 AM revealed there appeared to be no glue paper in it. During an interview at the time of the observation, the Administrator stated there appeared to be no glue paper in the main dining room ILT and they were unaware. The Administrator also stated the facility was responsible for replacing the glue paper and the facility had spare glue paper in stock. Additionally, at this time, the Administrator stated they started working at this facility in June 2022 and the flies were brought up by the residents at the June Resident Council Meeting. As a result of the Resident Council Meeting, the kitchen was deep cleaned, and the exterminator, who had not been to the facility since February 2022, was brought back in July 2022. 1p. Review of the exterminator's service report dated 7/15/22 revealed kitchen and bathrooms were inspected and treated for pest activity. The report included two observations dated 2/19/22 that had a pending status. The two observations were grease build-up and food debris present in the kitchen. 415.29(j)(5)

Based on observation, interview and record review conducted during the Standard survey completed on 2/22/19, the facility did not establish smoking policies in accordance with applicable federal, state, and local laws regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. One of one facility reviewed for smoking policies had issues with establishing smoking policies for active cigarette and/or e-cigarettes smokers, and the safety assessment for active smokers. This involved Resident's #8,12. The findings are: Public Health Law, Article 13-E prohibits the smoking of tobacco in nearly all indoor and certain outdoor public and work places. Effective (MONTH) 22, (YEAR), the law also applies to vaping, which is the use of electronic cigarettes and similar devices. The amendment to the New York State Public Health Law prohibits smoking outdoors on the grounds of hospitals and residential health care facilities. Smoking is prohibited within 15 feet of building entrance or exit and within 15 feet of the entrance to or exit from the grounds. Effective (MONTH) 22, (YEAR), the law also prohibits vaping (use of electronic cigarettes and similar devices). An untitled, undated facility smoking policy documented that smoking is forbidden in all indoor and outdoor areas of the facility for residents. The policy was not specific to the facility and did not offer guidance on how smoking would be managed for residents admitted to the facility that smoked cigarettes or e-cigarettes or how they would be assessed for smoking safety. An undated facility Policy Statement documented that electronic cigarettes (E-cigarettes) are permitted but must be minimal water vapor with nicotine only. No vaping electronic cigarettes are allowed. Residents may use e-cigarettes in hallway and in room near nursing station. 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/19/18 documented the resident was cognitively intact, understands others, and is understood by others. The admission MDS dated [DATE] documented that the resident was a smoker. Multiple observations between 2/15/19 through 2/22/19 were made of Resident #8 smoking cigarettes in the parking lot. Interview with the Licensed Practical Nurse (LPN) #3 on 2/22/19 at 11:02 AM revealed that if she saw a resident smoking she would inform them that this is a non-smoking facility. She would then report the incident to the Director of Nursing (DON) and Administrator. Interview with Registered Nurse (RN) #1 the Resident Care Coordinator (RCC) on 2/22/19 at 11:04 AM revealed that the if she saw a resident smoking she would inform them that this is a non-smoking facility. She would then report the incident to the DON and Administrator. Interview with Housekeeper #1 on 2/22/19 at 11:15 AM revealed that if she saw a resident smoking she would inform them that this was a non-smoking facility and report it to her supervisor. Interview with the Administrator on 2/22/19 at 11:20 AM revealed that he plans to bring up the smoking policy in the next Quality Assurance & Performance Improvement (QAPI) meeting to plan and update a smoking policy that will fit the facility needs. The policy needs to incorporate an assessment for residents who smoke. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented the resident is cognitively intact and does not use tobacco products. During an interview on 2/15/19 at 10:15 AM, the resident stated, I vape. I go outside with my husband or friends to vape outside. They (the staff) give it to me when I want it and I go outside. As long as I'm with a responsible adult I can go outside and vape. During an interview on 2/21/19 at 1:20 PM, Licensed Practical Nurse (LPN) #2 stated the only time the resident had the e-cigarette is if her family or visitors take her outside to use it. The family take her to the patio or the parking lot to use it. During an interview on 2/21/19 at 1:39 PM, the Administrator stated, We keep it (the e-cigarette) in the medication cart. I don't have a policy for vaping, I think I had one for e-cigarettes. I don't know if it's the same thing. She (resident) goes outside with her husband and it's not smoking so I didn't care if she did it. It's a private thing she and her husband or friends do. The Administrator added, it probably should be care planned. During an observation on 2/21/19 at 1:46 PM with the DON present, LPN #2 unlocked her medication cart and displayed a plastic container labeled with the resident's name in the bottom drawer of the cart. Inside the container were 3 white e-cigarettes. The DON stated she was just told about this and was not aware they were storing the e-cigarettes for the resident. During further interview on 2/21/19 at 1:50 PM, in regard to a smoking assessment, the Administrator stated, no smoking assessment needed to be done, there's no lighting the e-cigarette, and no flame. He will see if he can find a policy and will update the resident's care plan today. 225(4)(5)(a); 1339(i)(n)(2)(b)

Based on observation, interview and record review conducted during the Standard survey completed on 2/22/19, the facility did not ensure residents environment remained as free from accident hazards as possible for two (Residents #8,12) of two residents reviewed for smoking. Specifically, the residents did not have safe smoking evaluations completed since admission and the comprehensive care plan did not include safety measures for smoking including use of electronic cigarettes (e-cigarettes). The findings are: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/19/18 documented the resident was cognitively intact, understands others, and is understood by others. The admission MDS dated [DATE] documented that the resident was a smoker. Review of undated, untitled facility policy & procedure for smoking documented that the facility is a non-smoking facility and residents are prohibited from smoking. Residents who refuse to abide by this policy may be advised to seek placement in another setting. Interview with the resident on 2/19/19 at 2:00 PM revealed that the resident has been smoking since he was [AGE] years old. Multiple observations of the resident between 2/19/19 and 2/21/19 revealed that the resident was smoking cigarettes in the parking lot. Review of the resident's medical record from date of admission on 9/17/18 to present documented that the resident's Nursing Smoking Assessment was done on 2/15/19 and that Occupational Therapy (OT) was to complete a safe smoking assessment on 2/18/19 however, the OT Smoking Assessment was not completed on 2/18/19. Interview with the Maintenance Director on 2/20/19 at 8:45 AM revealed that the resident usually goes into the parking lot or the patio to smoke. Interview with the OT on 2/20/19 at 9:01 AM revealed that he was not aware that a smoking sssessment was to be performed by OT. He has never done a smoking assessment on any resident in the seven years he has been an OT and did not know that he was supposed to do the assessment on 2/18/19. He stated that the smoking assessment should be done at the time of admission to assess the resident's safety awareness, coordination, and the ability to transfer in and out of the facility. He stated, I will do the assessment right away. Interview with the Director of Nursing (DON) on 2/20/19 at 1:19 PM revealed that staff should have addressed and assessed the resident's smoking safety at the time of the resident's admission. She expects OT to perform the smoking assessment upon admission of a smoking resident. The DON added, even though this is a non-smoking facility, it is up to the discretion of the Administrator to let specific residents smoke on the facility property. Interview with the Administrator on 2/20/19 at 1:24 PM revealed that the smoking assessment was done late and should have been done sooner. The facility usually does not admit smokers, but they wanted to meet this resident's need to smoke. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented the resident is cognitively intact and does not use tobacco products. An undated facility Policy Statement documented that electronic cigarettes (E-cigarettes) are permitted but must be minimal water vapor with nicotine only. No vaping electronic cigarettes are allowed. Residents may use e-cigarettes in hallway, and in room near nursing station. During an interview on 2/15/19 at 10:15 AM, the resident stated, I vape. I go outside with my husband or friends to vape outside. They (the staff) give it to me when I want it and I go outside. As long as I'm with a responsible adult I can go outside and vape. The comprehensive care plan lacked a focus area for the resident's vaping/ smoking status. Nursing: Admit/ Readmit Screen dated 3/19/18 and 8/10/18 documented the resident is a current smoker. The 3/19/18 Screen documented that the resident has not smoked in 3 to 4 months. The 8/10/18 Screen does not include the amount or length of time for smoking. Review of the medical record revealed a smoking safety evaluation was not completed. Physician's notes documented the following: -7/5/18 Resident vapes but does not any longer smoke cigarettes. -8/14/18 Requested privileges to vape outside. -11/7/18 Only concern today is that a nicotine patch be ordered because she craves smoking. She does however vape at intervals. Discussed would order her a patch if she agreed not to vape, which she does. -12/4/18 Per staff resident goes outside to vape, though she agreed not to. -2/5/19 Still uses her vape pen. Nursing Progress Notes documented the following: -7/24/18 Per CNA (Certified Nurse Aide), resident swore at her repeatedly for not letting her have her e-cigarette in her room. -9/23/18 Staff found resident smoking her e-cigarette in her room. 1:1 regarding rules on smoking were given and e-cigarette was taken from resident and placed with others in cup at nurse's station. No e-cigarettes were noted in resident's room prior to husbands visit this morning. -12/9/18 Resident was found in her room vaping with her e-cigarette. The e-cigarette was removed from the resident's possession and placed in medication cart with her other e-cigarettes. Staff explained to resident that it is a nonsmoking facility and that she cannot have the e-cigarette within the facility, it was for outside use only. During an interview on 2/21/19 at 1:16 PM, CNA #1 stated that the resident does smoke. When her husband or other visitors come in they will go outside and smoke. The resident does not have the e-cigarette in her room, the nurses or her husband have it. During an interview on 2/21/19 at 1:19 PM, the Registered Nurse (RN) Resident Care Coordinator (RCC) stated the resident has an e-cigarette. The resident's husband or visitors will take her outside to use it, the staff do not take the resident outside. The RN RCC further stated, it probably should be care planned. During an interview on 2/21/19 at 1:20 PM, Licensed Practical Nurse (LPN) #2 stated the only time the resident had the e-cigarette is if her family or visitors take her outside to use it. The family takes her to the patio or the parking lot to use it. During an interview on 2/21/19 at 1:39 PM, the Administrator stated, We keep it (the e-cigarette) in the medication cart. I don't have a policy for vaping, I think I had one for e-cigarettes. I don't know if it's the same thing. She (resident) goes outside with her husband and it's not smoking so I didn't care if she did it. It's a private thing she and her husband or friends do. The Administrator added, It probably should be care planned. During an observation on 2/21/19 at 1:46 PM with the DON present, LPN #2 unlocked her medication cart and displayed a plastic container labeled with the resident's name in the bottom drawer of the cart. Inside the container were 3 white e-cigarettes. The DON stated she was just told about this and was not aware they were storing the e-cigarettes for the resident. During further interview on 2/21/19 at 1:50 PM, the Administrator stated no smoking assessment needed to be done, there's no lighting the e-cigarette, and no flame. He will see if he can find a policy and will update the resident's care plan today. 415.12(h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with resident's wishes for one (Resident #31) of two residents reviewed for advanced directives. Specifically, the facility did not ensure all resident advanced directives identifiers were consistent with the resident's wishes. The finding is: 1. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident is severely cognitively impaired. A facility policy and procedure entitled Documentation in Medical Record dated ,[DATE] documented the facility will ensure that each resident/ designated representative admitted to the facility have the right to implement Advance Directives. The Procedure documented; if the resident/ Health Care Proxy indicates that they have not yet made a decision, the resident will have a Full Code/CPR (cardio [MEDICAL CONDITION] resuscitation) bracelet applied to his/her wrist, ankle or wheelchair; and in order to ascertain the resident's wishes quickly in an emergency situation, residents in the facility are asked to wear a bracelet indicating if the resident has a Do Not Resuscitate (DNR) order or wishes to have CPR (resuscitate). Other identification systems are also used to tell the staff which residents have DNR orders and which residents want CPR. This information can be found on the resident's MOLST (Medical Orders for Life-Sustaining Treatment), physician order [REDACTED]. During intermittent observations on [DATE] at 10:40 AM, [DATE] at 2:54 PM and [DATE] at 11:13 AM, the resident had a blue identification (ID bracelet) on the right/ back side of her wheelchair (w/c); the resident had no additional wrist bands on. Admission Record (face sheet of the medical record listing important information) stamp dated Feb. 21, 2019 documented code status FULL CODE. MOLST dated [DATE] documented the resident's responsible party completed the MOLST, requested a DNR, Comfort Measures only, Do Not Intubate (DNI), No feeding tube status and the physician reviewed and signed the form on [DATE]. Physician order [REDACTED]. Medical Group Progress Notes interval visit dated [DATE] documented Advanced Directives Review - MOLST directs DNR and DNI, no feeding tube. The comprehensive care plan for Advanced Directives DNR, MOLST with a revision date of [DATE], documented DNR band worn on wrist initiated on [DATE] and MOLST in place initiated on [DATE]. Visual/ Bedside Kardex Report (guide to provide care) documented special instructions; DNR, DNI, MOLST and in the Advance Directives section documented DNR band worn on wrist, encourage not to remove arm band. Order Listing Report for DNR status dated [DATE] documented resident is on the DNR list and next to her name is a handwritten check mark and wheelchair. Medication Administration Record [REDACTED]. Progress Notes dated [DATE] through [DATE] had no documented evidence that a MOLST was completed, orders received and/ or resident's armband status changed from a Full Code to a DNR status. During an interview on [DATE] at 11:09 AM, the Director of Nursing (DON) revealed Advanced Directives are identified by the colored armband on the resident; a blue armband means the resident is a Full Code, a red armband means the resident is a DNR, and a white armband on the equipment is an equipment identifier. If the resident does not wear an armband, then the identifiable arm band is placed on the resident's equipment such as a walker or wheelchair. During an interview on [DATE] at 11:13 AM, Certified Nurse Aide (CNA) #2 stated residents wear colored armbands to identify their code status; red means the resident is a DNR and blue means the resident is a Full Code. During an interview on [DATE] at 11:16 AM, Licensed Practical Nurse (LPN) #1 stated the resident's code status is identified by the colored armbands; red means the resident is a DNR, blue means the resident is a Full Code and white is an equipment identifier. LPN #1 observed the resident's blue armband on the right back of the w/c and stated, This resident should have a red armband, not a blue armband. LPN #1 immediately changed the colored armband from blue to red. During an interview on [DATE] at 11:22 AM, Registered Nurse (RN) #1 Resident Care Coordinator (RCC), stated the identifier bracelets of the resident's wishes are applied upon admission and when there is a change. The resident was a Full Code upon admission therefore a blue armband was applied, but this is not correct because the MOLST was changed on (MONTH) 9, (YEAR) to a DNR; the resident should have a red armband on. During an interview on [DATE] at 11:54 AM, the Social Worker (SW) stated a blue arm band means the resident is a Full Code and a red armband means the resident is a DNR. Every resident should have the correct colored armband on either their wrist or the resident's equipment to quickly identify the resident's code status. SW stated she was concerned about maintaining the appropriate identifier ID bracelet because it was the responsibility of whoever is in the building. SW stated, everyone; nursing and SW are responsible to ensure the correct identifier is on; it's something that should have a constant check or tracking method once a month to ensure the correct armband is on, but there is no formal process at this time. SW revealed the resident was a Full Code since admission, but she had completed a MOLST (MONTH) (YEAR) with the Health Care Agent requesting the resident to be a DNR and she had missed changing the armband from a blue to a red. The SW stated it was her responsibility to have had it changed. The SW added there is a third check for code status for each resident by an identifier in the closets, a red paper indicates the resident is a DNR, a blue paper indicates the resident is a Full Code, to ensure something is not missed, and for a quick identification of code status in the room for staff. Observation on [DATE] at 12:06 PM with the SW present revealed the resident's closet had a blue paper, indicating the resident was a Full Code. During an interview on [DATE] at 12:12 PM, RN #1 RCC stated the resident should have a red armband on either her wrist or her equipment such as the w/c for a quick code status identifier. During an interview on [DATE] at 12:21 PM, the DON stated she was not aware there was a code status indicator in the closets; the armbands should be current of the resident's code status. If the SW is in the building the SW is responsible to ensure the armband initiation and any change of status is completed, and any admissions or changes when the SW is not in the building, is the responsibility of the nurses. 415.3(e)(1)(ii)

Based on interview and record review conducted during a Standard survey completed on 2/22/19, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. One (Resident #7) of one resident reviewed for investigation of abuse had issues. Specifically, the complaint was not reported timely, thoroughly investigated by staff, and lacked notification to family and physician. The finding is: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS - a resident assessment tool) dated 12/12/18 documented the resident was severely cognitively impaired, able to make self-understood and understands others. The facility policy and procedure entitled Abuse Prohibition Policy and Procedure revision date 10/09 documented that it is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of their property. This facility shall comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect and report, if applicable, any event that is not consistent with the usual operation of nursing facility or the standard care for certain residents. In addition; suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated, documented and reported to the physician, families, and/ or representative, and as required by state guidelines. Investigation Summary report with an event date 12/24/18 and event reported date 12/25/18 documented the Dietary Cook reported to the Dietary Supervisor an observation of an interaction between the resident and Certified Nurse Aide (CNA) #4 that held down the resident's hands and it appeared to him, CNA #4 had spit at the resident. On 12/25/18 a Registered Nurse (RN) skin assessment revealed no bruising, red areas, skin tears. The Conclusion dated 12/31/18 documented, After interviews and review of the medical record there is no evidence of abuse or neglect. Follow-up Actions dated 12/31/18 documented, CNA to follow-up with Social Worker for re-education re: handling an abusive resident. Employee Statement signed on 12/25/18 of the event from 12/24/18, the Dietary Cook observed CNA #4 trying to take a pop bottle away from the resident. CNA #4 got behind the resident and held her hands down. The resident spit at CNA #4 and it appeared CNA #4 spit back at the resident. Written statement from CNA #4 dated 12/24/18 documented, while in the dining room residents yelled that this resident was sliding out of her chair. She went to reposition her, and the resident became aggressive, hit, spit, scratched and dug her nails into her arm. The resident would not stop so she tried to hold her long enough to get away from her. Additional statements, attached to the investigation from two other CNAs and one RN Supervisor did not address the complaint of the staff member trying to take a pop bottle away from the resident, if the CNA was or was not observed holding the resident's hands down and/ or spit at the resident. Further review of CNA #4's written statement revealed it did not address the CNA trying to take a pop bottle away from the resident, or if the CNA spit at the resident. Further review of the Investigation Summary revealed there was no documented evidence the staff were questioned concerning the CNA trying to take a pop bottle away from the resident, if the CNA spit at the resident, or if the resident's responsible party or the physician were notified of the allegations of abuse. The Comprehensive Care Plan documented the resident had potential to be physically aggressive related to poor impulse control. Interventions initiated on 10/27/16 documented to adjust voice tone, re-approach and an intervention initiated on 10/23/17 documented the resident prefers not to be touched and placed in large groups. Medical Group Progress Notes dated 12/4/18 through 2/5/19 had no documented evidence the physician was notified of the allegations of abuse. Progress Notes dated 12/5/18 thorough 2/21/19 had no documented evidence of the reported allegation, RN assessment, or family and physician notification. During an interview on 2/21/19 at 1:02 PM, the Dietary Cook stated he reported the allegation of abuse that was witnessed on 12/24/18 at 6:00 PM to his supervisor on 12/25/18 because his supervisor was not scheduled until the next day. The Dietary Cook stated, I didn't know about reporting abuse allegations immediately to the nursing supervisor. During an interview on 2/21/19 at 4:01 PM, CNA #4 stated she was not questioned about trying to take a pop bottle away from the resident and did not recall any incident related to a pop bottle. CNA #4 was asked about spitting on the resident days after the reported allegation and denied ever spitting toward the resident. She was not asked to add the information to her statement. During an interview on 2/22/19 at 8:46 AM, the Director of Nursing (DON) stated all departments should report any allegations of abuse to the nursing supervisor immediately and an investigation should be initiated immediately of the specific allegations. The RN assessment, and family and physician notification should be done and documented in the Progress Notes. The physician should assess the resident related to the allegations of abuse. Upon review of the staff written statements and the Investigation Summary the DON stated there was no indication the allegation that the CNA tried to take a pop bottle away from the resident or spit at the resident had been investigated. The DON added that there was no education provided to the Dietary Cook for reporting suspected abuse and there was no education for CNA #4, according to the Follow-up Actions, to meet with SW for re-education re: handling an abusive resident. During an interview on 2/22/19 at 9:12 AM, the Administrator stated the expectation is all staff are to report any suspected abuse immediately to the Nursing personnel in charge to initiate an investigation immediately. Upon review of the complaint statement, follow-up statements and Investigation Summary; the Administrator stated there is no evidence staff were questioned about the specific complaint allegation the CNA tried to take a pop bottle away and/or spit at the resident. In addition; the Administrator stated there is no evidence the family and physician were notified of the allegation/ investigation and it should have been reported to both. 415.4(b)(3)

Based on observation, interview and record review conducted during the Standard survey completed on 2/22/19, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for one (Resident #3) of one resident reviewed for ADL's staff provided incomplete AM (morning) care. Specifically, staff did not wash the resident's underarms and under breasts; and the resident had long fingernails with dark brown debris beneath fingernails on both hands for multiple days. The finding is: 1. Resident #3 has [DIAGNOSES REDACTED].difficile - an infection of the colon), dementia and anxiety disorder. Minimum Data Set (MDS-a resident assessment tool) dated 11/14/18 documented the resident is severely cognitively impaired and required extensive assistance for all ADLs. An undated facility policy and procedure entitled A.M. CARE, documented A.M. Care will be given to all residents daily. The procedures include; wash, rinse and dry underarms, under female breasts, apply deodorant or powder as needed, and provide nail care. The comprehensive care plan with an initiated date of 10/25/16 and revised date of 8/22/17 documented the resident has an ADL self-care deficit related to confusion, dementia and limited mobility requiring extensive assistance of one staff for personal hygiene and bathing/ showering. Visual/ Bedside Kardex Report (guide to provide care) documented the resident required extensive assistance of one staff for personal hygiene and bathing/ showering and the ADL for bathing is one time a week on Monday day shift. During an observation on 2/15/19 at 11:22 AM, the resident had long fingernails with dark brown debris beneath multiple fingernails on both hands. During an observation on 2/19/19 at 2:57 PM, the resident was in bed sleeping. Long thumb nails were visible with brown debris beneath the nails. During an observation on 2/20/19 at 6:57 AM with Registered Nurse (RN) #1, Resident Care Coordinator (RCC) present, two Certified Nurse Aides (CNAs #2, 3) provided AM care. They washed the resident's face, hands, groin and buttocks areas; the resident was dressed and transferred out of bed. The resident's underarms and under breasts were not washed and CNA #2 or 3 did not offer or provide deodorant or powder to resident's underarms. In addition, the resident's fingernails were long with dark brown debris beneath multiple fingernails of both hands. During an observation on 2/21/19 at 7:35 AM, the resident was seated in the dining room at a table waiting for her meal. She had long fingernails and dark brown debris beneath multiple fingers of both hands. During an interview on 2/21/19 at 12:22 PM, RN #1 RCC revealed AM care includes washing the resident's face, hands, groin and buttocks area. RN #1 RCC stated, I would probably wash the resident's underarms, but unless the resident is getting a shower I wouldn't expect the staff to. At 1:32 PM, RN #1 RCC revealed the resident's fingernail care is done on shower day and as needed, unless a resident specifically required a nurse to provide care such as a diabetic, then the CNA is responsible to complete fingernail care. Upon observing the resident's fingernails at 1:34 PM, RN #1 RCC stated, The resident's shower day is on Mondays, but anyone could've cleaned her fingernails and they need to be done. During an interview on 2/21/19 at 1:24 PM, CNA #1 revealed AM care includes washing the resident's face, hands, underarms, groin and buttocks areas, and applying deodorant or powder. CNA #1 also revealed fingernail care is completed on shower day and when needed. During an interview on 2/21/19 at 1:40 PM, Licensed Practical Nurse (LPN) #2 revealed AM care includes washing the resident's face, hands, groin and buttocks areas but, I don't think staff need to wash resident's underarms or under breasts. During an interview on 2/21/19 at 1:43 PM, CNA #2 revealed AM care includes washing face, hands, underarms, groin and buttocks area and applying deodorant or powder. Fingernail care is completed on the shower day and when needed. CNA #2 stated she did not recall if the resident's underarms were washed during AM care yesterday but recalled the resident was not offered deodorant or powder. During an interview on 2/21/19 at 1:57 PM, the Director of Nursing (DON) revealed AM care includes washing the resident's face, hands, groin and buttocks areas, but uncertain if underarms are to be washed during AM care. After reviewing the AM Care policy, the DON stated the staff should wash the resident's underarms, under breasts and offer deodorant. During an interview on 2/22/19 at 9:04 AM, the DON stated although the staff do not sign for the completion of nail care, it is expected to be completed as part of the care on shower days and as needed. This resident's fingernails should've been trimmed and cleaned. 415.12(a)(3)

Based on observation, interview and record review conducted during the Standard survey completed on 2/22/19, the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection. One (Resident #3) of one resident observed for adherence to transmission-based precautions had issues involving staff not implementing proper contact precautions while providing resident care. The finding is: 1. Resident #3 has [DIAGNOSES REDACTED]. difficile - an infection of the colon), dementia and anxiety disorder. Minimum Data Set (MDS - a resident assessment tool) dated 11/14/18 documented that the resident is cognitively severely impaired. The resident requires extensive assistance for all activities of daily living (ADLs). The facility's undated policy and procedure (P&P) entitled Infection Control - Hand Washing Guidelines documented it is expectation of this facility that all personnel wash their hands appropriately in accordance with current standards of practice. Hands are to be washed: before and after patient contact, after contact with a source of microorganisms (body fluids and substances, mucous membrane, non-intact skin, inanimate objects that are likely to be contaminated), after removing gloves. Other aspects of hand care and protection, documented gloves should be used as an adjunct to, not a substitute for hand washing. The facility's undated P&P entitled Infection Control - Standard Precautions for Infection Control documented standard precautions are used for the care of all residents regardless of their [DIAGNOSES REDACTED]. The facility's undated P&P entitled Infection Control- Contact Precautions for Infection Control documented contact precautions are to be used for specific residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. The procedures include: Hands are to be washed with an antimicrobial agent immediately after glove removal, wear gloves when entering residents room, change gloves after having contact with infective material that may contain a high concentration of microorganisms, gowns are to worn when it is anticipated that it will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent, or has diarrhea and the gown is to be removed before leaving the resident's room and resident care equipment is to be cleaned and disinfected between resident uses. The comprehensive care plan with an initiated date of 1/26/19 documented the resident has [DIAGNOSES REDACTED]icile related to recurring use of antibiotic with interventions that include contact precautions. Visual/ Bedside Kardex Report (guide to provide care) documented in the Precautions/ Safety section; contact precautions. Infectious Disease Analysis, bacterial testing report for stool specimen collected on 1/24/19 documented the resident's stool is positive for [DIAGNOSES REDACTED]icile [MEDICATION NAME] and toxins A and B. During an observation of morning care with Registered Nurse (RN) #1 the Resident Care Coordinator (RCC) on 2/20/19 at 6:57 AM, two Certified Nurse Aides (CNAs #2, 3) donned gloves and gowns prior to entering the room to provide care. During incontinent care CNA #3 used disposable cloths to remove a large amount of loose stool from the peri, groin, and buttocks areas. After incontinent care was provided CNA #3 removed gloves and did not wash hands or reapply gloves; and continued to provide care. CNA #3 dressed then, transferred the resident from the bed to the chair by holding onto the transfer belt, adjusted the resident's wheelchair equipment and made the resident's bed without washing hands or re-applying gloves. During this same observation CNA #2 who had a gown and gloves on during incontinent care removed her gloves and washed her hands after care, then walked into the hallway with the protective gown on to retrieve the resident's wheelchair (w/c). Following the resident's transfer from the bed to the w/c, CNA #2 was observed to remove the transfer belt from the resident's waist and place it onto the roommate's bed. During an interview on 2/20/19 at 7:14 AM, CNA #2 revealed she had placed the transfer belt that was used to transfer the resident on precautions onto the roommate's bed. CNA #2 was observed to immediately pick up the transfer belt and strip the bedding and place all linens and the transfer belt into the soiled linen carts in the hallway. CNA #2 stated the transfer belt should not have been placed on the roommate's bed because it was used for the resident on precautions and may have cross contaminated the roommate's bed. She was not aware if residents who are on precautions are to have resident specific equipment such as transfer belts and did not know the P&P for equipment use for residents on precautions. CNA #2 additionally stated staff should remove gloves, wash hands and reapply gloves after providing incontinent care prior to continue any care such as dressing, making the bed and transferring the resident out of the bed to the w/c for those who are on precautions to prevent cross contamination from the resident/ linens to equipment or clothing. During an interview on 2/20/19 at 7:16 AM, CNA #3 stated, I don't have to wear gloves while adjusting the resident's clothing, transferring or making the bed because I wouldn't want the resident to think something is wrong. I don't agree with having to wear gloves after incontinent care is provided. In addition, CNA #3 did not know the P&P for equipment use for someone on precautions. During an interview on 2/20/19 at 7:21 AM, RN #1 RCC stated staff should wash hands and reapply gloves after incontinent care prior to continuing care such as dressing, making the bed and transferring the resident who is on precautions to prevent cross contamination to themselves and/ or others. After observing the transfer belt that was used on the resident who is on precaution placed on the roommate's bed RN #1 RCC stated, the transfer belt should not have been placed on the roommate's bed because it may cross contaminate. During an interview on 2/20/19 at 7:26 AM, the Director of Nursing (DON) stated staff should remove gloves, wash hands and reapply gloves after incontinent care and at appropriate times during care. Gloves should be worn while dressing, transferring and making the bed to prevent any possible cross contamination. Equipment is usually individualized such as thermometer or lift and would be sanitized after use, but a transfer belt does not need to be resident specific unless it comes in contact with contaminants. During an interview on 2/21/19 at 12:22 PM, RN #1 RCC stated she observed CNA #2 leave the room with the gown on to retrieve the resident equipment from the hallway and should not have. The CNA should have taken the contaminated gown off before leaving the room and put a clean gown on before reentering the room. During an interview on 2/21/19 at 1:24 PM, CNA #1 stated upon entering a room of a resident on precautions to provide care, staff should apply gloves and a gown. Staff are to remove gloves, gown and wash hands prior to going into the hallway. During an interview on 2/22/19 at 9:04 AM, the DON stated staff should not have placed the transfer belt on the roommate's bed and not leave a resident's room with a gown on to prevent cross contamination. The CNA should have removed the gown before leaving the room and reapplied another gown if she needed to reenter the room during care. 415.19(b)(2)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/19/18, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Two (Residents #31,34) of five residents reviewed for unnecessary medications had issues involving the lack of an attempt of a gradual dose reductions (GDRs) of [MEDICATION NAME] (antidepressant) for Resident #31 and [MEDICATION NAME] (antipsychotic) for Resident # 34 and lack of an assessment and identification of potential side effects of an antipsychotic medication (Resident #34). The findings are: Review of a facility policy and procedure (P&P) entitled Antipsychotic Medication Use revised 3/15 revealed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Nursing staff shall monitor for and report any of the following side effects to the Physician; dry mouth [MEDICAL CONDITION], sedation, neurological effects, extrapyramidal effects (EPS - drug induced movement disorders), tardive dyskinesia (side effect of antipsychotic medication that cause involuntary, repetitive body movements - may include grimacing, sticking out the tongue or smacking of the lips), stroke, or TIA ([MEDICAL CONDITION] - temporary blockage of blood flow to the brain, mini-stroke). The Physician shall respond by changing or stopping problematic doses or medications, or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Additional review of the Antipsychotic Medication Use P&P revealed the Physician is responsible to change or stop psychoactive medications, or clearly document why the benefits of the medication outweigh the risks or the suspected or confirmed adverse consequences Review of an undated P&P entitled Gradual Dose Reduction (GDR) Guideline revealed two GDR's must be conducted for antipsychotics on residents with any organic mental syndrome diagnosis. 1. Resident #34 was admitted to the facility on [DATE] with diagnose that include dementia, anxiety and depression. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/22/17 revealed the resident has moderate cognitive impairment, understands, is understood, has no behaviors and receives an antipsychotic medication daily. Review of a History and Physical, completed by the physician, dated 8/3/17 revealed the patient follows a community psychiatrist for chronic anxiety and lacks the capacity for decision making. Review of the Comprehensive Care Plan (CCP) revised 11/2/17 revealed a Focus area for Mood problem related to anxiety and [MEDICAL CONDITION] was initiated 10/10/16 with planned interventions to administer medications as ordered; monitor for side effects and effectiveness; and monitor/record/report mood patterns, signs and symptoms of depression, anxiety, and sad mood to the physician. The CCP also documented a Focus area for [MEDICAL CONDITION] Medications [MEDICATION NAME] related to Anxiety with planned interventions to administer [MEDICAL CONDITION] medications; monitor for side effects and effectiveness Q (every) shift; consult with Pharmacy and Physician to consider dose reduction when clinically appropriate at least quarterly; and monitor and report adverse reactions, unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking) frequent falls, dry mouth, and depression. Review of a physician's orders [REDACTED]. Review of the Annual History and Physicals dated 8/4/16 and 8/3/17 and Physician Interval Visit Notes dated 12/1/16 to 11/30/17 revealed the resident received [MEDICATION NAME] 200 mg daily. Review of the Medication Administration Record [REDACTED]. During an interview on 1/16/18 at 11:39 AM, the resident stated she had a dry mouth. The resident was observed with multiple tongue thrusts and lip smacking episodes during the interview. Observation on 11/18/18 at 8:25 AM revealed the resident was taking a sip of water from a glass from an over the bed table, smiling and talking. The resident stated she had just finished breakfast and her mouth continued to feel dry. The observation revealed four tongue thrust and nine lip smacking episodes were identified during the one-minute conversation. During an interview on 1/18/18 at 9:25 AM, the Social Worker (SW) stated the resident is followed by a community Psychiatrist for anxiety. The SW stated that the family is against any medication changes despite education to the responsible party regarding the use of [MEDICATION NAME] and that on admission the resident was on [MEDICATION NAME] 300 mg (milligrams) and her mood has been stable. The SW stated that the last GDR for [MEDICATION NAME] was 4/8/16 due to increased lethargy. Review of the Social Work Progress Notes dated 3/21/17 through 1/2/18 revealed there was no documentation that education was provided to the resident or the resident's responsible party regarding the use of [MEDICATION NAME] or any related behaviors. Observation on 1/18/18 at 10:58 AM, the resident was sitting in a chair in her room and eight tongue thrust and five lip smacking episodes occurred during the conversation. Observation on 1/18/18 at 11:19 AM revealed a license practical nurse (LPN #3) offered the resident a drink of water after the resident stated, my mouth is dry. Three episodes of lip smacking were observed during the conversation between the LPN and the resident. During an interview on 1/18/18 at 11:21 AM, LPN #3 stated she thought the resident just had a dry mouth and never really thought of it as lip smacking or tongue thrusting. When asked if she was aware of any behaviors that the resident displays, the LPN replied No. The LPN stated that the resident walks fast and requires reminders to slow down but otherwise is pleasant. She needs encouragement to attend activities. She likes to be in her room. Interviews with four CNAs (#1, 2, 5, 7) on 1/18/18 between 9:50 AM and 3:16 PM revealed the resident is cooperative with care, pleasant, and does not have any behaviors. Review of Behavior Detail Reports and Nursing Progress Notes, dated 10/21/17 through 1/18/18 revealed there were no behaviors documented. Review of a Note to the Attending Physician/Prescriber dated 11/16/17 revealed the Consultant Pharmacist documented that the resident continues to receive Quetiapine ([MEDICATION NAME]) 200 mg for anxiety, is followed by a psychiatrist and has been stable on her medications without adverse effects. The Consultant Pharmacist documented Please consider documenting that a gradual dosage reduction would not be in the best interest at this time. The Note was signed by the Physician on 12/14/17 with the response Agree - please prompt at next visit. Review of the monthly BMARC (Behavior Modification Assessment Record Committee) review dated 11/17/17 revealed the following: psychiatric consult 11/22/16, family resistant to any medication changes or GDR attempts per nursing. Review of a Physician Interval Note dated 11/30/17 revealed the resident receives [MEDICATION NAME] 200 mg at bedtime for anxiety; Patient did have reductions of dose of [MEDICATION NAME] due to sedation, but symptoms now seem well balanced. Review of a Pharmacy Consultant Review dated 12/14/17 revealed the Consultant recommended to continue [MEDICATION NAME] at the present dose; family resistant to any medication changes, GDR attempts. Review of a SW Quarterly Progress Note dated 1/2/18 revealed the Interdisciplinary Team (IDT) concurs that the residents plan of care continues to meet her needs. Review of a Psychiatric Consult dated 1/9/18 revealed major [MEDICAL CONDITION] - stable, generalized anxiety - stable and rule out [MEDICAL CONDITION]. No concerns or complaints. The resident is receiving [MEDICATION NAME] 200 mg at bedtime with no adverse effects noted. The patient was counseled and educated on the risks and benefits of treatment and the patient verbalized understanding of all instructions given. Recommendations: keep medications the same and follow up in six months. During a telephone interview on 1/18/18 at 11:34 AM, the Consultant Pharmacist stated that she typically conducts medical record reviews on the same day as the BMARC meeting, she typically reviews labs (laboratory reports), physician's orders [REDACTED]. The Pharmacist stated she does not always review the dosage of the medications on the MAR. If any concerns are identified, she will write a note to the Physician on a requisition form, places it in the Physician's folder for him to review and expects him to address it on his next visit unless it requires immediate attention. The Pharmacist stated she typically will prompt the Physician to provide the supporting documentation for a medication. The Consultant Pharmacist stated she is unsure whether a GDR was indicated for the [MEDICATION NAME] because the patient lacks capacity and is followed by community Psychiatrist. The Pharmacist stated, I go along with what the Psychiatrist recommends. On 1/18/18 at 1:35 PM, the Physician was observed to enter the resident's room where she was sitting in her chair. The Physician interviewed the resident and she stated that she was fine, felt good, and had a dry mouth. The observation revealed that the resident had multiple episodes of lip smacking during the five-minute conversation with the Physician. During interview on 1/18/18 at 1:45 PM, the Physician stated Honestly, I never paid attention to her mouth movements before, it is possible she may be having some side effects, but I can't say for certain. I always let the Psychiatrist make the recommendations and I follow them. He is the specialist. The Physician replied no when asked if he attended the monthly BMARC review. During a telephone interview on 1/19/18 at 10:08 AM, the Psychiatrist stated he would not consider this resident to be [MEDICAL CONDITION] but rather anxiety with depression and he relies on family and staff to notify him of any changes or adverse effects. I only see the patient every six months. The Psychiatrist stated that he was aware of her dry mouth but was not concerned. He stated he was not aware of any lip smacking or tongue thrusting, as nothing was reported by the staff or family. I thought she was making those movements with her mouth because of poor oral hygiene and tooth fragments on the top of her mouth. The Psychiatrist further stated he discusses medical treatment with the patient and her health care proxy. The family is highly against any medication changes. He would not be willing to make any medication changes at this time; he is aware of the regulations; he would not consider changing any medication and feels the benefits outweigh the risks. The Psychiatrist stated the patient's mood has been stable for some time and much improved from past history. During an interview on 1/19/18 at 11:20 AM, the Registered Nurse (RN #2) stated prior to residents going out on appointments, she is the one responsible to fill out any medical information pertinent to the appointment and if any changes in conditions, or adverse effects are noted. The RN stated that the Physician always follows the recommendations of the Psychiatrist. The RN further stated she never noted tongue thrusting or lip smacking and potential adverse effects are discussed during the IDT (Interdisciplinary Team) reviews and BMARC. During a telephone interview on 1/19/18 at 12:30 PM, the Medical Director stated he was not too familiar with the resident as a Physician of Specialty, he expects the facility Physician to honor the recommendations of the Psychiatrist. As a specialist, that is what we do. The Medical Director then stated he expects the nursing staff to be able to recognize adverse effects and notify the DON (Director of Nursing) and inform the specialist to warrant a return visit to the specialist. During interview on 1/19/18 at 10:45 AM, the DON stated she is unsure of when the last in-service regarding antipsychotic medications took place as she has only been in her position for a few months. the DON stated that she and the RN Unit Manager are responsible for conducting in-services and one will be scheduled on recognizing possible adverse effects of long term use of antipsychotic medications. The DON stated the expectations are for the nursing staff to recognize symptoms, document the symptoms and inform the Physician. 2. Resident #31 was readmitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/20/17 revealed the resident is cognitively intact, understands and is understood. The MDS documented that the resident's mood was assessed as depressed and tired without any behaviors. Review of the current Comprehensive Care Plan (CCP) revealed a Focus area for Depression was initiated 8/25/16 and last revised on 9/12/17. The CCP documented that the resident uses the antidepressant [MEDICATION NAME] with planned interventions to administer medications as ordered by the physician and monitor/document side effects and effectiveness. A Focus area for Anxiety was initiated on 8/29/16, revised on 9/12/17 with planned interventions to administer anti-anxiety medications as ordered by the physician and monitor for side effects and effectiveness. Review of physician's orders [REDACTED]. Review of a Physician Interval Note dated 2/9/17 revealed the resident was readmitted on [DATE] after hospitalization for [MEDICAL CONDITION] exacerbation with pneumonia. The physician documented that the resident was due for consideration of a GDR of the [MEDICATION NAME], however, the resident reported feeling quite stressed lately. The Physician documented that the resident had a previous failure with a GDR of [MEDICATION NAME] and that a current GDR was contraindicated. There was no documentation regarding the continued use of [MEDICATION NAME] for depression. Review of Medication Administration Records (MARs) dated 1/8/17 to 1/19/18 revealed the resident received [MEDICATION NAME] oxalate ([MEDICATION NAME]) 10 mg one time a day for depression. Additional review of the MARs revealed no documented evidence that a GDR was attempted for the [MEDICATION NAME]. Review of a Behavior/ Medication Monitoring Summary dated 4/13/17 revealed the resident had no documented behaviors of increased anxiety or depression and no changes to the resident's psychoactive medications were recommended. Review of a Consultant Pharmacy Report dated 9/21/17 revealed the Consultant Pharmacist (#1) documented consider [MEDICATION NAME] reduction or provide risk/ benefit. Review of a Behavior/ Medication Monitoring Summary dated 9/22/17 revealed the resident had no documented behaviors. The Summary documented that the resident had a GDR of [MEDICATION NAME] to 10 mg on 10/17/16. Further review of the Summary revealed the resident had a Senior Psych Consult on 10/26/17 and no changes were recommended. Review of a Psychological Services Diagnostic Evaluation dated 10/26/17 revealed the resident was on [MEDICATION NAME] and [MEDICATION NAME] for a history of anxiety and depression. There was no documented recommendation or determination regarding a GDR for [MEDICATION NAME]. Review of Physician's Progress Notes dated 10/12/17 and 12/14/17 revealed the resident received a periodic evaluation of the resident's medical diagnoses, however there was no documentation regarding the use of [MEDICATION NAME] and the Physician did not address the Pharmacy Consultant's recommendation dated 9/21/17. A Behavior/ Medication Monitoring Summary dated 10/31/17 documented that the Pharmacy Consultant recommended a reassessment of [MEDICATION NAME] for dose reduction consideration and that the resident has been on [MEDICATION NAME] 10 mg for one year. Review of a Pharmacy Consultant Review, completed by a Pharmacist Consultant (#2) dated 12/14/17 revealed the resident's last GDR for [MEDICATION NAME] ([MEDICATION NAME]) on 10/17/16 to10 mg was tolerated. Review of a physician progress notes [REDACTED]. The Physician documented that a GDR is contraindicated due to previous failure, ongoing benefit, and no adverse effect noted. Additional review of the physician progress notes [REDACTED]. During an interview on 1/18/18 at 11:32 AM, the Social Worker (SW) stated that the resident is doing well on current doses of [MEDICATION NAME] and [MEDICATION NAME] and that the resident has episodes of anxiety. The SW stated that the Pharmacy Consultant places recommendations in the physician's folder and the physicians are expected to act on those recommendations. The SW was unable to explain why the Pharmacist recommended the GDR of [MEDICATION NAME] on 9/21/17 and that it was not addressed by the Physician until December 2017. The SW stated that the Behavioral (BMARC) meeting is once a month and consists of the Pharmacist, SW, Director of Nursing (DON), and Registered Nurse (RN) Resident Care Coordinator (RCC), and Administrator. When the meeting is concluded, the utilization report is provided to the Physician with recommendations and the physician either agrees or disagrees with the recommendations. The SW stated that the Pharmacist wrote that a GDR was not in the resident's best interest, thus it was not done. During an interview on 1/18/18 at 1:29 PM, the Consultant Pharmacist (#2) stated that another Pharmacy Consultant (#1) wrote the 9/21/17 recommendation to reduce the [MEDICATION NAME] dose. The Pharmacist stated she was aware the resident did not have the GDR (recommended on 9/21/17); thus, she (the resident) was reviewed at the December 2017 BMARC meeting. The Administrator, RN RCC, and SW all felt the resident was stable on the current [MEDICATION NAME] does, thus the recommendation was made to the Physician to document the reasons why a GDR was currently contraindicated. The Consultant Pharmacist (#2) stated she wrote the recommendation to the Physician to document the GDR contraindication because the BMARC committee had come to that conclusion; she did not believe the Physician was present. During an interview on 1/18/18 at 3:21 PM, the Physician stated that when Resident #31 was readmitted to the facility after a hospitalization , she was receiving 10 mg of [MEDICATION NAME] and had previously been on 15 mg daily. The Physician stated he did not recommend a GDR because the resident failed a GDR for [MEDICATION NAME] in the past. the Physician had no explanation for not addressing the resident's depression or the 9/21/17 Pharmacist's recommendation for a GDR of the [MEDICATION NAME] (ordered for the resident's depression). The Physician stated he does not attend the BMARC meetings; however, the Pharmacy reports are usually dealt with when he receives them in his Physician folder for his weekly patient rounds. 415.12(l)(2)(i)(a)(ii)

Based on observation, record review and interview during the Standard Survey completed on 1/19/18, the facility did not ensure the resident's right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. One (Resident #23) of one resident reviewed for restraints was positioned in a reclined Geri-chair to prevent the resident from rising and there was no evaluation of the need to use the Gerichair as a physical restraint. The finding is: 1. Resident #23 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS - a resident assessment tool) dated 11/29/17 revealed the resident has severe cognitive impairment, understands, and is understood. Review of the current Comprehensive Care Plan (CCP) last reviewed 11/28/17 revealed the resident has limited physical mobility (identified 8/22/16), is non-ambulatory, and is totally dependent on staff for locomotion using a Gerichair. Additional review of the CCP revealed the resident was identified at risk for falls (8/8/16), she fell without injury on 4/17/17, and planned interventions include anticipating and meeting the resident's needs. Review of the Kardex Report (used by certified nurse aides (CNAs) to provide care) dated 1/18/18 revealed the resident utilizes a Gerichair for locomotion. Additional review of the Gerichair revealed there is no documentation regarding positioning the chair in a reclined position to prevent the resident from getting out of the chair. Review of the entire medical record revealed there was no documented evidence of a restraint evaluation for Resident #23. Observation on 1/17/18 at 10:08 AM revealed the resident was sitting in a reclined Gerichair in the doorway of her room. The resident was observed attempting to rise from the reclined Gerichair several times; she kicked off her slippers and her curved neck pillow fell to the floor. After several unsuccessful attempts to rise from the chair, the resident continued to fidget with her legs and arms in a non-purposeful manner. Additional observation on 1/18/18 at 11:04 AM revealed the resident was sitting in the reclined Gerichair in the doorway of her room; she was attempting to rise from the Gerichair repeatedly at least 30 times, and her blanket and neck pillow had fallen on hall floor. The resident was observed weeping at intervals and was intermittently agitated until 11:16 AM, when a CNA picked up the blanket from the floor and transported the resident (in the Gerichair) to the bathroom. During an interview on 1/18/18 at 11:25 AM, CNA #8 stated that the resident a lot of times starts jumping from the chair when she needs to go to the bathroom. If you don't get to her quick enough she could get up herself or fall. During further interview on 1/19/18 at 9:01 AM, CNA #8 stated that Resident #23 is placed in the reclined Gerichair after breakfast so she doesn't get out of the chair, she usually has difficulty getting out. During an interview on 1/19/18 at 10:11 AM, the Physical Therapy (PT) Rehabilitation Director stated he does bed rail assessments monthly with the Maintenance Director and he has a list of all the restraints in the facility. The PT Rehabilitation Director stated that Resident #23 does not have a restraint. When asked who completes a restraint assessment for other type of restraints other than side rails, the Director stated that nursing staff does. During an interview on 1/19/18 at 10:43 AM, the Registered Nurse (RN #2) Resident Care Coordinator (RCC) stated that staff are to recline the resident's Gerichair for her safety and it should have been evaluated as a restraint because the resident cannot easily rise form the Gerichair in that position. The RN RCC stated that Resident 323 is a fall risk. 415.4(a)(2)(iv)(3)(iii)

Based on observation, record review and interview during the Standard survey completed on 1/19/18, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #23) of three residents reviewed for accidents was improperly secured in a sling during a mechanical lift transfer. The finding is: 1. Resident #23 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS - a resident assessment tool) dated 11/29/17 revealed the resident has severe cognitive impairment, understands, is understood, and requires total staff assistance for transfer and toilet use. Review of the current Comprehensive Care Plan (CCP) last reviewed 11/28/17 and the current Kardex Report, used by certified nurse aides (CNAs) to provide care, revealed the resident is non-ambulatory and is transferred with the assistance of two staff using a Sit-to-Stand mechanical lift. Review of the User Manual for the Stand Up Patient Lift, utilized for resident care in the facility ,revealed the instructions for using the Standing Sling documented the bottom edge of the standing sling is positioned on the patient's lower back with the patient's arms outside of the sling. The instructions documented that the belt (of the Stand Assist Sling) must be snug but comfortable on the resident, otherwise the resident can slide out of the sling during transfer, possibly causing injury. Observation on 1/17/18 at 10:30 AM revealed a certified nurse aide (CNA #10) took the resident to the bathroom. Prior to trasferring the resident from the Gerichair to the toilet, CNAs # 9 and 10 placed a sling on the resident in preparation for the transfer. The observation revealed the the sling belt was not snug/properly secured around the resident's waist. When the CNA raised the mechanical arm of the stand-assist lift, the bottom edge of the sling was observed to slide to the resident's middle back and the upper edges of the sling were directly under the resident's armpits. The resident was holding onto the mechanical lift arms and the resident was moaning and stating oh, Lordy. After toileting, the resident was transferred from the toilet back to the Gerichair in the same manner and the CNAs did not adjust the sling and/or belt of the stand-assist lift. Additional observation on 1/18/18 at 11:16 AM revealed CNAs #2 and 8 took the resident to the bathroom. CNAs #2 and 8 were observed to place the sling on the resident in preparation for the transfer from the Gerichair to the toilet; however, the sling belt was not secured around the resident's waist. The CNAs began to raise the mechanical arm and the surveyor intervened and asked why the sling belt was not secured around the resident's waist. CNA #2 stated she'll scream and yell and then she secured the strap loosely aournd the resident. The bottom edge of the sling was observed to be positioned around the resident's middle back and the upper edges of the sling were directly under the resident's armpits as the resident held onto the arms of the mechanical lift. The resident was observed to be calm and cooperative during the entire process. Continued observation revealed the CNAs transferred the resident back back to the Gerichair from the toilet in the same manner without adjusting the sling. Observation on 1/18/18 at 1:42 PM, in the presence of the Physical Therapist, revealed CNAs #2 and 8 took the resident to the bathroom. CNAs # 2 and 8 were observed to place the sling on the resident in preparation for the transfer from the Gerichair to the toilet. The sling belt was positioned around the resident's waist and was not snug against the resident's body. During an interview on 1/18/18 at 1:46 PM, the Physical Therapist stated that staff just told her today that the sling belt bothered the resident. The Physical Therapist stated that if the resident were to slide out, the sling would still assist the resident transfer, however the Physical Therapist stated that the belt should be snug. During an interview on 1/19/18 at 10:43 AM, the Registered Nurse (RN #2) Resident Care Coordinator (RCC) stated that she knows the resident can become combative when securing the sling and the belt. The RN RCC stated that if the resident is combatative, staff should leave her alone and then re-approach; staff should not perform the transfer with the sling/belt unsecured. 425.12(h)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/16, the facility did not store, prepare, distribute, and serve food under sanitary conditions. One of one Kitchen observed for sanitary conditions had issues involving refrigerators and a dry storage area that contained undated and outdated food/ beverages. In addition, stacked pots and pans on the ready to use rack were wet. The findings are: 1. During the initial tour of the Kitchen on 10/25/16 from approximately 8:49 AM to 9:15 AM, the following was observed in the Kitchen refrigerators: a.) Small Kitchen refrigerator: - A large plastic container approximately one foot by one foot, was half full and labeled egg salad with a date of 10/19/16 -Three plastic 8 ounce (oz) serving bowls labeled tomato soup were filled to the top and were undated - One large plastic container of sour cream was approximately one-eighth full and was dated 10/6/16 - One opened box of cream cheese was undated -Three plastic wrapped packages of sliced orange cheese, each containing approximately 10 to 20 slices, were unlabeled and undated - Five plastic wrapped packages of sliced white cheese, each containing approximately 10 slices, were unlabeled and undated - A five pound plastic bag of shredded mozzarella cheese was approximately half full and was undated. b.) A large walk-in refrigerator had a sign on the door that read label and date all food items. The refrigerator contained: - Five serving trays containing individual glasses of a variety of drinks such as milkshakes, milk and juice. All of the drinks were undated - A tin container, approximately 8 x 10 in size, contained canned red apple rings and was dated 10/16/16 - A tin container, approximately 10 x 2 in size, was labeled extra chef salad and was undated - Opened plastic bag of lettuce half full undated c.) Dry Storage area: - A plastic zip lock bag contained two cups of corn chips. The bag was unlabeled and undated - A 1/2 full plastic bag of noodles was unlabeled and undated - An open box of biscuit mix was 1/ 4 full and was undated - An open plastic bag of cereal was undated - Pots and pans in the clean rack were ready for use per interview with the Food Service Director at the time of the observation. Two loaf pans; three tin pans approximately 3 x 8 in size; and three tin pans approximately 5 x 12 in size were all were stacked in the clean rack and were wet in between the pans. In addition, two 3x 8 tin pans had dried debris inside of the pans During an interview on 10/25/16 at approximately 8:49 AM, the Food Service Director stated Everything in the refrigerators should be labeled and dated. Anything that has been opened should be labeled and dated. Foods after five days should be thrown away. I will discard all the outdated and undated foods. The pots and pans should be fully dried before stacking them; we will rewash them. The drinks on the trays were for lunch and nourishments for today and they forgot to put the dates on them. Review of an undated Sanitation Checklist revealed the section for the Storeroom questioned whether all foods that have been opened were sealed tightly,dated, and labeled, if needed. The Cooler section questioned whether all foods were properly covered, labeled, and dated. The Equipment and Kitchenware section addressed whether all food contact surfaces of equipment were clean to sight and touch and the Pots and Pans section questioned whether the pots were allowed to air-dry. 415.14(h) 14-1.43(e) 14-1.110(c) 14-1.116

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/16, the facility did not inform the resident's legal representative or an interested family member when there was a significant change in the resident's physical status and there is a need to alter treatment significantly. One (Resident #36) of one resident reviewed for notification of change had issues involving the lack of timely notification of a resident's Health Care Agent regarding the need to initiate skin care treatment to the resident's buttocks and sacrum (area above the tail bone on the right and left buttocks). The finding is: 1. Resident #36 has [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS- a resident assessment tool) dated 10/12/16 revealed the resident rarely or never understands and has severely impaired cognitive skills. The MDS documented that the resident is always incontinent of bowel and bladder and is totally dependent on two persons for toileting, transfers and bed mobility. Review of the Admission Record dated 7/6/16 revealed the resident's wife is the resident's responsible party and Care Conference Person. Review of the Order Summary Report for the date range of 5/1/16 to 10/28/16 revealed orders for the following: - 8/14/16 - Dermaseptin (ointment that provides a skin barrier and promotes healing) to buttocks qs (every shift), dc (discontinue) when resolved (d/c date 9/2/16) - 9/16/16 - Dermaseptin to sacral slit red area qs until resolved, then dc (d/c 10/17/16) - 10/10/16 - Apply Dermamed (ointment that protects and helps relieve chafed & abraded skin) to bilateral buttocks every shift for shearing - 10/22/16 - Comfort Foam (absorbent foam dressing) every day shift, every three days, [MEDICATION NAME] (preventative measure) apply to sacrum (d/c 10/25/16) - 10/26/16 Apply Dermamed and Comfort Foam every day shift for [MEDICATION NAME], apply to sacrum The electronic medical record (EMR) Weekly Skin Check LPN (Shower Check) form dated 10/10/16 documented skin abnormality identified. The EMR Weekly Bruises, Skin Tear and Other form, dated 10/10/16, documented the following: - Right buttock 1.0 x 0.5 cm (centimeter) sheared area - Left buttock 0.4 x 1.6 cm sheared area Further review of the EMR Weekly bruises, skin tear and other form revealed on 10/25/16 the following was documented: - Right buttock 2 cm red area - Left buttock 1.5 cm red area During an interview on 10/25/16 at 1:24 PM, the resident's wife stated that she is the person who would be notified of a change in condition of the resident. The wife stated she was not informed of the large red area on his buttocks.The wife explained that while recently assisting a certified nurse aide (CNA) with the resident's HS (bedtime) care, the wife noticed a wound dressing on the resident's buttocks for the first time. The wife stated that the CNA showed her a reddened area on the resident's buttock that the wife was not aware of. During an observation of morning care on 10/27/16 at 7:03 AM, in the presence of the Registered Nurse (RN) Resident Care Coordinator (RCC), Resident #36 was rolled onto his left side. The resident had a wound dressing on the sacrum that was not adhered to the skin of the right buttock. The CNA removed the wound dressing upon the approval of the RN RCC. The resident was observed to have non-blanchable reddened areas on the left and right of the sacrum. The reddened area on the left buttock was observed to have pieces of loose flesh-tone material. The RN RCC stated that the loose material was skin and that there was an open area present on the left buttock. The RN RCC cleansed the area with a wound cleanser, and applied Dermamed ointment and a Comfort Foam to cover both reddened areas on the sacrum. Review of the EMR Progress Notes for the period of 4/23/16 to 10/27/16 revealed no documented evidence that the resident's responsible party was informed of the changes in the resident's skin integrity prior to a Progress Note written by the Registered Nurse on 10/27/16 at 22:29 PM (10:29 PM). The 10/27/16 Progress Note documented that the resident had a reddened sacral area, Dermamed and Comfort Foam was applied, and the wife (the responsible party) was made aware. During an interview on 10/28/16 at 9:28 AM, the RN RCC and the Director of Nursing (DON) stated that they try to inform families of a resident's change of treatment. The RN RCC stated that she thought she had informed the wife about the changes in Resident #36's skin but could not be sure. The RCC stated I did call her yesterday to update her about the changes to his bottom. 415.3(e)(2)(ii)(b)(c)

Based on interview and record review conducted during the Standard survey completed on 10/28/16, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. One of five employee files reviewed for state registry checks lacked verification with the New York State nurse aide registry prior to employment. The finding is: 1. Review of the employee file for Employee #1, a Housekeeping Aide, revealed the employee was hired on 7/1/16 and a Nurse Aide Registry Verification Report was conducted on the employee on 10/13/16. Review of a copy of the Employee's Time Detail report (a report containing the dates and times the employee worked at the facility) revealed the employee worked at the facility on 75 days between 7/1/16 and 10/13/16. Interview with the Business Office Manager/ Human Resource Director (Authorized Person) on 10/28/16 at approximately 11:07 AM revealed she had provided the employee with a copy of the employee's Nurse Aide Registry Verification Report on 10/13/16 per the employee's request. The Business Office Manager/ Human Resource Director stated, she knew she had conducted a Nurse Aide Registry Verification Report for the employee prior to the employee being employed by the facility and was not sure why that verification report was not in the employee's file. Review of a facility policy and procedure entitled Employment Policy effective June7, 2007 revealed Prior to any applicant interview, the following pre-employment checks will be completed: a) Nurse Aide Registry Verification Report. 415.4(b)(1)(ii)(b)

Based on interview and record review during the Standard survey completed 10/28/16, the facility did not develop comprehensive care plans to address the use of [MEDICAL CONDITION] (medications used to manage behaviors, stabilize mood or treat psychiatric conditions) medications. Two (Residents #34, #41) of five residents reviewed for unnecessary medications did not have a care plan developed to address the resident's behaviors and the use of a mood stabilizing medication (#34) and an antidepressant (#41). The findings are: 1. Resident #34 has [DIAGNOSES REDACTED]. Review of the quarterly MDS (minimum data set - a resident assessment tool) dated 8/3/16 revealed the resident is understood, understands and has severe cognitive impairment. The MDS documented that the resident has trouble falling or staying asleep, feels tired, and has a poor appetite. No behaviors were indicated. Review of physician's orders [REDACTED]. Review of a Physician's Progress Note dated 10/13/16 revealed the resident is receiving [MEDICATION NAME] sprinkles (a mood stabilizer) for behaviors. Review of the current Comprehensive Care Plan dated 9/7/16 revealed there was no care plan developed to address the resident's behaviors or the use of a mood stabilizing medication ([MEDICATION NAME]). The Care Guide, used by staff to provide care, dated 10/24/16 lacked approaches for behavior problems and the Behavior Section was blank. Interview with a Certified Nurse Aide (CNA #1) on 10/27/16 at 11:08 AM revealed the resident has behaviors including outbursts, is resistive to care, and has been known to swing at staff. During an interview on 10/27/16 at 11:14 AM, the Registered Nurse (RN) Resident Care Coordinator stated that behaviors are to be documented in the Nursing Progress Notes and there are no behavior monitoring sheets. Interview with the Consultant Pharmacist on 10/27/16 at 11:18 AM revealed that he monitors mood stabilizing medications but they are not reviewed at BMARC (behavior modification assessment record committee) meetings. Review of a facility policy and procedure entitled Care Plans dated 7/16 revealed Each discipline will develop 'Focus' problem/ need for that resident. Followed by a goal that is measurable and meets the resident's highest level of physical, mental and psychosocial well-being. Interventions to meet the resident's goal will be included on the comprehensive care plan. 2. Resident #41 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/16/16 revealed that the resident is cognitively intact, understands, and is understood. Review of a Physician Acute Visit note dated 10/13/16 revealed the resident had an unspecified adjustment disorder with a plan to start [MEDICATION NAME] (antidepressant medication) 25 mg (milligrams) daily. Review of a physician's orders [REDACTED]. Review of the Medication Review Record dated October 2016 revealed the resident received [MEDICATION NAME] 25 mg daily from 10/16/16 to 10/27/16. Review of a Physician Acute Visit note dated 10/20/16 revealed the resident has an unspecified adjustment disorder and receives [MEDICATION NAME] 25 mg daily. Review of Social Work Progress Notes dated 10/13/16 to 10/27/16 revealed there was no documentation that [MEDICATION NAME] was started. Review of the Comprehensive Care Plan printed 10/27/16 revealed there was no care plan developed for the use of the antidepressant [MEDICATION NAME]. During an interview on 10/27/16 at 12:21 PM, RN#1 stated There should be a care plan in there for an antidepressant, but I do not see one. During an interview on 10/27/16 at 12:22 PM, the Director of Nursing (DON) stated There should be a care plan in there for any antidepressant and/or antipsychotics. That care plan would be put in there by the Social Worker. During an interview on 10/27/16 at 12:24 PM, the Social Worker stated This resident should have a care plan for the antidepressant. I totally forgot to put the antidepressant on the care plan. Whenever a resident is placed on an antidepressant, antipsychotic, and/or an antianxiety medication, it needs to be placed on the care plan. Review of a policy and procedure (P&P) entitled Behavior Management Committee dated 7/13 revealed residents who receive antipsychotic, sedative/hypnotic, or antianxiety medication are to be maintained at the safest, lowest dosage necessary to manage the resident's condition. The P&P documented that Social Services will update the changes in the Care Plan. Review of P&P entitled Care Plans dated 8/08 revealed the facility will develop a comprehensive care plan for each resident that includes measurable objectives and goals to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 415.11(c)(1)

Based on interview and record review conducted during the Standard survey completed on 10/28/16, the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents when their Medicare coverage for skilled services was terminated. Three (Residents #2, 26, 41) of three residents reviewed for Liability Notices and Notices of Medicare Provider Non-Coverage (NOMNC) were not provided the SNFABN when Medicare coverage for skilled services was terminated. The findings are: 1. Resident #2 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 10/5/16 revealed the resident is cognitively intact, is understood, and understands. Review of the facility Resident Status History List revealed Medicare was the payor source from 3/7/16 through 5/2/16. Review of the NOMNC dated 4/29/16 revealed notice that skilled services for Physical and Occupational Therapy would end on 5/2/16. Review of the entire medical record (electronic - EMR) and paper record revealed no evidence the resident was provided with an SNFABN. Interview with the facility Business Office Manager on 10/27/16 at approximately 12:09 PM revealed Resident #2 had Medicare benefit days remaining when Medicare coverage for skilled services was terminated on 5/2/16. 2. Resident #26 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, is understood, and understands. Review of a facility Insurance Verification Questionnaire dated 5/24/16, revealed the resident was re-admitted to the facility on [DATE] with 100 Medicare days available. Review of the facility Resident Status History List revealed Medicare was the payor source from 5/24/16 through 6/20/16. Review of the NOMNC dated 6/16/16 revealed notice that skilled services for Physical and Occupational Therapy would end on 6/20/16. Review of the EMR and paper record revealed no evidence the resident was provided an SNFABN. 3. Resident #41 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, is understood, and understands. Review of a facility Insurance Verification Questionnaire, dated 8/9/16, revealed the resident was transferred to the facility on [DATE] with 75 Medicare days available. Review of the facility Resident Status History List revealed Medicare was the payor source from 8/9/16 through 8/20/16. Review of the NOMNC dated 8/18/16 revealed notice that skilled services for Physical and Occupational Therapy would end on 8/20/16. Review of the EMR and paper record revealed no evidence the resident was provided an SNFABN. Interview with the facility Business Office Manager on 10/26/16 at approximately 12:30 PM revealed when Medicare Part A services are terminated, the facility issues a NOMNC and no other notices are issued to the Beneficiary. Interview with the Administrator on 10/27/16 at approximately 9:30 AM revealed There are two letters (NOMNC and SNFABN) that are required to be given when a resident is cut from Medicare and remains in the facility. 415.3(g)(2)(i)

Based on observation, record review and staff and resident interview, the facility did not provide care and services necessary to meet the needs of the resident in order to attain the highest practicable, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. Specifically, for one (Resident #43) of one resident reviewed for quality of care the facility did not ensure effective pain management. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #43 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact. Review of the Care Plan dated 12/27/11 included a plan for the resident to have decreased pain, five or less on the pain scale, with each administration of pain medication, offer heat along with other interventions. During an interview on 1/31/12 at 11:06 AM, the resident answered approximately half of the interview questions then requested to stop the interview because he was in pain. Observation on 2/2/12 at 9:34 AM during personal care, when the CNA assisted the resident to roll from one side to the other and back, revealed the resident moaned and called out "oh oh" with each movement. The Director of Nursing (DON) (who was present during the observation) asked if she could ask the Medication Nurse if the resident could have pain medication and left the room. The certified nurse aide (CNA) did not ask the resident if he needed something for pain or wanted her to stop moving him. The resident continued to moan and call out when moved until the Registered Nurse (RN) Medication Nurse administered Tylenol to the resident at 9:45 AM. When interviewed on 2/2/12 at 10:02 AM the resident stated he hurts all over. When observed on 2/2/12 at 11:26 AM, two CNAs assisted the resident to the edge of the bed, applied a transfer sling, and attached it to the mechanical lift and started to raise the resident. The resident stated "ow, ow" and told the CNA not to raise the lift anymore. The resident was transferred from the bed to the wheelchair with his knees in a flexed position at approximately 90 degrees. During an interview on 2/2/12 at 11:45 AM, the Physical Therapist stated the resident has a problem with the left hip and has "a lot of pain going on with the left hip". She stated the resident is in a "holding pattern" waiting to see if he can get his hip replaced. She stated she will monitor to see if the resident has any back slide and added she does not know if the resident has had any decline. The PT stated the resident is getting ROM to lower extremity as far as she knows. During an interview on 2/2/12 at 12:26 PM, the Registered Nurse (RN) Resident Care Coordinator (RCC) stated the resident was admitted with hip pain and was on [MEDICATION NAME] (narcotic - pain medication) 5 milligrams (mg) every (q) 8 hrs prn (as needed) and was taking the medication at least twice a day. She stated on 12/12/11 an order for [REDACTED]. was not any better because the resident would forget to ask for pain medication. On 1/5/12 the [MEDICATION NAME] 5 mg was changed to q 6 hr around the clock (ATC) and the resident's pain was controlled for "a little bit". The RCC stated she spoke with the Nurse Practitioner (NP) and the NP informed her the dose could be increased if the pain was not controlled. At the surveyor's request on 2/2/12 at 1:05 PM, the DON told the Physician the resident had pain on movement but if he does not move he is not in pain. During an interview on 2/2/12 at 1:06 PM, the Physician stated the resident is not at maximum dose for [MEDICATION NAME] or [MEDICATION NAME] (narcotic- pain medication) and stated he will look at the resident today and evaluate his pain. During an interview on 2/2/12 at approximately 1:30 PM, the CNA assigned to the resident revealed she has done the resident's care before and he is always in pain and it is hard to cleanse his genitals because of it. She stated "The resident is in pain when I transfer him and he cannot straighten out his legs". Review of the Physical Therapy (PT) Progress Notes revealed the following: - 12/19/11 the resident is able to ambulate 40 feet x 1 in parallel bars with assist of 1 and requires moderate assist of one for sit to stand. - 1/9/12 the resident is non ambulatory due to pain. - 1/16/12 the resident is non ambulating due to pain awaiting word from hospital for potential hip surgery. Review of the Registered Physician Assistant 30 Day Visit dated 1/9/12 revealed the resident is currently participating in PT and ambulating with partial weight bearing with a wheelchair. Pain is controlled, requiring scheduled narcotic medication. The Physical Therapy Rehabilitation Screening form dated 1/21/12 revealed the resident has contractures of left hip/knee recommendations for Passive Range of Motion (PROM - exercises performed on the resident by nursing staff) to bilateral lower extremities 5 x week. When interviewed on 2/2/12 at 11:18 AM, the Director of Nursing (DON) stated the resident is no longer going to PT. The DON said she talked with the Physician last week about ordering an anti-[MEDICAL CONDITION] medication for the resident but no order was obtained and she does not know if the Physician has seen the resident. When interviewed on 2/2/12 at 11:35 AM, the Range of Motion (ROM) CNA stated she is filling in for the regular ROM CNA. She revealed the resident refused ROM because he is in too much pain. When observed on 2/2/12 at 11:38 AM, the ROM CNA approached the resident and he agreed to do ROM. The resident moaned during the PROM to the right leg and the CNA asked if she should stop and the resident said no. The CNA then informed the resident she was going to do PROM on the left leg and the resident stated he cannot put the left leg flat. The left leg is in a flexed position. When the CNA picked up the resident's left leg the resident said "ow, ow, ow" and stated it is too painful. The ROM CNA stopped and did not perform ROM to the left leg. When interviewed at this time the ROM CNA stated "The left leg is so stiff and painful I cannot do ROM". When interviewed on 2/3/12 at 11:09 AM, the PT stated the resident has not been on ROM long and no one reported there was any problem with the resident participating in ROM. She stated nursing would communicate to PT if there was a problem with the resident tolerating ROM. During an interview on 2/3/12 at 11:49 AM, the Director of Rehabilitation stated the resident rated his hip pain a 9 out of 10 (10 being the worse). She further revealed at one point the resident was able to transfer with limited assist of 1 person then the resident started complaining of more pain, plateaued in PT, and is now wheelchair bound. She stated the resident's pain was discussed at morning report. When interviewed again on 2/3/12 at 1:55 PM, the Director of Rehabilitation stated the resident was discharged from PT on 1/23/12 but was not put on ROM until 2/1/12. She explained she had hoped the resident was going out for surgery and when the resident did not go out she put him on ROM. The Director of Rehabilitation stated the ROM CNA mentioned to her that the resident was having pain and refused ROM to the left leg. She stated she talked with the resident today and the resident told her his pain was worse than it has ever been. When interviewed on 2/2/12 at 12:53 PM, the Director of Nursing (DON) stated she had just started to introduce the pain scale, 1 (no pain) to 10 (worse pain) in the facility. She stated she assessed the resident using the pain scale and his pain was a 5 and acceptable to him. Review of the facility form entitled Pain Assessment Draft dated 12/9/11 revealed the resident occasionally has pain and on a pain scale of zero to ten the pain is a five. Review of the Pain Assessment Draft dated 1/4/12 revealed the resident almost constantly has pain and the pain is a ten on a scale of zero to ten. Review of the Nurses Notes 12/9/11 to 2/3/12 and the Medication Administration Records (MARs) dated 12/1/11 to 2/3/12 revealed no documented evidence that the resident's pain was assessed using the pain scale zero (no pain) to ten (worse pain). Review of Physician's Progress Notes from 1/19/12 through 2/1/12 revealed no documented evidence that the physician was aware of the resident's increased pain. Review of the MAR indicated [REDACTED]. Review of the physician's orders [REDACTED]. When interviewed on 2/3/12 at 10:45 AM, the resident stated his pain has not been controlled. He stated he has pain all over and pain in the left hip even with the pain medication. The resident stated even though they changed the pain medication yesterday his hip still hurts and he does not know if it has made a difference yet. During an interview on 2/3/12 at 1:27 PM, the Director of Nursing (DON) stated the resident was discontinued from PT because of pain and explained that pain was always an issue. When interviewed on 2/6/12 at 11:28 AM, the RN RCC stated the resident's pain was discussed during morning report and it was decided to discontinue the resident from PT because of pain and lack of his progress. The RCC stated there is no documentation that the physician was notified about the resident's pain after 1/9/11 and "guesses" because he had routine [MEDICATION NAME], the Physician was not notified because the resident's pain was in PT. When interviewed on 2/6/12 at 11:00 AM, CNA #2 stated the resident has pain when she does his care. She stated the resident was always in pain and particularly when he moved his legs. The CNA stated when the resident was in pain she would ask the resident if he wanted her to come back and do care later. She stated during 1/2012 she notified the nurse that he was in pain and was told he already had pain medication. The CNA stated the resident always had pain in his legs so she would notify the nurse later in the day that the resident was in pain so he could be given something for pain. During an interview on 2/6/12 at 2:00 PM, the Licensed Practical Nurse (LPN) Medication Nurse stated that on occasion the CNA would come to her and report the resident had pain and she would go and see the resident. She explained that the resident would tell her he only had pain when he moved his legs and stated that when the resident moved his legs you could hear a cracking sound. In addition the LPN stated the resident was on scheduled [MEDICATION NAME] and at one point she told the resident he needed the pain medication increased and reported it to the RN RCC. 415.12