Every finding on record at Elderwood at Grand Island

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #2674904), the facility did not ensure that all alleged abuse violations were reported immediately but not later than two (2) hours after the allegation was made to the Administrator of the facility and to the State Survey Agency for one (1) (Resident #1) of three (3) residents reviewed. Specifically, staff did not report an allegation of physical abuse to the Administrator immediately which resulted in delayed reporting to the New York State Department of Health within the required time frames.The finding is: The policy titled Abuse Prevention, Identification, Protection and Reporting of Victims last revised on 4/30/2024 documented all facility staff were required to immediately report to the Administrator, Director of Nursing or designee when there was an observed act or suspicion of abuse, mistreatment or neglect. The facility Administrator or designee will report all alleged violations to, state agencies immediately, but no later than two (2) hours after the alleged abuse, mistreatment, and as required agencies (law enforcement, adult protective services, licensing authorities, state nurse aide registries when applicable) with in specified timeframes. All staff will be trained in identifying abuse. Resident #1 had diagnoses which included Alzheimer's Disease, anxiety and depression. The Minimum Data Set (a resident assessment tool) dated 11/13/2025 documented Resident #1 was severely cognitively impaired, was sometimes understood and sometimes understands, and had verbal and physical behavioral symptoms directed towards others. The comprehensive care plan revised on 02/11/2025, documented that Resident #1 had severe cognitive impairment, required assistance with activities of daily living, and ambulated independently. The resident had a history of confrontations with others. The plan included to approach the resident from the front in a calm gentle manner, explain all aspects of care, and if they became agitated, staff were to stop, ensure safety, then reapproach. Review of the New York State Department of Health Complaint Tracking System Complaint/Incident Investigation Report revealed the date/time of the alleged incident was on 11/18/2025 at 8:06AM. The date/time the Administrator was first made aware of the incident was 11/20/2025 at 5:57AM. It was submitted by the facility to the New York State Department of Health on 11/20/2025 at 8:13AM. The facility investigation dated 11/20/2025 at 8:13AM documented an altercation between a staff member and Resident #1 occurred on Tuesday 11/18/2025 at 5:57AM. Certified Nursing Assistant #2 left a note for the Director of Nursing that stated Resident #1 spat in Certified Nursing Assistant #1's face, then Certified Nursing Assistant #1 grabbed Resident #1's hair and slammed Resident #1's face on the bed. There were no additional witnesses to the alleged abuse. During a telephone interview on 12/02/2025 at 10:26AM, Certified Nursing Assistant #2 stated Resident #1 was combative when they provided care. They requested help from Certified Nursing Assistant #1 on 11/19/2025 at 5:57AM. Together they stood Resident #1 up at the side of the bed and provided fecal incontinent care. Certified Nursing Assistant #1 held Resident #1's hands while Certified Nursing Assistant #2 provided the care. Resident #1 spat in Certified Nursing Assistant #1's face, then Certified Nursing Assistant #1 grabbed Resident #1's hair and slammed their face into the mattress. Certified Nursing Assistant #2 was shocked and did not say anything to Certified Nursing Assistant #1. They knew they should have reported the abuse immediately, but they were afraid that Certified Nursing Assistant #1 would retaliate. Certified Nursing Assistant #2 then reported the abuse on 11/20/2025 to Registered Nurse #1 Nurse Supervisor and left a note under the Director of Nursing's door. During a telephone interview on 12/02/2025 at 10:59AM, Certified Nursing Assistant #1 denied grabbing Resident #1 and slamming Resident #1's face into the bed. That would be abuse, and they would never abuse a resident. During a telephone interview on 12/02/2025 at 11:43AM, Registered Nurse #1 Nursing Supervisor stated the alleged abuse was reported by Certified Nursing Assistant #2 on 11/20/2025. They questioned why they waited twenty-four (24) hours to report the abuse. They should have reported the incident immediately on 11/19/2025. During an interview on 12/02/2025 at 12:44PM, Registered Nurse #2 Unit Manager would have expected Certified Nursing Assistant #2 to intervene and immediately inform the nurse on duty. The nurse would then notify the nursing supervisor who then would notify the Director of Nursing or the Administrator. Allegations of abuse were required to be reported the Health Department within (2) two-hours. During an observation on 12/02/2025 at 1:20 PM, Resident #1 was independently ambulating in the halls on the unit with supervision. Resident #1 could not recall the incident, was pleasant and calm. No behaviors were noted, and no signs of physical abuse were identified. Staff were observed treating Resident #1 with respect and dignity. During an interview on 12/02/2025 at 2:00PM, the Director of Nursing stated the dates on the Complaint/Incident Investigation Report should have reflected the abuse allegation took place on Wednesday 11/19/2025 at 5:57AM. They were notified on Thursday 11/20/2025 at 8:06AM. The investigation was initiated and then reported to the State Agency at 8:13AM. Certified Nursing Assistant #2 should have reported the suspected abuse to the nurse or nursing supervisor immediately on 11/19/2025 to prevent further abuse to additional residents. During an interview on 12/02/2025 at 3:16 PM, the Administrator stated Certified Nursing Assistant #2 should have reported the suspected abuse immediately after witnessing the incident. Waiting one day to report the incident, resulted in a two (2) day delay in reporting the incident to the State Agency and was unacceptable. 10 NYCRR 415.4 (b)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/06/24, the facility did not ensure the Director of Nursing served as a charge nurse, only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing worked as a charge nurse when the facility had a daily average census of greater than 60. The finding is: Review of a facility provided document titled Director of Nursing, last revised 2/2024, revealed the Director of Nursing ensures the health and well-being of our residents by being responsible for oversight and operations of the nursing department and its staff including staffing, training, and development, and management of personnel. The Director of Nursing is responsible for upholding and following state, local, and federal regulations, and best practices within their scope of practice. Additionally, the Director of Nursing, in conjunction with the scheduler, monitors the master staffing plan for the department and approves the schedule. Responsible for the overall direction and ongoing supervision of all direct care carried out by department staff. The State Operational Manual dated 11/21/22 documented a charge nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care. The untitled facility resident census reports for November 2024 documented the following: 11/05/24 the census was 82. 11/06/24 the census was 82. 11/07/24 the census was 80. 11/11/24 the census was 78. 11/19/24 the census was 79. 11/25/24 the census was 81. The facility census at the time of survey entrance on 12/02/24 at 8:30 AM was 78 out of 90 available beds. Review of the Facility assessment dated [DATE] documented the facility's daily average census was 84. The services and programs the facility provides to its population include long term care/skilled nursing, subacute and rehabilitation services, respite care and memory care. Special treatments included but were not limited to assessment, respiratory treatments (tracheostomy care), bladder ultrasound, behavioral health needs, IV (intravenous) medications, ng (nasogastric) tubes, ostomy care, advanced wound care (wound vacs and drain management), cardiac care, and emergency services (life vest monitoring and left ventricle assist device). Review of the attached Facility Assessment Staffing Plan documented the minimum staffing numbers for nurses on the night shift with a census of 84 was one Nurse on Unit 1 and one Nurse on Unit 2. Adequate (budgeted staffing) staffing documented one Night Supervisor, one Nurse on Unit 1 and one Nurse on Unit 2. State mandated staffing numbers for nursing was the same as adequate staffing. Review of The Facility Daily Staffing Sheets dated 11/5/24 through 12/4/24 documented the following and revealed the Director of Nursing was counted in the facilities numbers to meet their minimum assessed numbers to provide direct care to the residents. 11/5/24 10:00 PM to 6:00 AM Shift: Unit 1 - there was no nurse scheduled. Unit 2 - there was one Registered Nurse and the Director of Nursing scheduled. 11/6/24 10:00 PM to 6:00 AM Shift: Unit 1 - there was no nurse scheduled. Unit 2 - there was one Registered Nurse and the Director of Nursing scheduled. 11/7/24 10:00 PM to 6:00 AM Shift: Unit 1 - there was one Licensed Practical Nurse scheduled. Unit 2 - the Director of Nursing was nurse scheduled. 11/11/24 10:00 PM to 6:00 AM Shift: Unit 1 - there was one Licensed Practical Nurse scheduled. Unit 2 - the Director of Nursing was nurse scheduled. 11/19/24 10:00 PM to 6:00 AM Shift: Unit 1 - there was one Licensed Practical Nurse scheduled. Unit 2 - the Director of Nursing was the nurse scheduled. 11/25/24 10:00 PM to 6:00 AM Shift: Unit 1 - there was one Licensed Practical Nurse scheduled. Unit 2 - the Director of Nursing was the nurse scheduled. During an observation and interview on 12/4/24 at 8:04 AM, the Director of Nursing stood at the 2nd floor team 2 medication cart. They stated they were passing medication until the Unit Manager arrived. They also stated they worked the night shift last night (12/3/24) because they were supposed to train a new employee, but that employee had called off. During an interview on 12/05/24 at 1:12 PM, the Scheduling Supervisor stated the Director of Nursing was on the schedule whenever there was a new nurse, and the educator was unavailable to train them. They also stated they preferred a Licensed Practical Nurses not to train a Registered Nurse because the Licensed Practical Nurse could not do intravenous therapy. They stated they prefer to have a Registered Nurse and a Licensed Practical Nurse on the units for overnights because if there was a fall the Registered Nurse was there to assess the resident. During an interview on 12/5/24 at 3:05 PM, the Director of Nursing they stated they picked up shifts in addition to their dedicated 8 hours as the Director of Nursing. They stated if there was an opening on the overnight shift that could not be filled, they would sign up for them. During an interview on 12/6/24 at 10:58 AM, the Supervisor Scheduler, stated the Director of Nursing worked the overnight shift of 10:00 PM - 6:00 AM on 11/5/24, 11/6/24, 11/7/24, 11/19/24 and 11/25/24 because there were no other nurses available. On 11/11/24 they worked the 10:00 PM to 6:00 AM because they needed a Registered Nurse to work because they will not schedule a Licensed Practical Nurse without a Registered Nurse on duty for the overnight shift. They stated that on 11/18/24, 11/26/24, and 11/29/24 the Director of Nursing worked overnight shift along with two other Registered Nurses because the Director of Nursing trained one of the nurses. They stated new Registered Nurses would train for four months, and the Director of Nursing would train them if no one else was available. During an interview on 12/06/24 at 1:14 PM, the Administrator stated the Director of Nursing was never acting as a charge nurse simultaneously with their Director of Nursing duties. During an interview on 12/6/24 at 3:34 PM, the Director of Nursing stated they worked their 40 hours per week as the Director of Nursing and when they worked on a cart that was in addition to the 40 hours of their Director of Nursing duties. 10NYCRR 415.13(b)(1)

Based on interview and record review conducted during the Standard survey completed on 12/6/24, the facility did not employ a qualified professional to furnish a specific service to be provided by the facility and the facility did not have that service furnished to residents by a person or agency outside the facility under an arrangement. Specifically, the facility did not have a dentist on their staff and did not have dental services provided by an outside person or agency under an arrangement. This had the potential to affect 78 of 78 residents. The finding is: The policy titled Dental Care Arrangements dated 6/18/18 documented routine or emergency dental services will be offered onsite on either staff or fee-for-services basis, as administered by or under either the personal or general supervision of a licensed and currently registered Dental consultant. Review of the Facility Survey Report (Form DOH-1550), signed by the Administrator on 12/2/24, revealed a handwritten note in the dental services section that the facility was in the process of procuring a new contract. The question Are routine dental services provided within your facility was inaccurately documented as yes and the question Does your facility have a cooperative agreement with an outside dental service, was left blank. The facility's Admission Agreement, provided by the Administrator on 12/3/24, documented services provided by the facility included physician services and the following physician-ordered services ancillary-services are available through duly licensed, registered, and/or certified practitioners: dental services. During an interview on 12/5/24 at 4:14 PM, the Registered Nurse Unit Manager #1 stated the facility didn't have a dentist and residents would have to wait for routine dental services. For any emergent dental issues, they assumed the resident would be sent to (the county medical center). They were not sure how long there had been no dentist. During an interview on 12/6/24 at 9:20 AM, the Unit Clerk #1 stated there had not been a dentist coming into the facility since April. If someone needed to see a dentist, they would send them to (the county medical center), but it took a little time to be seen. The last time they called to set up an appointment it was a 3 month wait. For routine cleanings or exams, they would talk to the family to see if they had a family dentist and go from there. During an interview on 12/6/24 at 9:33 AM, Registered Nurse Unit Manager #2 stated there was no dentist and they weren't sure how long it was been. If a resident had an issue that needed immediate attention, they would send them to an emergency room . They stated it was important to have a dentist for the resident's dental health and possibly their nutrition. During an interview on 12/6/24 at 11:59 AM, the Director of Nursing stated they didn't know how long they haven't had a dentist. They knew they were working on a contract. The medical provider will look at residents to see if there were any issues with their teeth, the Unit Clerks kept track of who needed annual exams. They haven't needed to use (the county medical center) for anything emergent, they would send a resident to the emergency room if it were very emergent. Routine oral or dental exams were not being completed by a dentist. During an interview on 12/6/24 at 12:56 PM, the Administrator stated corporate was in the process of obtaining a dental contract, there was no specific date as to when the contract will be in place. The Administrator stated the dentist used to come monthly, and they haven't had a dental contract since April (2024). They did not send a letter out to families or residents. The Administrator stated there should be a dentist available for residents because it was part of the regulations, and they didn't know if it was part of the facility admission agreement. 10 NYCRR 415.26(e)

Based on observations, record review, and interviews conducted during a Standard survey completed on 12/6/24, the facility did not ensure that all residents received services that provided reasonable accommodations of the resident's needs and preferences for one (Resident #1) of four residents reviewed. Specifically, the call system was not within reach as planned and unable to be used if desired. The finding is: The policy and procedure titled, Call Light/Call Bell/Nurse Call System with a revision date of 9/6/18, documented the Unit Manager/designee will ensure residents will be provided access to a call light when not in a common area of the facility, and the call light will be answered promptly by all nursing staff and unit clerks/designee when a resident signals for assistance. The Team Leader/Nursing Assistant is responsible for ensuring the call light signal apparatus is within reach of residents who remain in their rooms and are immobile. The call light is normally placed on the bed if the resident is not present in his/her room; or in the location designated by the resident who can move about on their own and locate the call light easily. Resident #1 had diagnoses of multiple sclerosis, hemiplegia (parallelization on one side of the body), hemiparesis (one sided muscle weakness) following a cerebral infarction (a block in the blood flow to the brain) affecting Resident #1's right dominant side. The Minimum Data Set (a resident tool assessment) dated 9/19/24 documented Resident #1 was moderately cognitively impaired and was sometimes understood and sometimes understands. Resident #1 was totally dependent on staff for bed mobility and transfers. The comprehensive care plan dated 10/6/24, documented Resident #1 had safety risks and their call light was to be kept within reach and provide a safe environment. Additionally, Resident #1 had an alteration in communication-speech/hearing and interventions included to instruct and reinforce the use of adaptive equipment to promote communication. The Kardex (a guide by staff to provide care) dated 9/19/24, documented that Resident #1 was to have their call light within reach and staff were to encourage use. During an observation on 12/2/24 at 9:00 AM there was a handwritten note signed by Occupational Therapist #2 posted on the wall in Resident 1's room at the head of the bed that documented the call bell was to be pinned at all times to Resident #1's stomach and chest area. An Occupational Therapy progress note dated 9/1/23, documented the writer promoted self-advocacy with use of modified call button multiple times during session; writer created sign and placed it next to call light for positioning of call button to ensure that patient can reach with range of motion. During a continuous observation on 12/02/24 from 9:00 AM through 10:41 AM Resident #1 was lying in their bed, their call light was on the floor and was not within their reach. During this time Resident #1 was heard moaning and was observed several times attempting to reposition themselves and sit up. At 10:41 AM the surveyor handed the resident their call bell and they were able to tap the bell for staff assistance. During an observation on 12/02/24 11:20 AM, Resident #was lying in bed, their call bell was pinned to the bed sheets below the resident's stomach and out of their reach. During an observation on 12/03/24 9:45 AM, Resident #1's was lying in bed and the call bell was on the floor. During a continuous observation on 12/04/24 from 8:34 AM to 11:00 AM Resident #1's call bell was hanging over the headboard behind the resident out of their reach. During an interview on 12/04/24 at 9:28 AM, Support Aide #1 stated they saw Resident #1's call bell hung behind the resident on the headboard. They stated Resident #1 would not have been able to reach their call bell if they needed to. Support Aide #1 took the call bell from behind the headboard and pinned it to Resident #1's stomach/chest area. During an interview on 12/04/24 at 9:55 AM, Certified Nurse Aide #1 stated they had left the call bell hung over the back of the bed (head board) when they completed Resident #1's care that morning and must have forgotten to pin it to within their reach. The resident would not have been able to reach their call. They stated it was important for the resident to be able to reach their call bell in case they needed help. During an interview on 12/06/24 at 10:02 AM, Licensed Practical Nurse #1, stated Resident #1 had a sign over their bed to place their call bell near their chest/stomach area so they could access the call bell easily. They stated Resident #1 had limited range of motion, poor dexterity and had a modified call bell designed to tap when help was needed. During an interview on 12/6/24 at 10:05 AM, Occupational Therapist #1 stated Resident #1 had a modified call device and it should rest near their stomach/chest area because they did not have the dexterity to press a button due to limited range of motion. They stated during the resident's assessment they were able to tap the modified device and a sign was posted above the resident's bed to notify the staff where to place the call bell so the resident would be able to utilize it. Occupational Therapist #1 stated the assessment was completed to ensure Resident #1's needs were accommodated, and the plan should be followed to ensure the resident's safety. During an interview on 12/06/24 at 10:08 AM, Registered Nurse Unit 1 Manager #2 stated they did not know there was a sign posted over Resident #1's bed, but they had a touch pad call bell put in place due to their poor dexterity. They stated it was important to have the call bell within reach so they could have their needs met. They stated it was everyone's responsibility to ensure when they leave the room the call bell was within reach. NYCRR 10 415.5 (e) (1)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/6/24, the facility did not develop a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for one (Resident #18) of three residents reviewed for elopement. Specifically, Resident #18 was assessed as a high risk for elopement and did not have a comprehensive care plan developed with interventions to address their wandering and exit seeking behaviors. The finding is: The policy and procedure titled Care Planning (IDT) last modified 1/22/19, documented the comprehensive care plan would include services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing. Designated staff of all disciplines will be responsible for the evaluation and updating of the inter-disciplinary resident care plan after the resident care planning meeting and as needed following changes in the status of the resident. The interdisciplinary team will review/revise the care plan after each assessment, including both the comprehensive and quarterly review assessments per the RAI (Resident Assessment Instrument - a guide that provides instructions to assess residents in nursing homes.) manual. The policy and procedure titled Elopement-Wandering-Missing Resident last modified 10/8/18, documented all residents are assessed upon admission, annually, and as needed to determine risk level for unsafe wandering/elopement. Appropriate safety measures are put into place for residents determined to be at risk. Resident #18 had diagnoses that included Alzheimer's Disease, vascular dementia, and post-traumatic stress disorder (a mental health disorder caused by extreme stress or terrifying event). The Minimum Data Set (MDS, a resident assessment tool) dated 11/14/24 documented Resident #18 was usually understood and usually understands and had severe cognitive impairment. The Minimum Data Set documented Resident #18 was independent with ambulation and displayed wandering behaviors that had occurred 1-3 days during the review. Additionally, the Minimum Data Set assessment documented these wandering behaviors would be care planned to avoid complications and minimize risks. Review of the comprehensive care plan dated 11/14/24 identified as the current care plan by the Registered Nurse Unit Manager #1 revealed there was no care plan developed for wandering and elopement. The Kardex Report (a guide used by staff to provide care) dated 12/3/24 documented Resident #18 was independent with transfers and ambulation. There were no documented safety interventions in place for wandering and elopement risk. The SNF (skilled nursing facility) Elopement assessment dated [DATE], documented Resident #18 was at high risk for elopement. They were regularly awake during the night, difficult to re-direct back to bed and would enter other resident's rooms. Review of a behavior monitoring progress note dated 12/1/24 completed by Licensed Practical Nurse #2, documented Resident #18 had been pacing continuously and exit seeking. Licensed Practical Nurse #2 documented that these behaviors had lasted over 60 minutes. Review of a behavior monitoring progress noted dated 11/23/24 completed by Registered Nurse Supervisor #2, documented Resident #18 had been pacing episodically and wandered into inappropriate places. Registered Nurse Supervisor #2 documented that these behaviors had lasted over 60 minutes. Review of nursing progress notes dated 11/22/24, 11/25/24, and 11/28/24, documented Resident #18 exhibited pacing and wandering behaviors in and out of other resident's rooms and hallways. During an observation on 12/2/24 at 3:28 PM, Resident #18 was observed on the unit wandering up and down north and south hallways going towards exit doors and had verbalized wanting to know how to get downstairs. During an observation on 12/4/24 at 3:58 PM, Resident #18 was observed to be ambulating down the south hall towards the exit door, Resident #18 had stopped by the door turned around and walked back up the hallway. Resident #18 verbalized while ambulating that they did not want to be here and were leaving. At 4:04 PM Resident #18 had ambulated down the north hallway to the exit door, which leads to a stairwell. They had grabbed and turned the doorknob of the exit door, the door was locked and did not open. Resident #18 then turned around and ambulated back up the hallway and headed towards the south hall exit door. Resident #18 grabbed and turned the doorknob of the south hall exit door. The door was locked and did not open. During an observation and interview with Certified Nurse Aid #2 on 12/4/24 at 4:08 PM, Certified Nurse Aide # 2 redirected Resident #18 away from the south hall exit door. Certified Nurse Aide #2 stated that Resident #18 could be anxious and confused and would wander the unit to try and find their way out. Certified Nurse Aide #2 stated they had just saw Resident #18 grab the doorknob on the south hall exit door and that was why they had intervened and redirected Resident #18 back to their room. During an interview on 12/5/24 at 9:04 AM, Certified Nurse Aide #3 stated Resident #18 was confused and could become agitated. They stated Resident #18 would wander up and down the unit hallways and would verbalize show me the exit. They stated Resident #18 would go to the exit doors on their unit but had not observed them attempting to open the doors. Certified Nurse Aide #3 stated that they would notify the nurse with resident's behaviors. During an interview on 12/5/24 at 11:11 AM, Licensed Practical Nurse #2 stated Resident #18 would wander the unit going hallway to hallway and had displayed exit seeking behaviors. They stated that Resident #18 would pull on doors but had not attempted to get on the elevator. They stated these wandering behaviors could last for hours and would need to be re-directed often. Licensed Practical Nurse #2 stated that they would document resident behaviors in the medical record. During an interview on 12/5/24 at 1:31 PM, Registered Nurse Unit Manager #1 stated the Interdisciplinary Team (IDT) would be responsible to update their own sections of the care plan. They stated that wandering and elopement would be care planned if the elopement assessment determined a resident to be at high risk. Registered Nurse Unit Manager #1 stated that Resident #18 would wander the entire unit and would go room to room actively trying to leave. They stated they had not seen Resident #18 grab at doors or make attempts to get on elevator and would expect staff to document and notify them of resident's exit seeking behaviors. Registered Nurse Unit Manager #1 stated that Resident #18 should be care planned for their wandering behaviors. During the interview Registered Nurse Unit Manager #1 reviewed Resident #18's current comprehensive care plan in the electronic medical record, and stated that Resident #18 did not have an active care plan in place to address their wandering or risk for elopement behaviors. Registered Nurse Unit Manager #1 then reviewed the quarterly elopement assessment completed on 11/14/24 for Resident #18 and stated the assessment documented Resident #18 was at high risk for elopement. They stated Resident #18 did wander the unit but did not feel they would leave the unit and was not sure if Resident #18 should be care planned for wandering and elopement. During an interview on 12/5/24 at 3:01 PM, Licensed Practical Nurse #3/PPS(Prospective Payment System) Coordinator stated they were responsible to complete the quarterly elopement assessments. They stated they would review the nurses' notes and Kardex prior to completing the elopement assessments and that they were familiar with the residents. Licensed Practical Nurse #3/PPS Coordinator stated they had just completed the assessments and were not responsible to update care plan and did not update the interdisciplinary team with changes noted on the assessments or the Minimum Data Set assessment. During the interview with Licensed Practical Nurse #3/PPS Coordinator, reviewed the most recent comprehensive assessment for Resident #18 dated 11/14/24 and stated that it documented that wandering behaviors were present and the Care Area Assessment (CAA) of the Minimum Data Set documented these behaviors would be addressed in the care plan. The Licensed Practical Nurse #3/PPS Coordinator stated that any care area that was triggered on the Minimum Data Set assessment should be care planned. During an interview on 12/6/24 at 10:50 AM, the Director of Nursing stated that nursing was responsible to complete elopement assessments on admission and quarterly; and that the interdisciplinary team would be responsible for updating the care plans. Interim Director of Nursing #1 stated that if a resident was wandering on the unit, exit seeking and triggered as a high risk for elopement, they would expect those behaviors to be care planned. They stated that Resident #18 would wander on the unit but would not exit seek. They stated exit seeking behaviors consisted of going to doors, grabbing handles, and attempting to get out. Interim Director of Nursing #1 stated that if a resident triggered as a high risk on the elopement assessment it would be up to the interdisciplinary team to decide if the care plan should be developed. 10NYCRR 415.11 (c) (1)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/11/24, the facility did not ensure that services being provided met professional standards of quality for one (Resident #37) of one resident reviewed. Specifically, provider orders were not implemented resulting in a delay in treatment. The finding is: Review of the policy titled Clinics and Consultations (dentist, podiatrist, optometrist, audiologist, other), last revised 03/19, documented designated staff will assist the resident in obtaining outside optometry services as ordered by a physician. The Unit Manager/Charge Nurse contacts the attending physician about the orders or recommendations of the consult. All onsite clinics are recorded in the nursing progress notes, including any recommendations from the medical consultant. The attending physician approves, modifies, or cancels the order with a physician's order. Review of the policy titled Nursing Supervisor, last revised 04/21, documented the Nursing Supervisor assists with ensuring the health and well-being of our residents by being responsible for nursing care rendered at the facility during the assigned shift. Document as applicable in the care plans, nursing notes, medical administration records, treatment administration records and other required records according to the service excellence standards and goals. Contact physician for orders or update according to resident response to treatment plan and/or situation and participates in change-of shift report and is responsible for bringing personnel of next shift up to date about the care and needs of residents. Review of the policy titled Unit Manager, last revised 04/21, documented the Unit Manager is responsible for the Nursing services and oversight of social programming for all residents on their assigned unit for a twenty-four-hour basis; involves communication with physicians. This individual is responsible for nursing care reporting, documentation planning, implementation, and evaluation. Identifies residents' problems and nursing interventions and solicits interdisciplinary approaches to problems or needs of the residents. Resident #37 had diagnoses which included unspecified macular degeneration (gradual loss of sharp central vision), type 2 diabetes, and dementia with anxiety, mood, and psychotic disturbances. The Minimum Data Set (a resident assessment tool) dated 9/5/24 documented Resident #37 was moderately cognitively impaired, was usually understood, and usually understands. Additionally, the Minimum Data Set documented that Resident #37 was dependent on staff for personal hygiene. The comprehensive care plan dated 9/19/22 documented Resident #37 had impaired vision related to macular degeneration with interventions to monitor visual status and Ophthalmology/Optometrist consult as needed. Review of Optometrist consult form, dated 11/12/24, documented Resident #37 was seen by Optometrist for a dilated fundus exam (a procedure that uses eye drops to enlarge the pupil, to allow an examiner to view the inside of the eye). Recommendations were made to provide a prescription for lid hygiene twice a day for blepharitis (inflammation along the edges of the eye lids caused from bacteria on the eye lids and base of eye lashes) to both eyes. There were two sets of initials with dates next to them, dated 11/13 and 11/14, on the bottom of the document. Review of Resident #37's physician orders dated 11/12/24 to 12/03/24 revealed there was no physicians order for lid hygiene. Review of a secure conversation message thread dated 11/13/24 documented Registered Nurse Nursing Supervisor #1 sent a message to Nurse Practitioner #1 at 10:37 AM regarding recommendations for lid hygiene twice a day made by Optometrist for Resident #37. Nurse Practitioner #1 responded at 11:05 AM ok-did you order lid hygiene. The secure conversation documented 12+ people received message thread. There was no documented evidence of a response until 12/04/24 by Registered Nurse Unit Manager #1 at 10:26 AM. Review of Nursing Report sheets dated 11/12/24 and 11/13/24 revealed there was no documented evidence that recommendation was carried out for Resident #37. During an observation on 12/02/24 at 9:40 AM, Resident #37 was sitting in their wheelchair in the common area. The sclera (white portion) of both their eyes was red and glossy and there was a large amount of yellow dried debris in the inner corner of their left eye. There was dried white debris and clear drainage running down the left side of their face from their left eye. During an observation on 12/03/24 at 8:47 AM, Resident #37 was sitting in their wheelchair in the common area. Both eyes remained red and glossy. The lashes on both eyes had dried yellow crust on them. During a follow up observation on 12/04/24 at 8:37 AM, Resident #37 was sitting in the lounge area. Both eyes remained red and glossy, there was drainage coming from their left eye and dried yellow crust was in their eye lashes on both eyes. During an interview on 12/04/24 at 10:03 AM, Registered Nurse Unit Manager #1 stated the process for consultant recommendations would be to update provider through secure conversation message of the recommendation and obtain order to follow through with recommendation if they agreed. Registered Nurse Unit Manager #1 stated Resident #37 had an eye consultation in November of this year. They reviewed the eye consult in the resident's medical record and reviewed the physician orders and stated, I don't see that the order was carried through, the provider was not updated and there was never an order placed for this recommendation from the Optometrist. Registered Nurse Unit Manager #1 identified that one signature on the bottom of the consult as Registered Nurse Supervisor #1, dated 11/13, and the second signature was from Nurse Practitioner #1, dated 11/14. Registered Nurse Unit Manager #1 stated the nurse that received the consult was responsible for ensuring the order recommendations were carried out. During a telephone interview on 12/04/24 at 11:17 AM, Registered Nurse Supervisor #1 stated the provider should be updated through a secure conversation message of consultants recommendation and obtain an order if the provider agreed with recommendation. The order then would be added into the resident's medical record. Registered Nurse Nursing Supervisor #1 stated they did not recall specifically about Resident #37's consult recommendations, but they stated they recalled there were eye exams conducted that day in the facility. They stated if there were any consults from that day, they would have been placed into the providers folder for them to sign. They stated if there was a recommendation, they would have written it on the 24-hour report sheet to alert staff to new order. During an interview on 12/04/24 at 11:44 AM, Certified Nurse Aide #4 stated they noticed Resident #37 had dried yellow debris in the corners of their eyes that morning, so they cleaned them. During an interview on 12/04/24 at 1:28 PM, Nurse Practitioner #1 stated they received a secure conversation message on 11/13/24 regarding Resident #37 and pulled up the text thread on the computer to review. They stated they responded to the message that they agreed with the Optometrist recommendation and asked if the lid hygiene was ordered. There was no response. Nurse Practitioner #1 stated they expected that the recommendation for Resident #37 would have been carried through. Nurse Practitioner #1 stated there was never an order placed for lid hygiene for Resident #37 on 11/13/24, and they were unable to enter orders themselves. They observed all staff the message was sent to and stated the Unit Manager and Nursing Supervisor were on the message thread, along with 10 other people but no one replied or carried the order out, and any person on the message thread could have carried the order out. Nurse Practitioner #1 stated Registered Nurse Unit Manager #1 replied to message on 12/04/24 at 10:36 AM and lid hygiene was ordered for Resident #37 as of 12/04/24. During an interview on 12/05/24 at 10:12 AM, Registered Nurse Unit Manager #1 stated their secure conversation messenger was not working properly after the last update and they were not receiving alerts. Registered Nurse Unit Manager #1 reviewed secure conversation message thread regarding Resident #37 and stated they were unaware they received a message from Nurse Practitioner #1. They stated no one had documented there was a new recommendation for Resident #37. Registered Nurse Unit Manager #1 stated whoever sent the message was responsible for following through with recommendation order. They stated it should have been written on the 24-hour nurse report sheet, and a nursing progress note should have been written so the next shift coming on was aware of the new recommendation. During an interview on 12/05/24 at 12:31 PM, the Director of Nursing stated the person that received the recommendation should follow through with any new order if there was one. It should be documented in the nursing progress noted and written on the 24-hour nurse report sheet. The Director of Nursing stated they do not know why the secure message was sent to multiple people, it only needed to be sent to whoever was normally in charge of Resident #37. They stated there should have been was no documentation and it was important to carry out recommendations from providers to ensure residents' quality of life. 10NYCRR 415.11(c)(3)(i)

Based on interview and record review conducted during an Abbreviated Survey (complaint # NY00313153) completed on 5/5/23, the facility did not ensure that all alleged violations involving abuse were reported immediately but no later than 2 hours after the allegation is made to the appropriate officials (including the State Survey Agency) for one (Resident #1) of three residents reviewed for abuse. Specifically, the facility did not implement policies and procedures for covered individuals to identify and report alleged violations of abuse and mistreatment. The alleged violation of abuse was not reported to the Administrator, as well as the New York State (NYS) Department of Health (DOH) within the required time frames. The finding is: The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 12/2022 documented all facility staff are required to immediately report to the Administrator, Director of Nursing (DON) or designee when observed act or suspicion of abuse, mistreatment, neglect is observed or suspected. The facility Administrator or designees will report all alleged violations to state agencies immediately, but no later than two hours after the alleged abuse, mistreatment; and as required to all other agencies within specified timeframes. 1. Resident #1 had diagnoses including dementia, Alzheimer's disease, and anxiety. The Minimum Data Set (MDS-a resident assessment tool) dated 2/17/23 documented Resident #1 had severe impaired cognition and had verbal behavioral symptoms directed towards others that occurred one to three days during the seven day look back period. The undated comprehensive care plan (CCP) documented Resident #1 had the potential for alteration in mood and behavior related to behaviors which may affect others and had a history of physical/verbal altercations with staff and others. Interventions included to re-approach as appropriate. The Closet Care Plan (guide used by staff to provide care) with an as of date 2/2/23 documented that if Resident #1 was agitated, stop, ensure safety and re-approach. The Investigation Summary Report completed by the Director of Nursing on 3/21/23 documented that on 3/9/23 Certified Nurse Aide (CNA) #2, was asked by the nurse to assist CNA #1 with Resident #1. CNA #2 entered Resident #1's room and observed CNA #1 holding up their closed fist at Resident #1 and stated, If you do that again, I'll kick your (explicit word), as Resident #1 was combative. CNA #2 intervened and told CNA #1 to leave the room while CNA#2 finished care for Resident #1. CAN #2 reported the incident to Licensed Practical Nurse, (LPN) #1 Unit Manager the following morning on 3/10/23. LPN #1 did not report the alleged verbal abuse to the Administrator, interim DON, or DON until 3/21/23. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/Incident Investigation Report documented the date/time of occurrence was 3/9/23 at 2:00 PM and was submitted by the facility on 3/21/23 at 9:25 AM. During a telephone interview on 5/4/23 at 2:40 PM, CNA #2 stated upon entering Resident #1's room on 3/9/23 to assist CNA #1 with care, CNA #2 witnessed CNA #1 flinching their clenched fist at Resident #1 and stated, If you ever do that again, I will kick your (explicit word). CNA #1 was abrupt with Resident #1. CNA #2 intervened, instructed CNA #1 to leave the room, and completed Resident #1's care. CNA #2 reported the incident to LPN #1 Unit Manager on 3/10/23 and couldn't remember the time they reported it. During a telephone interview on 5/5/23 at 8:48 AM, LPN #1 stated the incident on 3/9/23 was reported by CNA #2 on the morning of 3/10/23 and should have been reported immediately to the Administrator, DON, or interim DON on 3/9/23. LPN #1 did not report the allegation until 3/21/23 when the current DON returned to the facility. During a telephone interview on 5/5/23 at 10:04 AM, Registered Nurse (RN) #1 stated at the time of the alleged violation of abuse (3/9/23) they were the interim DON. RN #1 stated that CNA #2 and LPN #1 did not report the alleged abuse on 3/9/23. Abuse was to be reported immediately for the safety of the residents and RN #1 stated they would have been reported the alleged abuse right away to the Administrator. During a telephone interview on 5/5/23 at 11:07 AM, the current DON stated CNA #2 acted appropriately by having CNA #1 leave the room. LPN #1 and CNA #2 should have reported the incident immediately instead of waiting. This incident was verbal abuse and was required to be reported to the NYS DOH with 2- hours. During a telephone interview on 5/5/23 at 11:23 AM, Administrator #1 stated CNA #1 and LPN #1 were required to report the alleged violation of abuse at the time of the incident. Administrator #1 stated they were unaware of the alleged violation until 3/21/23, therefor it was not reported with in the required time frames. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 257) started 11/21/22 and completed 11/23/22, the facility did not ensure the resident's right to be free from abuse for one (Resident #1) of three residents reviewed for sexual abuse. Specifically, Residents #1 and Resident #2 were observed by staff engaged in oral sex and Resident #1 lacked the ability to consent. The finding is: The facility policy and procedure (P&P) titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 4/17/2019 documented that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment exploitation and involuntary seclusion. The P&P documented those residents with needs and behaviors that might lead to conflict, or neglect will be monitored and assessed daily, and appropriate care planning provided as needed to prevent the occurrences of abuse or neglect. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 3/22/22 documented Resident #1 had severely impaired decision making was usually understood, and usually understands. The MDS documented the resident required supervision with bed mobility, transfers, and walking. The comprehensive care plan (CCP) dated 7/1/21 documented that Resident #1 had an alteration in communication relate to impaired cognition and dementia. Resident #1's speech quality usually was clear, stutters, repeated words, and yelled at times. Review of the Determination of Incapacity for Medical Decision-Making documented that MD #2 signed on 7/26/20 and MD #1 signed on 8/7/21 that Resident #2 did not have capacity to make own medical/health care decisions due to advance dementia. Review of the Nurses Notes dated 3/28/22 at 7:25 AM, Licensed Practical Nurse (LPN) #1 documented they witnessed Resident #1 standing next to Resident #2's bed with their pants at their ankles. Resident #2 was laying across the bed leaning toward Resident #1 performing oral sex on Resident #1. The residents were immediately separated. Review of the Provider Visit note dated 3/28/22 at 1:18 PM, MD #2 documented that Resident #1 was seen for an acute visit related to inappropriate sexual behavior. Review of the Psychiatry Consult dated 3/30/22 the Psychiatrist documented they saw Resident #1 due to sexually inappropriate behavior. The consult documented that Resident #1 could not account for the events that reportedly transpired with the roommate, could not recall having a roommate nor was missing the roommate. The Psychiatrist documented that there was not a consult request called into their office for the other individual implicated in the oral sexual behavior. The psychiatrist documented that Resident #1 seemed to have been a passive participant and it is unclear whether they knowingly engaged in the sexual behavior. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #2 had moderate cognitive impairment, was understood, and understands. The resident required an extensive assist of two for bed mobility and toileting; and an extensive assist of one for hygiene and transfers. The Comprehensive Care plan (CCP) with initiated date of 11/5/2021 documented Resident #2 had periods of confusion. Review of the Determination of Incapacity for Medical Decision-Making documented that Nurse Practitioner (NP) signed on 11/18/21 and MD #1 signed on 12/15/21 that Resident #1 did not have capacity to make own medical/health care decisions due to moderate/severe dementia. Review of the Psychiatry Consult dated 4/3/22 the Psychiatrist documented that Resident #2 was seen due to sexually inappropriate behavior. The Psychiatrist documented that Resident #2 stated they acknowledged recently moving to a new floor and they did not like being in a single room. The Psychiatrist documented that Resident #2 could not account for the events that transpired with the roommate and when inquiries were made, Resident #2 stated they were not harmed in the sexual interaction, and they did not feel compelled to engage in the actions. Review of the Provider Visit notes from 3/28/22-5/23/22, MD #1 did not document about the sexual activity that occurred between Resident #2 and Resident #1. Review of the 'Facility Investigation unsigned and dated 3/28/22 documented that Resident #1 and Resident #2 were found by a staff nurse engaged in oral sex in their shared room on 3/28/22 at 7:25 AM. The facility investigation documented that both residents were immediately separated. The facility investigation documented that Resident #1 statement was yea yea and their Brief Interview for Mental Status (BIMS) score was severe impairment. RN #1 conducted an interview with Resident #2 and the resident stated that Resident #1 approached them with an erection that Resident #1 seemed proud of and was saying that it hurt. Resident #2 also stated in the interview that they just both came/joined together and it was a joint effort, then the nurse walked in on us. It was documented that Resident #2 stated in their interview they would have felt a lot better if we hadn't gotten caught and they had done this once before when they were a teenager. The SW completed a BIMS score on Resident #2, and they had severe impairment. During an interview on 11/22/22 at 11:00 AM, the SW stated that due to Resident #1's vocabulary they were unable to know if Resident #1 would be able to consent to a sexual act. The SW stated in March of 2022 Resident #2 would have had the ability to say no to a sexual act. During an interview on 11/22/22 at 11:45 AM, LPN #1 stated when they entered Resident #1 and #2's shared room, they observed Resident #1 next to Resident #2's bed with their pants around their ankles. LPN #1 stated that Resident #2 was lying in bed with their body turned to the side resting on their elbow. LPN #1 stated they shouted, what are you doing and Resident #2 stopped performing oral sex on Resident #1. LPN #1 stated they separated the residents and called the nursing supervisor. LPN #1 stated they do not know if Resident #1 knew what was happening but Resident #2 did. LPN #1 stated that Resident #2 got red in the face with embarrassment. During a telephone interview on 11/22/22 at 12:41 PM, MD #1 stated that Resident #2 had capacity to consent to the oral sexual act even though they had a low BIMS score because Resident #2 could recall the incident after it happened. MD #1 stated that Resident #2 saw that their friend was in distress, and they wanted to help them out. In a further interview on 11/23/22 at 12:16 PM, the MD #1 stated that they do not recall when they saw Resident #2 after the sexual act occurred, but the nursing staff called them at the time of the incident. The MD #1 further added that they felt the sexual act was inappropriate act with good intentions of helping a friend out with a problem. During an interview on 11/22/22 at 1:08 PM, RN #1 stated when they interviewed Resident #2, the resident was clear in their cognition, and they were embarrassed they got caught in the sexual act. RN #1 stated that Resident #2 stated Resident #1 came over to them but would not go into detail about who initiated the sexual act and that they just came together. RN #1 stated they could not get an interview from Resident #1 because of their cognition and speech difficulties. During a telephone interview on 11/22/22 at 1:47 PM, the Psychiatrist stated that consent for a sexual act with dementia residents would depend on their advancement of the dementia and they usually cannot remark on the capacity of a dementia resident to consent to a sexual act because they were not seeing the person at the time in act occurred. During a telephone interview on 11/22/22 at 1:50 PM, MD #2 stated that they were Resident #1's doctor, and that Resident #1 had an isolated sexual act. MD #2 stated that Resident #1 lacked capacity to make financial and medical decisions so therefore they lacked capacity to consent to a sexual act. MD #2 stated that Resident #2 had advanced dementia. During an interview on 11/22/22 at 3:11 PM, the Director of Nursing (DON) stated that they were not involved in the investigation of the sexual act between Resident #1 and Resident #2 and did not know if the oral sex act would be considered sexual abuse. During an interview at 11/22/22 at 3:23 PM, RN #2 Regional Nurse stated the former Administrator called them with the investigation for Resident #1 and Resident #2. RN #2 stated that they could not rule in or rule out sexual abuse because both residents had dementia. RN #2 stated that was the reason why they reported the incident to the Department of Health. During a telephone interview on 11/23/22 at 12:09 PM, the former Administrator stated their conclusion to the alleged sexual abuse investigation occurred because there was a witness. The former Administrator stated that Resident #1 and Resident #2 were both non-consenting adults because both had severe cognitive impairment. The former Administrator stated the MD determines a resident's capacity and if the MD's stated that one resident was able to consent to a sexual act, and the other resident was unable to consent to a sexual act it would be considered sexual abuse. 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/6/21, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) receives the necessary services to maintain grooming and personal hygiene. Specifically, two (Resident #13 and #25) of two residents reviewed for ADL's had long (#13) and dirty fingernails (#13, 25) during multiple observations. The findings are: The facility policy and procedure (P&P) titled Hand and Nail Care dated 1/25/19 documented that residents will receive nail care for cleanliness and to prevent infection. Appropriately trained nursing assistants will provide nail care for all residents except those with diabetes mellitus or severe [CONDITION(S)] (PVD). The facility P&P titled ADL Assistance and Supervision dated 1/8/18 documented the Unit Manager (UM)/ designee will ensure that a plan of care for receiving ADL assistance is incorporated into the daily nursing care of each resident. The UM/ designee will also ensure that the ADL status of each resident is monitored on an ongoing basis. 1. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 8/24/21 documented Resident #13 was severely cognitively impaired, did not reject care and required extensive assistance of one person for personal hygiene. The undated Comprehensive Care Plan (identified as current) documented Resident #13 had an ADL function/mobility deficit and required total assistance of one person for personal hygiene. The care plan documented diabetes and included an intervention that fingernail care was to be complete by nurse. The untitled Kardex (a guide used by staff to provide care) dated 12/6/21 documented Resident #13's fingernail care was to be completed by the nurse. Review of the Progress Notes dated 11/1/21 through 12/6/21 for Resident #13 revealed there was no documented evidence that nail care was provided, or the resident refused care. During intermittent observations on 11/30/21 at 11:23 AM, 12/1/21 at 8:50 AM and 1:42 PM, 12/2/21 at 11:31 AM, 12/3/21 at 11:52 AM, and 12/6/21 at 8:38 AM revealed Resident #13 had long fingernails (beyond the fingertips) on both hands and their left- hand fingernails were dirty with dark brown/black debris. During an interview and observation on 12/6/21 at 8:55 AM, CNA #2 stated they provided morning care to Resident #13 on 12/3/21, 12/5/21 and 12/6/21. CNA #2 stated they had not cleaned Resident #13's fingernails on the dates identified. At this time, CNA #2 observed Resident #13's fingernails and stated the resident's fingernails on both hands were long and the fingernails on their left-hand were dirty. CNA #2 stated the resident needed to have their nails cleaned and needed to be trimmed by the nurse. During an observation and interview on 12/6/21 at 8:53 AM, LPN #3 stated they were assigned to Resident #13 on 12/3/21 and 12/6/21 and did not notice the resident's fingernails needed to be cleaned and trimmed and should have. LPN #3 stated they were responsible to ensure the CNAs cleaned Resident #13's fingernails and they were responsible to ensure the resident's fingernails were trimmed. 2. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS a resident assessment tool) dated 9/6/21 documented Resident #25 was severely cognitively impaired, did not reject care and required total assistance of one person for personal hygiene. The undated Comprehensive Care Plan (identified as current) documented Resident #25 had and ADL deficit in function/mobility related to impaired cognition, decreased mobility and required total assistance of one person for personal hygiene. The untitled Kardex dated 12/6/21 documented Resident #25 required total assistance of one person for personal hygiene. Review of the Progress Notes dated 11/1/21 through 12/6/21 for Resident #25 revealed there was no documented evidence that nail care was provided, or the resident refused care. During intermittent observations on 11/30/21 at 11:29 AM, 12/1/21 at 8:49 AM and 1:40 PM, 12/2/21 at 9:03 AM, 12/3/21 at 8:49 AM, and 12/6/21 at 8:55 AM revealed Resident #25 were dirty with dark brown/ black debris beneath all fingernails on both hands. During an observation and interview on 12/6/21 at 8:55 AM, CNA #2 observed Resident #25's fingernails and stated they were dirty with dark brown/ black debris on both hands and need to be cleaned. CNA #2 stated they provided morning care to Resident #25 on 12/3/21, 12/5/21 and 12/6/21 and had not cleaned Resident #25's fingernails. During an interview and observation on 12/6/21 at 8:53 AM, LPN #3 stated Resident #25's fingernails on both hands were dirty with dark brown/black debris beneath all fingernails and they need to be cleaned. LPN #3 stated they were assigned to Resident #25 on 12/3/21 and 12/6/21 and did not notice the resident's fingernails needed to be cleaned and should have. LPN #3 stated they were responsible to ensure the CNAs cleaned Resident #25's fingernails. During an interview on 12/6/21 at 9:56 AM, the RN Unit Manager #2 for both Resident #13 and #25 stated the CNAs were responsible to clean resident's fingernails during showers and as needed. The staff nurses were responsible to trim fingernails of those residents with diabetes. RN #2 stated the staff nurses were responsible to ensure the CNAs are completing all ADL tasks. The UM stated they were ultimately responsible to ensure residents were receiving ADL care. During an interview on 12/6/21 at 9:56 AM, the Director of Nursing (DON) stated they expect all resident's fingernails to always be clean and trimmed to an appropriate length for safety and infection control purposes. 415.12 (a)(3) 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/14/19, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene. Specifically, one (Resident #52) of three residents reviewed for activities of daily living (ADL) who required extensive assistance had long facial hair. The finding is: The policy and procedure (P&P) titled ADL Assistance and Supervision dated 1/18 documented that the Unit Manager/designee will ensure that a plan of care for receiving ADL assistance and/or supervision is incorporated into the daily nursing care of each resident. The Nursing Assistant provides ADL assistance/supervision to assigned residents and assists other Nursing Assistants in giving ADL care as needed. 1. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, the MDS documented that the resident requires the extensive assistance of one person for personal hygiene including shaving. Review of the current, undated Comprehensive Care Plan (CCP) revealed the resident has a deficit in ADL function/mobility related to cognitive deficits secondary to dementia. The resident requires the extensive assist of one person for personal hygiene including shaving and the person responsible for shaving is the Certified Nurse Aide (CNA). Review of the current, undated CNA Kardex Care Plan revealed the resident has an electric razor and requires the extensive assistance of one person for personal hygiene. Observation of the resident in his private room on 8/7/19 revealed the following: -11:15 AM - The resident had beard stubble on the front of his chin, upper lip, and both cheeks. His sideburns, from his ears to his neck and under his chin, had white beard hair with varying lengths, from ¼ inch to ½ inch long. There was an electric razor on the dresser. There were numerous family pictures of the resident on the wall and he was clean shaven in the family pictures. Observations on 8/8/19 at 7:08 AM and 8/9/19 at 8:18 AM revealed the resident was in a common area near the Unit Two Nurses' Station. The resident was dressed in clean clothes. He had stubble on the front of his chin, upper lip, and both cheeks. His sideburns, from his ears to his neck and under his chin, had white beard hair with varying lengths from ¼ inch to ½ inch long. During an interview on 8/9/19 at 9:10 AM, CNA #1 stated that the resident's original CNA who was taking care of him was sent home. They did not know the reason why. CNA #1 stated that the resident should be shaved and should be shaved every day. I will shave him now. An observation following the interview revealed that CNA #1 shaved the resident with the electric razor in the resident's room. While the resident was being shaved, the CNA stated that the resident's sideburns and hairs under his chin were long. During an interview on 8/9/19 at 9:33 AM, the Registered Nurse (RN #1) Unit Manager (UM) stated that she shaved the resident the day before, but he can be difficult to shave sometimes. The RN UM stated that the resident should be shaved every day. During an interview on 8/14/19 at 9:49 AM, Director of Nursing (DON) stated that the resident should be shaved daily. 415.12(a)(3)

Based on observation, interviews, and record review conducted during the Standard survey, completed on [DATE], the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #25) of one resident reviewed for feeding tubes. Specifically, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: A facility policy titled Tube Feeding (TF), Enteral Policy dated [DATE] documented designated nursing staff will implement an enteral tube feeding regimen whose clinical condition demonstrates that the use of an enteral feeding tube is unavoidable. When a decision is made to insert a feeding tube, the Unit Manager obtains an order from the attending Physician which includes the following: The method used to deliver the feeding. The formula name, strength, and rate of delivery. The total amount of cc's (cubic centimeters- liquid measurement) and the total calories infused in a 24-hour period. The order should identify whether a pump is required and the amount and frequency of the flush. 1. Resident #25 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented the resident was severely cognitively impaired and received tube feedings. The MOLST (Medical Orders for Life-sustaining Treatment) documented comfort measures only, DNR (do not resuscitate- to withhold CPR (cardiopulmonary resuscitation) and emergency life saving measures in the event of the absence of a heartbeat and or respiration), DNI (do not intubate), do not send to the hospital, long-term feeding tube, weights and labs per physician order [REDACTED]. Review of a Progress Note dated [DATE] revealed recommendations to change TF to a lower rate for better tolerance and to include Diabetisource AC (advanced control) to 85 cc / hr. (hour) x 20 hours for a total of 1700 cc, 2040 kilocalories (kcal), and 102 grams (gms) protein. This meets the residents estimated nutritional needs of ,[DATE] kcal, ,[DATE] gms protein. Review of a physician order [REDACTED]. to equal 1700 cc, 85 cc/hr. x 20 hours. During an observation of the resident on [DATE] at 8:30 AM revealed Impact 1.5 tube feeding formula was running (infusing) at 85 cc, not Diabetisource AC as ordered. Review of the Treatment Administration Record (TAR) revealed Diabetisource AC was initiated at [DATE] at 3:53 PM by Licensed Practical Nurse (LPN #4), however Impact 1.5 was hung and administered in error. During an interview on [DATE] at 8:45 AM, Registered Dietitian (RD) stated the resident should be receiving Diabetisource AC. The Impact 1.5 was the wrong formula. Review of the nutritional specification for Diabetisource AC revealed it is a specialized formula to meet the nutritional needs of individuals with diabetes and stress-induced [MEDICAL CONDITION] (high blood glucose). The formula does not contain sugar alcohols. The Impact formula is a non-diabetic formula and is not sugar free. In an initial interview with the RD on [DATE] at 9:21 AM she stated the Impact 1.5 could have adverse effects on the resident including high blood sugar. The physician did request a blood glucose level in lieu of the mishap with the formula. The results of the blood draw on [DATE] was 164 above normal limits of ,[DATE]. During a later interview with the RD on [DATE] at 11:50 AM stated the Impact 1.5 formula wouldn't have adversely affected the resident. She stated agreed the residents blood sugar was slightly high at 164 but since they were no longer doing fingersticks on the resident, it was hard to assess a trend. During an interview on [DATE] at 8:20 AM, Licensed Practical Nurse (LPN #2) stated the 2:00 PM - 10:00 PM shift LPN #4 was responsible for hanging the wrong tube feed formula on [DATE]. Additionally, stated on [DATE] when she came in for 6:00 AM - 2:00 PM shift she did not notice the TF was the wrong formula. During an interview on [DATE] at 2:30 PM, LPN #4 stated she grabbed the formula from a box in the clean utility room and hung it and she didn't stop to think that there was more than one kind of formula in the box. During an interview on [DATE] at 9:27 AM, Registered Nurse (RN) #2 Unit Manager (UM) stated that she checked the clean utility room and there were two bags of Impact 1.5. The formula was old and she removed the bags of Impact 1.5 from the clean utility room. During an interview on [DATE] at 9:00 AM, the Physician stated he did not think the Impact 1.5 formula would cause any harm to the resident but the facility should be using Diabetisource AC formula that was ordered. 415.12(g)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/14/19, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs for one (Resident #14) of six residents reviewed for unnecessary medications. Specifically, issues involved the lack of a gradual dose reduction (GDR) attempt for a resident on an antipsychotic medication with tardive dyskinesia (a side effect of antipsychotic medication causing involuntary movements of the tongue, lips, face and trunk) and lack of documented behaviors to support the continued use of the medication. The finding is: A facility policy and procedure (P&P) titled [MEDICAL CONDITION] Drugs dated 7/6/18 documented that residents prescribed [MEDICAL CONDITION] drugs will receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s); have non-pharmacological interventions (such as behavior interventions) considered and used when indicated, instead of, or in addition to, medication; minimize any clinically significant adverse consequences; and have the regime evaluated or modified when potential contribution of the medication regimen to the unanticipated decline or newly emerging or worsening symptom is recognized. The management of [MEDICAL CONDITION] drugs will include, but is not limited to: -Monitoring the efficacy and adverse consequences -Tapering or perform a GDR, as required per regulatory standards -Preventing, identifying and responding to adverse consequences related to [MEDICAL CONDITION] drugs. The policy further documented that within the first year in which a resident is admitted on an antipsychotic or after the care center has initiated an antipsychotic, a GDR must be attempted in two (2) separate quarters (with at least one (1) month between attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. A P&P titled Behavior Monitoring dated 6/19/19 documented that the Unit Manager (UM)/Charge Nurse in cooperation with the Unit Social Worker (SW) will ensure that the mood, behavior and social problems or psychosocial adjustment difficulties of individual residents are monitored, reported, recorded, and included in inter-disciplinary care planning, as needed. The Unit Manager/Charge Nurse monitors the mood/behavior/social/adjustment problems of a resident through personal observations; daily reports from Team Leaders and Nursing Assistants; and reports from other facility staff, residents or visitors. Recording of behavior monitoring will be initiated by the Unit Manager (UM). Documentation will be recorded in the medical record (progress notes, EMR (electronic medical record) behavior monitoring log or paper flow sheets) for residents including, but not limited to: - All residents currently receiving antipsychotics (as deemed appropriate) - Residents exhibiting mood/behavior problems interfering with daily function. 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 5/14/19 documented the resident was cognitively intact. The MDS also documented that the resident had no potential indicators of [MEDICAL CONDITION], no behavioral symptoms directed toward self or others and no behaviors exhibited during care. The resident received antipsychotic medication on a routine basis and had a GDR attempted on 5/18/18. The Physician documented a GDR was clinically contraindicated on 4/19/19. Review of the current, undated Comprehensive Care Plan (CCP) revealed a Focus area for Mood/Behavior with the following interventions: - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Document mood/behavior status/changes and update MD/NP (Nurse Practitioner)/PA (Physician Assistant) as needed. Additional review of the CCP revealed a Focus area related to the use of an antipsychotic medication for a [DIAGNOSES REDACTED]. Review of the current, undated Certified Nurse Aide (CNA) Kardex Care Plan revealed that the resident may smear liquids in her hair (dressing, syrup, etc.) and think that she attends school when she is in her room reading books on her bed. She will talk to you about school, sings in her room and likes to be called Beyonce. In addition, the Kardex documented that staff are to provide reminders and re-orient as needed (PRN). Intermittent observations from 8/7/19 to 8/13/19, between 10:15 AM and 1:34 PM, revealed the resident was calm, friendly, and pleasant without behavioral concerns. She ate well, folded clothes in her dresser, made her bed, and spoke appropriately during conversations. The resident was observed to have slight tongue movements, rolled her tongue from side to side in her mouth and occasionally puckered her lips. Review of a Psychiatrist physician progress notes [REDACTED]. The resident was described as pleasant and engaging with slight vermicular (worm like) tongue movement, occasional lip puckering, but no tongue protrusion, chewing motion, jaw clenching, or dyskinesia of the limbs or shoulder shrugging (this is less movement than what had been assessed last time that I saw her). The assessment documented [MEDICAL CONDITION] rule out [MEDICAL CONDITION], neurocognitive disorder (vascular) and mild tardive dyskinesia (TD) secondary to antipsychotic use. The Psychiatrist documented that it seemed reasonable to continue the [MEDICATION NAME] however, it was imperative to monitor her (at least every 6 months) for the emergence of worsening TD. The latter can be quite disabling if it is magnified and the worse it gets, the less reversable it becomes. If TD develops, we can consider use of Ingrezza 40 mg (milligrams) daily to decrease TD symptoms and/or substitutions of the [MEDICATION NAME]. Review of an Order Summary Report dated 8/14/19 revealed an order for [REDACTED]. Review of Medication Administration Reports (MARs) dated (MONTH) (YEAR) through 8/14/19 revealed the resident received [MEDICATION NAME] 0.25 mg daily as ordered. Review of a Mandated 30/60 Day Provider Visit note dated 6/13/19 revealed the Physician documented that the resident feels her psych med is helping her. Some report of strange behaviors such as putting mashed potatoes in her hair, but no adverse or distressing consequences. A Physician Annual History and Physical (H&P) dated 8/8/19 documented that the resident reported she was feeling well and denied any complaints. Resident reported stable mood, staff reported she was doing well and denied any new issues or concerns. Ongoing problems with putting food and other items in her hair with staff concerned that she does not allow her hair to be washed often enough. [DIAGNOSES REDACTED]. We have decreased her [MEDICATION NAME] in the past but has been on 0.25 mg daily for >1 year. She is on minimal dose and appears to be tolerating it well. It appears that decreasing it further would be detrimental, given her ongoing symptoms. Review of Progress Notes dated 11/2/18 through 8/13/19 revealed the following: -12/2/18 - SW (Social Work) Plan of Care Note: Resident is alert with some confusion, able to make her needs known. Signs of minimal depression, including little interest in activities outside of room, and trouble concentrating at times. Resident utilizes [MEDICAL CONDITION] medication [MEDICATION NAME] for [MEDICAL CONDITION], utilizing lowest effective dose for current condition. Resident gets along well with staff and peers. -1/28/19 - SW Plan of Care Note: Resident utilizes [MEDICATION NAME] for [MEDICAL CONDITION]. Resident has utilized current dose of medication for some time. Staff to monitor for adverse effects of medication, changes in mood/behavior, interactions with staff/peers. There are no suggestions from interdisciplinary team (IDT) as of today's date. -3/7/19 - SW Plan of Care Note: Resident utilizes [MEDICAL CONDITION] medication [MEDICATION NAME] for her diagnosis (dx) of [MEDICAL CONDITION]. Resident gets along well with staff and peers, although she does not come out of her room except to shower. -5/30/19 - SW Plan of Care Note: Resident utilizes [MEDICAL CONDITION] medication [MEDICATION NAME] for her dx of [MEDICAL CONDITION]. Resident gets along well with staff and peers. Review of IDT Psychoactive Med Review Evaluation Notes dated 12/10/18 through 5/13/19 revealed the following: - No adverse reactions from psychoactive medication use - Medically stable, does talk to herself in room on a daily basis but does not talk about negative/harmful topics. - Staff observation indicates mood/behaviors have been stable. Resident talks to self, this is baseline behavior, it is not disturbing to other residents. Easily redirected without incident. [MEDICAL CONDITION] controlled on low dose [MEDICATION NAME]. -GDR of [MEDICATION NAME] is likely contraindicated due to lowest therapeutic dose for maintenance of [MEDICAL CONDITION] dx. -Medically stable. Talks to herself and spends 99% of time in her room, she is content and high functioning. She will come out rarely when she wants to. -Resident talks to self at baseline, it is not disturbing to other residents. There are no other behaviors noted or documented by staff. Review of Point of Care CNA reports dated (MONTH) (YEAR) to (MONTH) 2019 for PRN (as needed) documentation of physical/verbal behavior symptoms directed toward self or others revealed there were no behaviors observed. During an interview on 8/9/19 at 9:14 AM, a Registered Nurse (RN #3) stated the resident has no negative behaviors. She will talk to herself, sing, put salad dressing in her hair, and put juice on a washcloth and wash herself, then wash it off. She likes to keep things in her room like juice, yogurt, fruit cups, and washcloths that she has poured juice on. During an interview on 8/9/19 at 9:24 AM, CNA #3 stated she tries to clean up every time she goes into the resident's room. She is usually pretty good about it if you just do a little at a time. She is never aggressive or agitated. During an interview on 8/12/19 at 9:18 AM, CNA #2 stated the resident talks to herself, sings a lot and sometimes puts salad dressing or yogurt on her face. She likes to hide towels and washcloths in her closet. She doesn't really like to come out of her room much. She doesn't have any behaviors. During an interview on 8/12/19 at 1:34 PM, the RN (#1) Unit Manager (UM) stated Resident #14 is very pleasant. She rubs things on herself, puts liquids on herself and doesn't like to come out of her room but that is her preference. There is no formal tool for monitoring for psych med side effects, such as TD. She stated there have been discussions about the Beers Criteria (guidelines for healthcare professionals to help improve the safety of prescribing medications for older adults) with the Pharmacy Consultant. Talks of incorporating a monitoring tool for things we should be looking at based on the Beers List, but officially it has not been implemented. During an interview on 8/13/19 at 9:16 AM, the Social Worker (SW #2) stated they have an antipsychotic medication review monthly and review all [MEDICAL CONDITION] medications. She has worked at the facility for almost a year and the resident has been on the same dose of [MEDICATION NAME] for a [DIAGNOSES REDACTED]. She watches TV, talks to herself, rubs things on herself but her behaviors are not harmful to herself or others. I am aware of the GDR regulation unless clinically contraindicated. We discuss the lowest effective dose at monthly meetings. I am not a Doctor, so I don't want to overstep bounds. During an interview on 8/14/19 at 9:47 AM, the Medical Director stated the resident has a [DIAGNOSES REDACTED]. The last time I saw her she told me she gets hired to give lectures. They are not distressing behaviors. At our last [MEDICAL CONDITION] meeting, it was reported that she put mashed potatoes in her hair and staff wanted to increase her [MEDICATION NAME]. I said let's not increase and try non pharmacological interventions first. We meet monthly to discuss GDR. She is on a tiny dose. She has had TD for years, it is part of her, we don't even notice. Antipsychotics can also mask TD and taking away the medication can exacerbate the symptoms. It seems like we are not documenting her behaviors enough to contraindicate a GDR. During an interview on 8/14/19 at 10:59 AM, the Psychiatrist stated he did not diagnose the resident with [MEDICAL CONDITION]. He diagnosed the resident with neurocognitive disorder, which is dementia, rule out [MEDICAL CONDITION]. I would expect the facility to attempt a GDR. I make recommendations and the facility doesn't always follow through. I recommended to monitor the TD, made suggestions of medications to substitute or add to help manage the TD. Did the facility do any of those things? No. During an interview on 8/14/19 at 11:30 AM, the DON stated they were nervous about her last GDR in (MONTH) (YEAR). With her history of [MEDICAL CONDITION], we felt as a team it was the lowest effective dose for her. She stated the resident had a slight increase in talking to herself in her room and hoarding things a little bit more. The DON stated the behaviors were not distressing to the resident or anyone else. 415.12(l)(2)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/14/19, it was determined that the facility did not maintain medical records on each resident, in accordance with accepted professional standards, that are complete and accurately documented. Specifically, one (Resident #43) of five residents reviewed for medical record documentation related to dementia care had issues with the lack of documentation of behaviors. The finding is: A policy and procedure (P&P) titled Behavior Monitoring dated 6/19 documented that the Unit Manager/ Charge Nurse, in cooperation with the Unit Social Worker, will ensure that the mood, behavior and social problems or psychosocial adjustment difficulties of individual residents are monitored reported, recorded, and included in inter-disciplinary care planning, as needed. The Unit Manager/ Charge Nurse monitors the mood /behavior/ social/ adjustment problems of a resident through personal observations, daily reports from Team Leaders and Nursing Assistants, and reports from other facility staff, residents, or visitors. 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 6/25/19 documented that the resident was severely cognitively impaired, usually understands and was usually understood by others. The MDS documented that the resident had verbal behaviors of threatening others, screaming at others, cursing at others and this behavior happened most days of the week. Review of Physician order [REDACTED]. Review of the current, undated Comprehensive Care Plan (CCP) revealed that the resident had behaviors of calling out and screaming at staff and received a [MEDICAL CONDITION] medication related to dementia with behaviors, agitation, and anxiety. The CCP documented interventions to document mood/behavior status/changes and update the physician as needed. The current, undated Certified Nurse Aide (CNA) Kardex Care Plan documented that the resident had behaviors of yelling and wheeling herself in her wheelchair. The Kardex documented that staff are to redirect, offer snacks, and place the resident in a low stimulating area. Observations from 8/9/19 to 8/14/19 revealed the following: - 8/9/19 at 8:17 AM - The resident ate breakfast, no behaviors noted. - 8/12/19 at 9:47 AM - The resident self-propelled herself in her wheelchair down the hall by the Nurses' Station, towards the television lounge, laughing to herself. - 8/12/19 at 10:49 AM - The resident self-propelling herself in her wheelchair, while being escorted to activities. She listened to the music entertainment in the first floor Dining Room, nodding along with the music. - 8/13/19 at 12:25 PM - The resident ate lunch, no behaviors noted. Review of Point of Care (P[NAME]) CNA reports for Behavior Symptoms (hitting, thrashing, agitation) dated (MONTH) (YEAR) to (MONTH) 2019 revealed Resident #43 had yelling behaviors. Additional review of the reports revealed the following: - (MONTH) (YEAR) - There were 24 shifts without documentation of behaviors or lack of behaviors - (MONTH) 2019 - 23 shifts with no documentation - (MONTH) 2019 - 26 shifts with no documentation - (MONTH) 2019 - 18 shifts with no documentation - (MONTH) 2019 - 25 shifts with no documentation - (MONTH) 2019 - 22 shifts with no documentation - (MONTH) 2019 - 27 shifts with no documentation - (MONTH) 2019 -14 shifts with no documentation - (MONTH) 1 to (MONTH) 14, 2019 - Eight shifts with no documentation. Staff interviews from 8/9/19 to 8/14/19 revealed the following: - 8/9/19 at 8:03 AM - a Licensed Practical Nurse (LPN #3) stated that the nurses document behaviors in the Progress Notes and the CNAs document behaviors in P[NAME] in the task section. - 8/12/19 at 12:05 PM - the Social Worker (SW #1) stated that Resident #43 would refuse hands on care and had yelling out behaviors. The CNAs should be documenting behaviors every shift in P[NAME]. - 8/13/19 at 9:49 AM - CNA #1 stated that the CNAs are supposed to document every day in the P[NAME] tasks section whether the resident had behaviors. - 8/13/19 at 9:57 AM - the Registered Nurse (RN #1) Unit Manager stated that she expects the CNAs to document behaviors on every shift in P[NAME]. - 8/13/19 at 10:12 AM - SW #1 stated that the reason why CNAs should be documenting every shift is because the CNAs see most of the behaviors that occur during care. They want to see if there is a change in behavior, a new behavior, a new pattern of behaviors, or if a new medication is working for the resident. - 8/14/19 at 8:40 AM - CNA #2 stated that CNAs are supposed to document behaviors in P[NAME] on every shift. During an interview on 8/14/19 at 9:49 AM, the Director of Nursing stated that P[NAME] has the task option to remind the CNAs to document when the resident has a behavior. She expects her staff to document a behavior if the resident has one. 415.22(a)(1,2)

Based on interview and record review conducted during the extended survey completed on 11/2/18, the facility did not implement written policies and procedures for screening employees that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, sixteen (four Housekeeping Aides, two Registered Nurses (RNs), three Licensed Practical Nurses (LPNs), one Physical Therapist, three Dietary Aides, one Cook, one Maintenance Assistant, and one Certified Nurse Aide (CNA) of twenty employees who were subject to the New York State (NYS) Nurse Aide Registry, had not been screened through the New York State Nurse Aide Registry prior to their employment. This resulted in substandard quality of care. The finding is: The facility policy and procedure entitled, Reference Check, approved 9/28/18, documented all potential hires are screened by contacting the New York State Nurse Aide Registry or other state registry to verify credentials and/or check for prior history of reported abuse. 1. On 11/1/18, a record review of twenty personnel files of individuals hired during (YEAR), revealed sixteen employees were not screened through the New York State Nurse Aide Registry prior to their employment. The sixteen employees included four Housekeeping Aides, two RNs, three LPNs, one Physical Therapist, three Dietary Aides, one Cook, one Maintenance Assistant, and one CNA. Further record review on 11/1/18 revealed the sixteen employees identified had hire dates that ranged from 1/17/18 through 10/9/18, and eleven of sixteen employees were still actively employed at the facility. During an interview on 11/1/18 at 11:05 AM, the Human Resources Coordinator stated she did not screen employees through the New York State Nurse Aide Registry, other than CNAs. Additionally, on 11/1/18 at 1:55 PM, the Human Resources Coordinator stated she was hired during (MONTH) (YEAR), but at that time, her assistant was conducting Nurse Aide Registry verifications. The Human Resources Coordinator's assistant left employment during (MONTH) (YEAR), at which time, the Nurse Aide Registry verifications became one of her tasks. The Human Resources Coordinator stated she was trained by her assistant and by several corporate level Human Resources employees, but was not aware that all employees must be screened through the Nurse Aide Registry. She believed it was only a task to be done for CNAs. Record review on 11/1/18, of a Human Resources document entitled Basic Hiring Worksheet, revealed the task Nurse Aide Registry Check * Completed for ALL new hires-print for file appeared in the Interview Process box. During an interview on 11/1/18 at 1:55 PM, the Human Resources Coordinator stated she uses the Basic Hiring Worksheet regularly and her practice was to put a dash through the Nurse Aide Registry line for all new hires except CNAs, because it was not applicable, and she didn't realize it said, All new hires. During an interview on 11/1/18 at 12:05 PM, the Administrator stated he was aware that the New York State Nurse Aide Registry must be checked for all employees and he thought it was being checked for all employees by the Human Resources Coordinator. Additionally, on 11/1/18 at 12:50 PM, the Administrator stated the sixteen employees identified without Nurse Aide Registry verification prior to employment had worked on all three shifts and had resident access on two of two resident units. During an interview on 11/2/18 at 10:30 AM, the Administrator further stated he should have been aware that the checks were not being done for all employees. There were no audits or system checks and balances in place for the Nurse Aide Registry checks, and he was ultimately responsible for the completion of the Nurse Aide Registry checks prior to employment. During an interview on 11/1/18 at 2:25 PM, the Administrator stated the facility performed an audit today (11/1/18) and found an additional twelve current employees who were not screened through the New York State Nurse Aide Registry prior to employment, not inclusive of individuals who are no longer employed at this facility. 415.4(b)

Based on interview and record review conducted during an extended survey completed on 11/2/18, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not ensure that all employees were screened through the New York State Nurse Aide Registry prior to employment. The finding is: Refer to F 607 Develop/Implement Abuse/Neglect Policies - Scope/Severity = F 1. On 11/1/18, a record review of twenty personnel files of individuals hired during (YEAR), revealed sixteen employees were not screened through the New York State Nurse Aide Registry prior to their employment. The sixteen employees included four Housekeeping Aides, two Registered Nurses (RNs), three Licensed Practical Nurses (LPNs), one Physical Therapist, three Dietary Aides, one Cook, one Maintenance Assistant, and one certified nurse aide (CNA). Further record review on 11/1/18 revealed the sixteen employees identified had hire dates that ranged from 1/17/18 to 10/9/18, and eleven of sixteen employees were still actively employed at the facility. During an interview on 11/1/18 at 11:05 AM, the Human Resources Coordinator stated she did not screen employees through the New York State Nurse Aide Registry, other than CNAs. Additionally, on 11/1/18 at 1:55 PM, the Human Resources Coordinator stated she was hired during (MONTH) (YEAR), but at that time, her assistant was conducting Nurse Aide Registry verifications. The Human Resources Coordinator's assistant left employment during (MONTH) (YEAR), at which time, the Nurse Aide Registry verifications became one of her tasks. The Human Resources Coordinator stated she was trained by her assistant and by several corporate level Human Resources employees, but was not aware that all employees must be screened through the Nurse Aide Registry. She believed it was only a task to be done for CNAs. During an interview on 11/1/18 at 12:05 PM, the Administrator stated he was aware that the New York State Nurse Aide Registry must be checked for all employees and he thought it was being checked for all employees by the Human Resources Coordinator. Additionally, on 11/1/18 at 12:50 PM, the Administrator stated the sixteen employees identified without Nurse Aide Registry verification prior to employment had worked on all three shifts and had resident access on two of two resident units. During an interview on 11/2/18 at 10:30 AM, the Administrator further stated he should have been aware the checks were not being done for all employees, there were no audits or system checks and balances in place for the Nurse Aide Registry checks, and he was ultimately responsible for the completion of the Nurse Aide Registry checks prior to employment. Record review of the facility policy and procedure entitled, Reference Check, approved 9/28/18, revealed all potential hires are screened by contacting the New York State Nurse Aide Registry or other state registry to verify credentials and/or check for prior history of reported abuse. 415.26

Based on observation, interview and record review conducted during an extended survey completed on 11/2/18 the facility did not meet the nutritional needs of residents in accordance with established national guidelines. Specifically, the facility did not provide adequate meal portions to meet the nutritional needs of the residents on 10/31/18. Additionally, residents on a pureed diet did receive a vegetable as planned on 10/29/18. Resident's A and B are involved. The findings are: 1. Review of the undated policy entitled Menus and diet requirements revealed the following basic three-meal menu pattern used at this facility provides residents with approximately 1800-2000 calories and 90-100 grams of protein daily: Breakfast: - Juice - Cereal - 2 to 3 oz. ounces (oz.) protein (egg, sausage, or bacon) - Toast, waffle, pancake, or French toast - Milk and hot beverage Lunch and Dinner: - Protein 3 to 4 oz. serving - Starch (potato or substitute, ½ cup) - Vegetable, ½ cup - Dessert a. Review of the lunch menu for 10/29/18 for the regular and the pureed diets revealed ham, sweet potatoes and green bean casserole were being served. Observation of the Dinner (noon) meal on Unit 1,10/29/18 from 12:00 PM through 1:00 PM revealed ham, sweet potato and green bean casserole served to most residents. Resident A, on a puree diet, was observed to have two scoops of food items on his plate. One scoop of ham and one scoop of sweet potatoes. During an interview at the time of the observation, Resident A stated he usually had three scoops of food on his plate. The server at this time stated she didn't know if he should have three scoops, and they did not have any pureed green bean casserole on the steam table for service. During an interview on 10/29/18 at 12:22 PM, the Registered Dietitian (RD) stated they should have pureed green bean casserole. During an interview on 10/29/18 at 12:45 PM, the Food Service Director (FSD) stated they planned to call the kitchen and get pureed green bean casserole for the puree diets. A test tray completed at 1:05 PM revealed the residents on puree diets were provided pureed green beans and not green bean casserole as planned. Observation of a Dinner (noon) meal on Unit 2, 10/29/18 at 12:20 PM, revealed Resident B received 4 oz. pureed ham, 4 oz. pureed sweet potatoes and 4 oz. pureed green bean casserole. The pureed ham did not appear fully pureed and had approximately 1/8 (one eighth) inch chunks of ham. A family member returned the meal and asked for another with pureed ham meal. At 1:00 PM, the resident received a second plate as requested containing approximately one fourth cup pureed ham, 4 oz. sweet potato and there was no vegetable. b. Review of the Week 1 Fall/ Winter menu dated (YEAR) revealed the Dinner (noon) menu for 10/31/18 consisted of goulash and mixed vegetables, and the alternate was a crab cake and coleslaw. Review of the Production Counts Week 1 Wednesday -10/31/18 (Dinner meal) revealed the residents would receive 8 oz. of goulash and 4 oz. of mixed vegetables. The alternate meal was 1 crab cake and 4 oz. of coleslaw. During observation of the Dinner (noon meal) service on 10/31/18 from 12:00 PM through 1:00 PM on Unit 1 and Unit 2 the cook/ servers were observed using a grey #8/ 4 oz. scoop to portion out the goulash for regular diets, ground, and puree diets. Each resident received one 4 oz. scoop of goulash and one 4 oz. scoop of mixed vegetable. Residents who preferred the alternate meal received 1 crab cake and 4 oz. of coleslaw. During an interview on 10/31/18 at 1:00 PM, the cook/ server revealed she has been working at the facility for [AGE] years and has been serving 1 scoop of casserole (goulash) for some time. During an interview on 10/31/18 at 1:05 PM, the RD stated the resident should be getting 8 oz. portions of a casserole (goulash) to meet their nutritional needs. That would be two 4 oz. scoops. Review of the product description for the premade frozen crab cakes, provided by the Food Service Director, revealed each crab cake contains 7 grams (gm) of protein equaling 1 oz. total of protein per crab cake. During an interview on 11/1/18 at 10:00 AM, the RD stated the residents should be receiving 3 to 4 oz. of protein at both dinner and supper meal. They should be receiving more than just one crab cake at the meal. Review of the production counts for Week 1 Wednesday- 10/31/18 (supper meal) revealed the residents were scheduled to receive 2 oz. of chicken fingers, 4 oz. of peas, and 4 oz. of potato wedges. Interview with the Registered Dietitian (RD) and Food Service Director on 10/31/18 at 3:45 PM revealed education was being conducted to kitchen staff on preparing proper consistency and proper portion sizes. During an interview on 10/31/18 at 4:30 PM, the RD stated a 2-oz. portion wasn't enough. They went to the grocery store and bought more chicken fingers. The RD stated they would serve the resident 5 to 6 chicken finger portions. During observation of the Supper meal residents received 5 pieces of chicken fingers. Review of the Nutrition labels revealed brand A provided 80 calories and 5 gm of protein per piece equaling a total of 400 calories and 3.6 oz. of protein. Brand B provided 400 calories and 2.6 oz. protein per portion which is below the 3 to 4 oz. of protein planned for the resident's diet requirements. 415.14(c)(1-3)(d)(3)

Based on observation, interview and record review conducted during an extended survey completed on 11/2/18, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Two (Residents #43, 59) of four residents observed for accidents had issues involving the lack of effective interventions and revisions to the plan of care to prevent accidents (Residents #43). Additionally, providing a resident on aspiration precautions with the incorrect meal consistency (Resident #59). The findings are: 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (minimum data set-resident assessment tool) dated 9/7/18 revealed the resident had severe cognitive impairment, and was at high risk for falls. Review of the policy entitled Accident/ Incident Reporting and Review (Staff/ Visitors/ Residents) dated 6/20/18 revealed an accident/ incident report form is completed and forwarded to director of nursing services. The accident/ incident and plan of prevention is recorded on the care plan. Review of the care plan, identified as current by facility staff, revealed a focus area of safety the resident was at risk for falls related to dementia, orthostatic [MEDICAL CONDITION] (low blood pressure), double vision and history of falls. Interventions included to offer ambulation in the hall after supper as accepted (9/14/18), walker in reach at all times (9/14/18); give soft football or other item to hold at HS (bedtime) to decrease anxiety (9/10/18); low bed (9/10/18); reinforce safety every shift; has poor safety awareness (9/14/18); encourage out of room/ may lounge on couch for comfort as needed (9/10/18 and revised 10/24/18). There was no care plan intervention to prevent further falls on 10/2/18. Review of Kardex (used by staff to provide care) with a print date of 11/2/18 revealed the resident required limited assist of one person with a rolling walker for ambulation, was frequently incontinent of bladder. Review of the accident and incident reports dated 9/7/18 through 10/30/18 revealed the resident had seven falls. During this time frame four of the falls occurred within the resident's room. Three of the four reports documented predisposing factors that included incontinence. Review of a Nurse's Progress Note dated 10/2/18 revealed the resident was found on the floor by an unidentified CNA (certified nurse's aide). The resident stated he got dizzy and fell down. The CNA stated resident got himself up from floor to a seated position in a chair. Two abrasions were noted on the right scapula (shoulder blade), no bleeding was noted. The resident had no complaints of pain, active ROM (range of motion-movement of joints), resident cooperative, neuro checks (assessment to determine a person's neurological status after an injury) initiated and WNL (within normal limits). Further review of a facility accident and incident repot (A/I) dated 10/2/18 at 6:40 AM revealed the RN (Registered Nurse) was called to the unit by the floor nurse reporting that resident was on the floor and trying to get himself up. Resident was seated in chair when the RN arrived on the unit and the CNA was assisting with ADL's, an abrasion was seen on the resident's back. Immediate action taken included the assessment of ROM and was without complaints of pain. A skin assessment was completed and abrasions measured, vital signs were stable, neuro checks were initiated and WNL. The resident was cooperative and went to TV (television) room. During an interview on 11/02/18 at 10:20 AM, RN Unit Manager #1 stated the resident doesn't have good safety awareness and they have done a lot of interventions with him. For the 10/2 fall she couldn't remember what they changed for that fall; we normally do a care plan change after a fall and usually the supervisors are the ones that need to change something immediately to prevent further falls. The RN reviewed the A/I report dated 10/2/18 and reviewed nurse's notes and resident's care plan in the EMR (electronic medical record). RN #1 stated she didn't see anything in the nurse's notes or care plan that documented an intervention after this fall. The RN further stated it would be the supervisor on duty that would put a care plan change in place after a fall, the supervisor that was here on 10/2 is newer to us. During a telephone interview on 11/2/18 at 11:35 AM, RN #2 stated that she did not remember this resident, but in general when someone falls she does an assessment and notifies the doctor. The RN stated she makes sure the things were in place to prevent falls, that were on the care plan. If not, then she lets someone know. The RN also stated when she does an A/I the DON (Director of Nursing) looks it over to see if anything else can be put into place. The RN stated she doesn't know if she did a care plan intervention for this fall, and that she didn't see that there was anything else they could do to stop a fall. During an interview on 11/2/18 at 12:30 PM, the DON stated after a fall an RN assessment is completed. We expect some kind of change, for example medical work up, offering snacks, toileting, an activity box, it could be anything that's resident specific. The DON stated she would expect the supervisor to make that change to the care plan. 2. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with eating. Review of both the undated Comprehensive Care Plan (identified as current) and the Kardex with a print date of 11/2/18 revealed the resident was on aspiration precautions and required extensive assistance with one person physically assisting the resident to eat. Review of a Speech Therapy consult dated 6/18/18 revealed a recommendation for a pureed diet with nectar thick liquids. Review of the lunch menu for (MONTH) 29, (YEAR) for the regular and the pureed diets revealed ham, sweet potatoes and green bean casserole were being served. Observation of a lunch meal on 10/29/18 at 12:20 PM revealed the resident received 4 ounces (oz.) of pureed ham, 4 oz. of pureed sweet potatoes and 4 oz. of pureed green bean casserole. The pureed ham was not fully pureed and had approximately one eighth inch chunks of ham. At the time of the observation a family member returned the meal and asked for another meal with pureed ham. During an interview on 10/29/18 at 12:25 PM, a Food Service Worker (serving food at the servery) revealed the cook had pureed the ham for at least 10 minutes but it was difficult to puree it further. During an interview on 10/31/18 at 3:45 PM with the Registered Dietitian (RD) and Food Service Director, revealed education was being conducted to kitchen staff on preparing proper consistency. 415.12(h)(1)(2)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 094) during the Standard survey completed on 7/26/17 the facility did not inform the resident's legal representative or interested family member or immediately consult with the resident's Physician when there is a significant change in the resident's physical, mental or psychological status and a need to alter treatment significantly. One (Resident #126) of one residents reviewed for family and Physician notification had issues. Specifically, nursing staff did not immediately notify the Physician and family of the resident's blood pressure of 209/94 and of the development of swelling of the face and lower extremities. The findings are: 1. Resident #126 was admitted to the facility on [DATE] and discharged to an acute care facility on 3/29/16 with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 3/15/16 revealed the resident has moderate cognitive impairment, usually understands and is usually understood. Review of the Admission Record, printed on 7/26/17 revealed in the section labeled Contact had the name, address and phone numbers of a daughter and two sons. The resident's daughter was listed as the Health Care Proxy and the first emergency contact. Review of the Telephone/ Verbal Order Signature Details from 1/6/15 to 3/29/16 revealed a Physician's Order signed 1/6/15 to obtain a blood pressure every week, one time a day, every Tuesday. Review of the March 2016 Medication Administration Record [REDACTED] - 3/1/16 150/90 (normal,120/80) - 3/8/16 132/64 - 3/15/16 122/64 - 3/22/16 132/68 - 3/30/16 209/94 Review of the electronic Progress Notes revealed the following: - On 3/29/16 at 1:05 PM, Licensed Practical Nurse (LPN #5) documented, Lethargic, lt (left) leg [MEDICAL CONDITION] (swelling caused by excess fluid accumulation), lt side of face swelling, vitals 96.6 (temperature, normal, 98.6°F), 76 (heart rate, normal 80- 100), 209/94 (blood pressure), accucheck (blood glucose monitor) ac (before meals) b/fast (breakfast) 112 (normal 70 to 100 mg/dL), recheck accucheck at noon 65, supervisor updated. - On 3/29/16 at 6:42 PM, the Physician documented, I came to evaluate (Resident #126) due to concerns expressed via phone about lethargy, incr (increased) LE (lower extremity) [MEDICAL CONDITION] and incr BP (blood pressure). See Nursing Notes. Pt (patient) unable to express any c/o (complaints) - not answering my questions. BP improved to 150's. Pt awake and makes eye contact but not following any commands. PERL (pupils equal reactive to light). Left side of face with mild droop. Left arm is floppy at elbow. Cor (heart) regular. Lungs clear bilateral. Both LE's have [MEDICAL CONDITION] up to knee 3+. Coughs after a sip of water. A/P (Assessment/ Plan) AMS (altered mental status) and left sided weakness, [MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), spoke with daughter (HCP- health care proxy). Discussed conservative vs aggressive Rx (treatment). She would like pt evaluated in ED (emergency department) - will arrange. - On 4/5/16 at 12:20 PM, the Registered Nurse (RN #3) documented, Late entry for 3/29/16. This writer was informed after lunch that there was a change in resident's condition. This writer immediately went to assess resident who was laying in bed at this time. Left lower extremity noted with 4+ [MEDICAL CONDITION], right leg 2+ [MEDICAL CONDITION], temp (temperature) 96.5, b/p (blood pressure) 171/79, spO2 (oxygen saturation) 95% @ (at) RA (room air), slight swelling of left side of face/ neck. Message was sent to MD (Medical Doctor) awaiting response. Review of the undated Facility Investigation revealed the following: - On 3/29/16 at approximately 7:30 AM, the Certified Nurse Aide (CNA #2) informed LPN #5 of swelling in the resident's left leg. - LPN #5 observed the swelling of the left leg and informed to RN Supervisor (RN #2). - The RN Supervisor requested LPN #5 obtained the resident's vital signs and inform the RN Charge (RN #3) or the RN Supervisor (RN #2) of the findings. - At approximately 8:30 AM to 9:00 AM, LPN #5 obtained the vital signs as documented in the Progress Notes and administered the resident's medication. - LPN #5 informed the RN Charge (RN #3) of the resident vital signs and requested an RN assessment. Further review of the undated Facility Investigation reveals: - RN #3 completed an assessment of the resident and left a message for the Physician. The facility investigation does not identify when the RN's assessment was completed or when the Physician was informed of the change in the resident's status. - The Physician returned a call to the facility (time of call not included) and received an update of the resident's status as follows: LPN #1 checked on the resident (whom was in bed) and it was reported that (Resident #126) was noted to have 2+ [MEDICAL CONDITION] to leg and that her face did appear to be slightly puffy and that it had been communicated during report that (resident) was lethargic and had an elevated b/p. The Physician stated he would be in later to evaluate. The facility obtained a statement from the Physician during course of the investigation that revealed the Physician received a secure message from RN #3 in the early afternoon regarding the resident have a high BP (blood pressure) and 4+ LE (lower extremity) [MEDICAL CONDITION]. The Physician statement continued, I called back to the floor and spoke to one of the floor nurses to clarify the details and was told that the [MEDICAL CONDITION] was 2+. They did not notice any facial swelling. Lethargy was mild. I informed them that I would come in later in the evening to evaluate her. Further review of the Physician's statement revealed the Physician saw the resident at approximately 6:00 PM. The Physician noted mild left facial droop and LUE (left upper extremity) weakness. The resident was not answering any questions- this was a change from her baseline. The Physician noted there was [MEDICAL CONDITION] in both LE equally. The Physician documented he was concerned about a possible stroke and contacted the resident's daughter on the phone immediately and explained the situation and options. Interview with LPN #5 on 7/25/17 at 11:26 AM revealed LPN #5 gave report on Resident #126 to the RN Charge (RN #3) early in morning on 3/29/16. LPN #5 stated he was asked to check the resident blood pressure. LPN #5 stated he was concerned about the swelling in the resident's legs and brought it to the attention of RN #3. LPN #5 stated that the resident was gotten out of bed and he remembered feeding the resident lunch in the dining room. The resident was put back to bed after lunch because the resident appeared more tired looking. LPN #5 stated he gave verbal report including the residents vital signs to RN #3 and thought she was following up on the resident concerns. During an interview with the Administrator and Director of Nursing (DON) on 7/25/17 at 12:46 PM, the DON stated she would expect nursing staff to call immediately call the Physician regarding a change in the resident's condition, follow the Physician orders and inform the responsible party. The Administrator stated that RN #3 was no longer employed with the facility. The Administrator further stated that the facility had completed an investigation of the situation. Review of the facility policy entitled Notification of Changes, dated 12/14 printed 7/26/17 revealed the facility will immediately inform the resident; consult with the resident's Physician and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 415.3 (e)(2)(ii)(b)

Based on interview and record review conducted during Complaint Investigations (Complaint #NY 094) during the Standard survey completed on 7/26/17, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Two (Residents #66, 126) of 30 residents reviewed for quality of care had issues involving the lack of a Registered Nurse (RN) assessment and on- going monitoring for a resident with an elevated blood pressure and the lack of facility oversight of the resident's pacemaker to ensure proper function. The findings are: 1. Resident #126 was admitted to the facility on [DATE] and discharge to an acute care facility on 3/29/16 with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 3/15/16 revealed the resident had moderate cognitive impairment, usually understands and is usually understood Review of the Telephone/ Verbal Order Signature Details from 1/6/15 to 3/29/16 revealed a Physician order [REDACTED]. The Physician order [REDACTED]. Review of the March 2016 Medication Administration Record [REDACTED] - 3/1/16 150/90 (normal,120/80) - 3/8/16 132/64 - 3/15/16 122/64 - 3/22/16 132/68 - 3/30/16 209/94 Review of the electronic Progress Notes revealed the following: - On 3/29/16 at 1:05 PM, the Licensed Practical Nurse (LPN #5) documented, Lethargic, lt (left) leg [MEDICAL CONDITION], lt side of face swelling, vitals 96.6 (temperature, normal, 98.6°F), 76 (heart rate, normal 80- 100), 209/94 (blood pressure), accucheck (blood glucose monitor) ac (before meals) b/fast (breakfast) 112 (normal 70 to 100 mg/dL), recheck accucheck at noon was 65, supervisor updated. - On 3/29/16 at 6:42 PM, the Physician documented, I came to evaluate (Resident #126) due to concerns express via phone about lethargy, incr (increased) LE (lower extremity) [MEDICAL CONDITION] and incr BP (blood pressure). See nursing notes. Pt (patient) unable to express any c/o (complaints) - not answering my questions. BP improved to 150s. Pt awake and makes eye contact but not following any commands. PERL (pupils equal reactive to light). Left side of face with mild droop. Left arm is floppy at elbow. Cor (heart) regular. Lungs clear bilateral. Both LE's (lower extremities) have [MEDICAL CONDITION] up to knee 3+. Coughs after a sip of water. A/P (Assessment/Plan) AMS (altered mental status) and left sided weakness, [MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), spoke with daughter (HCP- health care proxy). Discussed conservative vs aggressive Rx (treatment). She would like pt evaluated in ED (emergency department) - will arrange. - On 3/29/16 at 6:59 PM, an LPN documented, (Physician) spoke with RP (responsible party and N.O. (new order obtained to send to (acute care facility) for evaluation. - On 3/29/16 at 7:22 PM LPN #1 documented, Alert, slow to respond. Color pale, skin warm and dry to touch. VS 97.8, 72, 18, 155/73, pox (oxygen saturation) 96% on room air. Accucheck at 1700 (5:00 PM) 93, LE 2+ noted. In bed, legs elevated as tolerated. Facial swelling noted, also left sided weakness. (Physician) in to eval (evaluate), spoke with responsible party, daughter. New order received to send to (acute care facility) ER (emergency room ) for eval, ambulance in to transport at this time. - On 4/5/16 at 12:20 PM, the Registered Nurse (RN #3) documented, Late entry for 3/29/16. This writer was informed after lunch that there was a change in resident's condition. This writer immediately went to assess resident who was laying in bed at this time. Left lower extremity noted with 4+ [MEDICAL CONDITION], right leg 2+ [MEDICAL CONDITION], temp (temperature) 96.5, b/p (blood pressure) 171/79, spO2 (oxygen saturation) 95% @ (at) RA (room air), slight swelling of left side of face/neck. Message was sent to MD (medical doctor) awaiting response. Review of the undated Facility Investigation revealed the following: - On 3/29/16 at approximately 7:30 AM, the Certified Nurse Aide (CNA #2) informed the LPN (LPN #5) of swelling in the resident's left leg. - LPN #5 observed the swelling of the left leg and informed to RN Supervisor (RN #2). - The RN Supervisor requested LPN #5 obtained the resident's vital signs and inform the RN Charge (RN #3) or the RN Supervisor (RN #2) of the findings. - At approximately 8:30 AM to 9:00 AM, LPN #5 obtained the vital signs as documented in the Progress Notes and administered the resident's medication. - LPN #5 informed the RN Charge (RN #3) of the resident vital signs and requested an RN assessment. Further review of the undated Facility Investigation revealed: - RN #5 completed an assessment of the resident and left a message for the Physician. The facility investigation does not identify when the RN's assessment was completed or when the Physician was informed of the change in the resident's status. - The Physician returned a call to the facility (time of call not included) and received an update of the resident's status as follows: LPN #1 checked on the resident (whom was in bed) and it was reported that (Resident #126) was noted to have 2+ [MEDICAL CONDITION] to leg and that her face did appear to be slightly puffy and that it had been communicated during report that (resident) was lethargic and had an elevated b/p. The Physician stated he would be in later to evaluate. - Resident was then transferred OOB (out of bed) for dinner and brought to the dining room. The resident did not eat dinner. Physician was in to assess the resident at approximately 6:00 PM. - The facility obtained a statement from the Physician during the course of the investigation that revealed the Physician received a secure message from RN #3 in the early afternoon regarding the resident have a high BP (blood pressure) and 4+ LE [MEDICAL CONDITION]. The Physician statement continued, I called back to the floor and spoke to one of the floor nurses to clarify the details and was told that the [MEDICAL CONDITION] was 2+. They did not notice any facial swelling. Lethargy was mild. I informed them that I would come in later in the evening to evaluate her. - Further review of the Physician statement revealed the Physician saw the resident at approximately 6:00 PM. The Physician noted mild left facial droop and LUE (left upper extremity) weakness. The resident was not answering any questions- this was a change from her baseline. The Physician noted there was [MEDICAL CONDITION] in both LE (lower extremities) equally. The Physician documented he was concerned about a possible stroke and contacted the resident's daughter on the phone immediately and explained the situation and options. Request of the facility 24-hour shift report for 3/29/16 revealed the facility was unable to locate a copy of the 24-hour shift report for the nursing unit. There is no documented evidence of a timely assessment by the Registered Nurse of the resident's elevated blood pressure and ongoing assessments of the resident's status, including a neurological assessment, while awaiting a response from the Physician. Interview with LPN #5 on 7/25/17 at 11:26 AM revealed LPN #5 gave report on Resident #126 to the RN Charge (RN #3) early in morning on 3/29/16. LPN #5 stated he was asked to check the resident blood pressure. LPN #5 stated he was concerned about the swelling in the resident's legs and brought it to the attention of RN #3. LPN #5 stated that the resident was gotten out of bed and he remembered feeding the resident lunch in the dining room. The resident was put back to bed after lunch because the resident appeared more tired looking. When asked if the LPN obtained any additional vital signs on the resident on that day, LPN #5 stated he gave verbal report including the resident's vital signs to RN #3 and thought she was following up on the resident concerns. During an interview with the Administrator and Director of Nursing (DON) on 7/25/17 at 12:46 PM, the Administrator stated that RN #3 was no longer employed with the facility and the evening RN Charge Nurse working on the unit when the Physician arrived was no longer working in the facility. The Administrator further stated that the facility had completed an investigation During an interview with LPN #1 on 7/25/17 at 3:04 PM, LPN #1 stated she begins work at 2:00 PM. LPN #1 further stated that she was asked to check on Resident #126 when she first came in on 3/29/16 because the evening charge nurse was on the phone with the Physician. LPN #1 stated, I checked her legs and her face. The doctor was coming in. The resident was in dining room when doctor came in and he asked me to check her vital signs. During an interview with the Physician on 7/26/17 at 1:01 PM, the Physician stated that he would expect staff to reassess a resident blood pressure within a couple of hours if the resident was symptomatic. The Physician further stated that he should be called immediately if there are neurological changes in a resident. 2. Resident #66 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired and is usually understood and usually understands. Review of physician's orders [REDACTED]. Review of both, the electron medical record (eMAR) and paper medical record revealed the resident did not have any advanced directives. Review of the provider progress notes dated 2/12/16 through 5/22/17 revealed no documented plan to monitor the resident pacemaker to ensure proper functioning. During an interview on 7/21/17 at 1:27 PM the Registered Nurse (RN) Regional Educator stated that a pacemaker would be checked per the doctor's protocol, and the only reason why a resident would not have a pacemaker check would be if the resident was on palliative care. During an interview on 7/21/17 at 1:34 PM, the Registered Nurse Unit Manager (RN#2) stated if a resident has a pacemaker it would be documented on the initial assessment. Then we usually contact the resident's cardiologist to see if they check the pacemaker function at their office or if we can conduct the check over the phone. It is usually case by case. The RN further stated that a care plan should be developed to address the pacemaker. Review of a Nursing Admission Evaluation dated 2/11/16 revealed the resident had a permanent pacemaker in her right upper chest. Review of both, the electron medical record (eMAR) and paper medical record revealed there was no documented evidence that the resident had a pacemaker check since admission to the facility to ensure its proper function. During an additional interview on 7/21/17 at approximately 2:06 PM, the RN #2 Unit Manager stated they were unable to find any reports or documentation the resident had a pacemaker check since her admission. RN #2 Unit Manager stated the resident should have had a pacemaker check. The RN further stated that she will contact the family to find out who the resident's cardiologist is and set something up to have the resident's pacemaker checked. During an interview on 7/21/17 at approximately 2:17 PM, the Director of Nursing (DON) stated the resident should have had a pacemaker check completed to ensure proper functioning. During a phone interview on 7/21/17 at approximately 2:24 PM, the Physician stated the need for a pacemaker check would be determined by the resident's care goals and if the resident was not receiving palliative care; the resident should have had a pacemaker check at least every six months. Review of a policy and procedure entitled Pacemaker, Monitoring and Transmission of, dated 8/00 revealed that residents who have permanent pacemakers will be monitored to insure proper functioning of the pacemaker 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/17, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain good grooming and personal hygiene. One (Resident #33) of four residents observed for ADL's had dark, crusted material under the fingernails over four days of observations. The finding is: 1. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/13/17 revealed the resident has severe cognitive impairment and sometimes understands. Further review of the MDS revealed there was no documentation of behavioral symptoms and no rejection of care. The MDS documented that the resident requires the extensive assistance of one person for personal hygiene, dressing and eating and is totally dependent on one person for bathing. Observation on 7/21/17 at 1:52 PM revealed Resident #33 had dark, crusted substance under the fingernails on both hands. The fingernails were at least 1/8 inch over the tips of each finger. Observation of morning care on 7/24/17 at 7:49 AM, CNA #2 and CNA #3 washed and dried the resident's upper body and dressed the resident in a top. The resident's hands were not washed during morning care. The resident's nails remained soiled with a dark crusted substance under the fingernails on both hands with the length of the fingernails remaining at least 1/8 inch over the tips of each finger. Observation on 7/25/17 at 10:40 AM, Resident #33 fingernails remained long and dirty. Review of the Comprehensive Care Plan with a revised date of 7/3/17 revealed the resident has a deficit in ADL function and is totally dependent on one staff for bathing and requires extensive assistance of one person for personal hygiene. Review of the Treatment Administration Record (TAR) for July 2017 revealed instructions for Skin examination report to RN (Registered Nurse) and document in Medical Record if new skin condition is identified, every day shift every Thursday. Review of the undated CNA (Certified Nurse Aide) Kardex (used by staff to provide care) revealed the resident is totally dependent on one person for physical assistance with bathing and extensive assistance of one person with personal hygiene. Review of the undated Second Floor Resident Shower Schedule revealed Resident #33 is scheduled for a shower on Sunday evening and Thursday during the day. During an interview on 7/25/17 at approximately 9:30 AM, Licensed Practical Nurse (LPN #5) stated that the CNA's are responsible for the resident's nail care. During an interview with the Registered Nurse (RN #1) Unit Manager (UM) on 7/25/17 at 10:51 AM, the UM stated the nurse would check on any resident skin concerns that would need to be tracked. The nurse would sign off for skin checks on the TAR. The UM continued to state that the CNA is responsible to check and care for the resident's nails on shower days. During further interview with the UM (RN #1) on 7/25/17 at 2:00 PM, the UM stated she had asked the aides to take care the resident's nails last week but no one told me she refused. I will get someone to take care of her nails right away. 415.12(a)(3)

Based on observation, interview and record review conducted during a Complaint investigation (Complaints #NY 212, NY 071) conducted during a Standard survey completed on 8/5/16, the facility did not ensure that each resident's drug regimen was adequately monitored to ensure that correct dosing of the drug was maintained to prevent adverse consequences. Three(Residents #45, 113, 151) of ten residents reviewed for unnecessary drugs had an issue where the resident received [MEDICATION NAME] (anticoagulant medication) with no monitoring of the resident's PT([MEDICATION NAME] time-clotting time)INR (international normalizing ratio-standardized normalized blood clotting values) from 6/30/16 until 7/14/16. On 7/14/16 the resident had a critically high INR value of 18 (reference range is 0.9 - 1.2) which indicates a lack of blood clotting. The resident developed left upper extremity (LUE) bruising and a hematoma (collection of blood under the skin) as well as conjunctival (mucous membrane surrounding the eye) hemorrhage that required hospitalization . There was actual harm that is not immediate jeopardy. In addition, there was a lack of adequate monitoring while on a Beta Blocker (medication used to treat hypertension, [MEDICAL CONDITION], abnormal heart rhythms, and chest pain) (Resident #113), and the lack of adequate monitoring while on a Beta Blocker and diuretic (promotes excretion of urine) medication (Resident #151). The findings are: 1. Resident #45 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for subacute rehabilitation. Review of the hospital Discharge Summary dated 6/29/16 revealed a discharge medication list which included the medication Eliquis (anticoagulant medication) 2.5 milligrams (mg) twice a day. Under the [DIAGNOSES REDACTED]. The discharge medication list did not include [MEDICATION NAME]. Review of the hospital Transfer/Post OP (operative) Medication Orders printed on 6/29/16 revealed an order for [REDACTED]. Review of the hospital Medication Administration Record (MAR) revealed [MEDICATION NAME] 5 mg was last administered on 6/28/16 at 8:47 PM. Review of hospital Laboratory (lab) Reports revealed an INR performed on 6/28/16 was 1.38 and an INR performed on 6/29/16 was 2.4 (INR goal range 2-3). Review of the facility Medication Reconciliation / Physician Orders worksheet dated 6/29/16 revealed admission orders [REDACTED]. The worksheet included admission lab orders for CBC (complete blood count), CMP (complete metabolic profile), and Hgb A1C (blood test to determine average blood glucose levels). In addition, orders for routine labs of a CBC and BMP (basic metabolic profile) to be done weekly. The worksheet was completed by RN #1 and co-signed by RN #2 as the second Nurse Reconciliation Review. The area indicating labs for PT/INR was blank. Review of a Progress Note written by the day Supervisor RN #1 dated 6/29/16 at 9:39 PM revealed the resident was admitted to the unit on 6/29/16 in the evening with [DIAGNOSES REDACTED]. The orders were confirmed with the PA (Physician Assistant). RN #1 clarified the order for Eliquis 2.5 mg BID (twice daily) which was on the med list from the hospital, however in the discharge narrative, [MEDICATION NAME] was chosen over Eliquis due to the resident's fluctuating creatinine (blood test to determine kidney function). RN #1 documented that [MEDICATION NAME] will be started. Review of an Order Summary Report (Physician's Orders) dated 6/29/16 revealed an order for [REDACTED]. Review of a Progress Note - Order Note dated 6/29/16 signed by RN #2 revealed a lengthy note describing possible drug interactions between [MEDICATION NAME] and multiple other medications that were ordered for the resident. There is no documented evidence that the medical provider was notified of these potential interactions. Review of a fax from the hospital pharmacy labeled Anticoagulant Management Service to the facility dated 6/30/16 documented that the patient has been discharged from the hospital on [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The discharge dosage directions were to hold [MEDICATION NAME] ([MEDICATION NAME]) tonight (6/29/16) due to a 1 pt (point) jump in INR over past 24 hours after only 2 doses. The fax indicated that [MEDICATION NAME] 5 mg was administered in the hospital on [DATE] and 6/28/16. The discharge comments on the fax state to obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. (It should be noted that the document was faxed to the facility on [DATE] at 12:03 PM, the day after the resident was admitted to the facility). Review of the History and Physical (H&P) exam dated 6/30/16 completed by the Physician revealed Eliquis was discontinued due to renal function fluctuations and the resident was placed on [MEDICATION NAME]. The Physician note documents the discrepancy noted between the Hospital Discharge medication list, the Discharge Summary and the facility medication list. The H&P revealed that the resident is on [MEDICATION NAME] and off Eliquis and the plan is to monitor INRs while on [MEDICATION NAME]. Review of a Nurse Practitioner note (NP) #2 dated 7/5/16 revealed the resident has chronic [MEDICAL CONDITION] and the rate was stable on [MEDICATION NAME] and [MEDICATION NAME] (medication used to treat high blood pressure, heart failure and chest pain). The plan is to follow the INR and monitor rate. Review of a Progress Note written by RN #3 dated 7/14/16 at 8:22 AM revealed the resident complained of an inability to move her left shoulder and arm this morning. Some bruising was noted near the axilla (arm pit) and upper deltoid (shoulder muscle) area. The resident is unsure how the bruising occurred. Review of a NP #2 note dated 7/14/16 revealed that staff reported the resident had LUE pain and ecchymosis (purplish patch caused by blood under the skin), the resident denied injury to the area. The resident was also noted with conjunctival hemorrhage and was unaware of how she acquired it. Multiple areas of ecchymosis were observed over the left clavicle (shoulder blade) into the axillary area. The area was tender to palpation. Pain in the left arm appears to be musculoskeletal in nature. The plan is to get an x-ray to rule out underlying pathology, to check the INR to rule out a hypercoaguable (condition in which there is an abnormally increased tendency toward blood clotting) state, and to order pain medication. The resident likely developed a hematoma in the area due to repetitive exercises. Under assessment for [MEDICAL CONDITION] revealed that the rate is stable on [MEDICATION NAME] and [MEDICATION NAME] and the plan is to follow the INR closely as the resident has been hypercoaguable in the past. Review of an Order Summary Report dated 7/14/16 revealed an order for [REDACTED]. Review of a Licensed Practical Nurse (LPN) Progress Note dated 7/14/16 at 1:38 PM revealed NP #2 was in to see the resident with new orders for [MEDICATION NAME] (opioid pain medication) 10/325 mg every 4 hours as needed for pain and a CBC on 7/18/16. The Progress Note revealed an INR was not ordered at this time. Review of a Progress Note dated 7/14/16 at 10:26 PM revealed the left shoulder x-ray showed [MEDICAL CONDITION] changes and no fracture or dislocation. The left humerus x-ray showed no acute fracture or destructive lesion. Review of the Medication Administration Summary for June and July 2016 revealed the resident received [MEDICATION NAME] 4 mg at 9:00 PM every day from 6/30/16 through and including 7/14/16. Review of an Order Summary Report dated 7/14/16 revealed an order from the NP for a stat (immediate) PT/INR. Review of the lab slip dated 7/14/16 revealed the PT/INR was drawn at 11:35 PM. Review of the lab report dated 7/14/16 revealed the PT value reported on 7/15/16 at 12:30 AM was 230.2 (reference range is 9.3 - 13.5) and the INR value was 18 (reference range is 0.9 - 1.2). Review of an RN Progress Note dated 7/15/16 at 12:30 AM revealed the resident had a critically high PT/INR, the NP was called and gave orders for a Vitamin K (helps to clot the blood) 10 mg injection one time now. The resident denied chest pain, shortness of breath and there were no new areas of bruising noted on the resident. Labs are to be repeated in the morning. Review of a Progress Note written by RN #1 dated 7/15/16 at 2:43 PM revealed the INR result was 12.3. The NP was notified of the result by a secure text. Review of a Progress Note dated 7/15/16 at 5:32 PM revealed the NP returned the call related to the INR result of 12.3 and discontinued [MEDICATION NAME] and ordered Vitamin K 10 mg SQ (subcutaneously-beneath the skin) stat; repeat INR in the morning and call the NP with the results. Review of a LPN Progress Note dated 7/15/16 at 10:10 PM revealed that a sling is in place at all times to the left shoulder/arm; and bruising remains to the left upper arm. Review of an unsigned Progress Note dated 7/16/16 at 11:51 AM revealed the NP reviewed the labs from today and yesterday, the INR remained the same at 12.3. Vitamin K was given twice on 7/15/16. New order was received to send the resident to the ER (emergency room ) for evaluation due to uncorrected critical level. The resident left via ambulance on 7/16/16 at 12:30 PM. Review of an RN Progress Note dated 7/16/16 at 11:59 PM revealed the resident returned from the ER at approximately 9:30 PM. The resident was given oral Vitamin K in the ER and had a repeat INR of 13.2. There were no new recommendations or orders. The Physician service was notified of the resident's return and left message to question when the next INR level to be drawn. The Care Plan and Door Profile were changed to reflect bleeding/bruising precautions and a nurse order to monitor every shift for bleeding/bruising for 7 days. Review of a RN Progress Note dated 7/17/16 at 2:33 PM revealed that no signs of bleeding or new bruises were noted. Orders were received to repeat PT/INR on 7/18/16. Review of the lab slip dated 7/18/16 revealed the INR value remained high at 3.9. Review of an Order Summary Report dated 7/20/16 revealed an order for [REDACTED]. Review of the lab slip dated 7/20/16 revealed the INR value was 2.9. Review of an email from NP #2 to the facility dated 7/20/16 revealed NP #2 saw the resident on 7/5/16 and noted the resident was on [MEDICATION NAME] from a review of the Discharge Summary and the 6/30/16 Physician Note. NP #2 documented in the email that on 7/5/16 she requested lab results but was told by staff that the results were not available for her visit. NP #2 was told the facility had not received the results from the lab as of the time of her visit as Monday was a holiday and all routine labs were done on Tuesday. NP #2 stated in the email that she did not specifically ask for an INR at the time, she just asked for lab values. NP #2 further stated that on 7/14/16 she saw the resident for an acute onset of LUE pain/decreased ROM (range of motion). She noted ecchymosis at her shoulder and a conjunctival hemorrhage, the resident denied injury and was unaware of the hemorrhage. NP #2 documented that she spoke with the nurse and requested the INR results. After investigating further, the nurse discovered that the INR had not been done in two weeks. The email states that a stat INR was requested at that time. Review of the facility investigation related to the incident dated 7/14/16 revealed that the resident was admitted to the facility on [DATE]. The Discharge Summary indicated Eliquis 2.5 mg orally twice a day. The narrative indicated that [MEDICATION NAME] was chosen over Eliquis due to fluctuating renal function. The resident had been receiving [MEDICATION NAME] in the hospital and her INR was therapeutic at 1.38 on 6/28/16 per the hospital Discharge Summary dated 6/29/16. [MEDICATION NAME] 4 mg was started on 6/30/16 after clarification with the PA per the Nurse's Note dated 6/29/16. Drug to drug interaction notifications were present per Nurse's Note review, however the facility was unable to locate documentation that the covering NP/MD (medical doctor) was notified by RN Supervisor (RN #2) who entered the orders and received notification of the drug to drug interactions. The Medication Reconciliation/Physician Order worksheet reflects that the area indicating labs for PT/INR was blank. The worksheet was completed by RN #1 as the primary nurse and was signed by RN #2 as the second nurse as the Nurse Reconciliation Review. The facility investigation conclusions included the following: -The resident received multiple doses of [MEDICATION NAME] in the absence of PT/INR monitoring and exhibited bruising, conjunctival hemorrhage and the need for treatment with two doses of vitamin K in the facility and an ER visit with one dose of Vitamin K administered. -Licensed nurses failed to verify PT/INR results prior to administration of [MEDICATION NAME] (per the Therapeutic Anticoagulation Monitoring System Policy) resulting in an elevated PT/INR. -RN #2 failed to appropriately obtain an order for [REDACTED]. Observation and interview of the resident on 7/25/16 at approximately 1:30 PM revealed the resident had a bluish large bruise to the left upper arm axillary area. The resident stated that the area hurts at times and she takes pain pills for the pain. During an interview with RN #1 on 7/25/16 at approximately 11:45 AM, RN #1 stated that on 6/29/16 she worked a double shift and the resident was admitted to the facility between approximately 7:00 PM - 8:00 PM. RN #1 stated that Nursing Supervisors do the new admissions. RN #1 stated that she did the medication reconciliation using the Discharge Summary, and MARs from the hospital. RN #1 stated she documented her admission orders [REDACTED]. She reviewed the admission medications by telephone with the PA who ordered [MEDICATION NAME] 4 mg for the resident. RN #1 stated that there was some confusion with this case because the hospital Discharge Summary medication list stated that the resident was to continue on Eliquis. RN #1 stated that it was only through reviewing the written narrative in the Discharge Summary the resident was to be on [MEDICATION NAME] instead of Eliquis because of the resident's kidney function. RN #1 stated that she does not recall discussing the need for INRs with the PA and stated that there was no order for an INR on the worksheet that she used. RN #1 stated that normally PT/INRs are done with the admission labs usually within 24 - 48 hours of admission. RN #1 stated that she left the facility at 10:00 PM on 6/29/16 and handed off the admission paperwork to the night shift RN Supervisor who entered the admission orders [REDACTED]. RN #1 stated that the [MEDICATION NAME] Worksheet was never written up for the resident. [MEDICATION NAME] Worksheets are normally kept in the lab book maintained on each unit that contain the lab reports for all residents. RN #1 stated that the medication nurses are supposed to check the [MEDICATION NAME] Worksheet prior to administering any dose of [MEDICATION NAME] to check the most recent INR value. In addition, RN #1 stated that she did not see the fax from the hospital pharmacy dated 6/30/16 that gave instructions to hold the [MEDICATION NAME] on 6/29/16 and obtain a PT/INR the morning of 6/30/16 for further [MEDICATION NAME] dosing. RN #1 stated that the fax was sent by the hospital pharmacy on 6/30/16 at approximately 12:00 PM. In addition, RN #1 stated that NP #2 assessed the resident earlier in the day on 7/14/16 due to the resident's complaints of pain, immobility and bruising to the LUE ordered an x-ray and INR to be drawn. There was no order to hold [MEDICATION NAME] on 7/14/16. (Surveyor review of the orders revealed NP #2 did not order an INR on 7/14/16 but ordered a CBC to be done on 7/18/16). RN #1 stated that she was the Nursing Supervisor and acting as medication nurse on 7/14/16 during the evening shift and administered [MEDICATION NAME] 4 mg at bedtime. Later in the evening RN #1 was looking for the resident's INR results and could not find one. She informed NP #2 that ordered a stat INR. The results on 7/15/16 at approximately 12:30 AM was 18.0 critically high. During an interview on 7/25/16 at approximately 3:15 PM, LPN #1 stated that per the initials on the MAR she administered [MEDICATION NAME] 4 mg to the resident at approximately 9:00 PM on 6/30/16, 7/2/16, 7/7/16, 7/8/16, 7/11/16, and 7/12/16. LPN #1 stated that she did not check for the INR level prior to administering the medication. LPN #1 stated that it was a mistake not to check the INR level and she has been re-educated on the importance of checking the INR value prior to administering [MEDICATION NAME] to any resident. The Physician stated during a telephone interview on 7/26/16 at approximately 2:30 PM that on 6/30/16 she completed the resident's initial H&P exam and also noted the discrepancy between the Eliquis and [MEDICATION NAME] while reviewing records on the computer system. The Physician stated that she did not find any INR results in the computer system and asked a nurse about the INRs. The nurse told her that they were monitoring the INRs and the nurses were still in the process of entering orders on the resident. The Physician stated that the nurses seemed to be aware of the need to monitor INRs and that it is her expectation that INRs are monitored on all residents on [MEDICATION NAME]. During a telephone interview on 8/3/16 at approximately 11:30 AM, NP #2 stated she made a visit to the resident on 7/5/16 and asked the nurse about the labs. She was told that labs were not done on 7/4/16 due to the holiday, labs were done on 7/5/16 and the results were not available during her visit. NP #2 stated that she noted that the Physician had seen the resident on 6/30/16 and had documented that INRs were being monitored. NP #2 stated she did not note whether there were orders for the INRs. NP #2 further stated that on 7/14/16 she evaluated the resident and noted bruising and pain to the resident's LUE and a conjunctival hemorrhage and ordered an x-ray of the LUE. She asked about the INR and nurse could not find one so NP #2 stated that she ordered a stat INR. NP #2 stated that she did not attempt to review previous labs because she did not have access to the facility's computer lab program as she was covering for another NP who was on vacation. NP #2 stated that the stat INR result was not reported until after she had left the facility and the on-call practitioners were taking calls. Review of the facility policy and procedure (P&P) entitled Therapeutic Anticoagulation Monitoring System for Nursing Services dated 9/2008 revealed that residents receiving anticoagulation therapy for the management of thrombus (blood clot), thrombus prevention or for management of [MEDICAL CONDITION] will receive periodic monitoring of PT/INR levels as ordered by the Attending Physician. Procedure #1 regarding PT/INR testing-Results are recorded on the MAR and/or [MEDICATION NAME] Record. The medication nurse must verify PT/INR test results prior to anticoagulant medication administration, as indicated. All PT/INR parameters are followed accordingly. Any contact with the Attending Physician regarding test results is recorded in the Nursing Progress Notes. Review of the facility P&P entitled Admission, Annual and Routine Lab Tests for Medical Services dated 11/2007 revealed under Procedure #3 -Routine Tests Based on Medical Conditions: Laboratory tests will be obtained routinely for residents with identified Medical Conditions and/or medication orders, according to the schedule below and/or as ordered by the Physician. a.)[MEDICATION NAME]/ [MEDICATION NAME]/Anticoagulant Therapy- PT/INR time is obtained weekly. If the resident is stable, PT/INR may be obtained every (2) weeks. 2. Resident #113 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/15/16 revealed the resident is cognitively intact, understood, and understands. Review of the Order Summary Report dated 4/9/16 revealed an order for [REDACTED]. Give 12.5 mg by mouth one time a day [MEDICAL CONDITION](Use ½ of 25 mg tablet); Hold if SBP (systolic-the upper blood pressure (BP) number that measures the pressure exerted by circulating blood on the blood vessels) is less than 100 or pulse less than 60. Review of the April 2016 MARs revealed [MEDICATION NAME] ([MEDICATION NAME]) signed as administered 4/9/16 through 4/23/16. Review of the Electronic Medical Record (EMR) revealed the resident's pulse was not monitored prior to the administration of t [MEDICATION NAME] on the following dates: 4/12/16, 4/13/16, 4/15/16, 4/16/16, 4/17/16, 4/18/16, 4/19/16, 4/21/16, 4/22/16 and 4/23/16. During an interview on 8/4/16 at approximately 8:59 AM RN #3 stated, There is usually a box on the MAR to document the BP and pulse, I don't know what happened here, there should be some documentation of the BP. If he (Physician) has parameters to hold a med (medication) that should be documented on the MAR. 3. Resident #151 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understood, and understands. Review of the Order Summary Report dated 7/21/16 revealed orders for [MEDICATION NAME] (Beta-Blocker) ER (extended release) Tablet 24 Hour 25 mg. Give 3 tablets by mouth one time a day for HTN. 3 tablets = 75mg. Hold if SBP is less than 100. [MEDICATION NAME] (diuretic) Tablet 25 mg. Give 1 tablet by mouth one time a day for HTN. Hold if SBP is less than 100. Review of the July 2016 and August 2016 MARs revealed [MEDICATION NAME] ER Tablet and [MEDICATION NAME] signed as administered 7/21/16 through 8/4/16. Review of the EMR revealed BPs taken from 7/18/16 through 7/21/16 range 93/52 (low) to 126/76 (normal) with the last documented BP 94/62 (low) on 7/21/16 at 11:30 PM. During an interview on 8/4/16 at approximately 8:59 AM RN #3 stated, There is usually a box on the MAR to document the BP and pulse, I don't know what happened here, there should be some documentation of the BP. If he (Physician) has parameters to hold a med that should be documented on the MAR. Review of the undated facility policy entitled Vital Signs (Monitoring) included the following: -A resident's pulse or BP is recorded on the MAR prior to the administration of specified medications. -A resident's vital signs are monitored for specific medical conditions, as designated by Physician order or as deemed necessary by the Unit Manager/designee. 415.12(l)(1)