Every finding on record at Forest View Center for Rehabilitation & Nursing

Based on record review and interviews conducted during Recertification and Abbreviated (NY00321724) survey from 04/29/2024 to 05/06/2024 , the facility did not ensure that all alleged violations involving neglect and injuries of unknown source were reported immediately but not later than 2 hours after the allegation was made to the New York State Department of Health. This was evident for 2 (Residents #62 and #70 ) of 38 total sampled residents. Specifically, 1.) On 02/22/2023, Resident #62 sustained a swelling on the forehead. The injury was not witnessed, and the source of injury could not be explained by the Resident. The injury was not reported to the New York State Department of Health. 2.) On 04/11/2024, Resident #70 had an unwitnessed fall that resulted in an acute left femoral fracture. The Resident was unable to explain the occurrence. The injury was not reported to the New York State Department of Health. The findings are: The facility policy titled Abuse Prevention with a reviewed date od 04/14/2023 documented that the facility will report any incident and/or violation where abuse, neglect, exploitation, or mistreatment is suspected or has reasonable cause to believe that abuse has occurred. The facility will notify the New York State Department of Health when an investigation identifies abuse. 1. Resident #62 had diagnoses of Dementia, Parkinson Disease, Depression, and Psychotic Disorder. The Minimum Data Set assessment (an assessment tool that measures health status of nursing home residents) dated 01/11/2024 documented that Resident #62 was severely cognitively impaired and required extensive assistance of 2 person for transfers and personal hygiene. Registered Nurse's note dated 02/22/2023 documented that at around 4:30 PM of 02/22/2023, they were approached by Resident #62's sister who was visiting the resident at that time to check resident's forehead. Resident #62's forehead was observed with mild swelling to left side of his forehead. The facility Accident/Incident Investigation Report Summary documented that on 02/22/2023 at approximately 4:30 PM, Resident #62 was observed by their family member with a bump on the forehead. Upon assessment, resident was noted with a swelling to the left side of the forehead measuring 2.5 by 3.5 centimeters. Resident was interviewed and could not relate to the event due to poor cognition. A review of the Accident / Incident Report and employee statements did not indicate any witness to how Resident #62 sustained the forehead swelling. There was no documented evidence that the swelling to Resident #62's forehead was reported to the New York State Department of Health. On 05/03/2024 at 02:03 PM, an interview was conducted with the Director of Nursing who stated that allegations of abuse were reported to the New York State Department of Health when the investigation was completed. The Director of Nursing stated they rule out abuse before deciding if an incident need to be reported to the New York State Department of Health. The Director of Nursing stated Resident # 62's alleged incident was not reported because they believed Resident #62 may have hit their forehead on the upper side rails while in bed and concluded that it was not abuse. 37787 2. Resident #70 was admitted to the facility with diagnoses of Anxiety Disorder, Dementia with Behavioral Disturbances, and Repeated Falls. The Minimum Data Set, dated dated dated [DATE] documented Resident #70 had short and long term memory problem and moderately impaired cognitive skills. Resident #70 was incontinent of bowel and bladder. The assessment further documented that Resident #1 required supervision for transfers and was able to walk 150 feet with supervision. A facility's Accident / Incident Report dated 04/11/2024 documented that on 04/11/2024 at 3:00 AM, Resident #70 was observed lying on their right side by the right side of their bed. Resident was unable to state what happened. A review of the Accident / Incident Report and employee statements did not indicate any witness to Resident #70's fall occurrence. A nurse's progress notes dated 04/16/2024 at 6:19 PM documented that Resident #70's x-ray (a test that captures images of the structures inside the body particularly the bones) showed acute left femoral neck (thigh bone close to the hip joint) fracture (a break in a bone) . Resident #70 was transferred to the hospital. On 05/06/2024 at 9:28 AM, an interview was conducted with the Assistant Director of Nursing who stated that Resident #70's fracture was not reported to the New York state Department of Health because they assumed Resident #70's fracture was related to the fall that occurred on 04/11/2024. 10 NYCRR 415.4 (b)

Based on record review and interview conducted during the Recertification Survey from 04/29/2024 to 05/06/2024, the facility did not ensure that the Minimum Data Set assessment accurately reflect the resident's status. This was evident in 3 (Resident # 16, # 63, and #65) of 38 total sampled residents. Specifically, 1.) Resident #16's Minimum Data Set assessment did not reflect the Resident being in hospice care, 2.) Resident #63's Minimum Data Set assessment did not document Resident having colostomy, and 3.) Resident #65's Minimum Data Set assessment did not document any active diagnoses. The findings are: The facility have not provided a documented policy on Minimum Data Set assessment and completion. 1.) Resident #16 was admitted to the facility with diagnoses of Dysphasia and Abnormal Results of Liver Function Studies. A nurse's progress notes dated 03/16/2024 documented Resident #16 remained alert and verbally responsive. The note documented that Resident #16 was evaluated by the Hospice nurse and was accepted to hospice care. The Minimum Data Set assessment with reference date of 03/29/2024 did not document Resident #16 being in hospice care. 2.) Resident #63 was admitted to the facility with diagnoses of Cerebrovascular Accident, Pancreatic Mass, and Stercoral Colitis. A physician's readmission note dated 03/26/2024 documented that Resident #63 had a colostomy on the left lower abdomen. The Minimum Data Set assessment with reference date of 03/31/2024 did not document Resident #16 having colostomy. 3.) Resident #65 was admitted to the facility with diagnoses of Recurrent Depressive Disorder, Psychotic Disorder, Insomnia, Hypertension, and Embolism. The Minimum Data Set assessment with reference date of 01/23/2024 did not document any of Resident #65's active diagnoses. On 05/03/2024 at 11:00 am, the Minimum Data Set Coordinator was interviewed and stated each department was responsible for ensuring that their sections were completed timely and accurately. The Minimum Data Set Coordinator stated they were responsible for scheduling and ensuring completion for timely submission of the Minimum Data Set assessment. 10 NYCRR 415.11(b)

Based on record review and interview conducted during the Recertification survey, the facility did not ensure that allegations of abuse were thoroughly investigated for 1 of 1 residents reviewed for Abuse in a sample of 32 (Resident #95). Specifically, Resident #95 had a left wrist fracture of unknown origin that was not investigated. The findings are: The facility policy titled Abuse Preventions Policy, dated 04/14/22, documented the facility will investigate allegations of abuse by interviewing and obtaining statements from the staff and witnesses, and reviewing medical records. The undated facility policy titled Accident and Incident documented the facility will investigate every accident, incident or occurrence of residents in the facility. Resident #95 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance of one person to perform activities of daily living. On 04/14/22 at 02:20 PM, Resident #95 was observed to be restless in their wheelchair and attempted to get up unassisted several times. A Nursing note (NN) dated 10/15/2021 documented Resident #95 was restless, exhibited pain to the left wrist, the Medical Doctor (MD) was made aware, and an left wrist x-ray was ordered. NN dated 10/15/21 subsequently documented the left wrist x-ray showed an acute distal radial and ulnar styloid fracture. The MD was made aware and Resident #95 was transferred to the hospital. An x-ray Patient Report dated 10/15/21 documented Resident #95 had an acute distal radial and ulnar styloid fracture of the left wrist. NN dated 10/16/2021 at 1:31 PM documented Resident #95 was readmitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence the facility conducted an investigation for the resident's fracture of unknown origin to rule out abuse, neglect, or mistreatment. On 04/20/22 at 9:45 AM, Registered Nurse (RN) #1 was interviewed and stated on 10/15/21, Resident #95's family member reported that Resident #95 had a swollen left wrist. RN #1 assessed Resident #95, informed the MD, and endorsed the matter to RN #2 who no longer works in the facility. RN #2 received the x-ray results and coordinated Resident #95's transfer to the hospital. Thee Assistant Director of Nursing (ADNS) and Director of Nursing (DON) were informed of the incident. On 04/20/22 at 11:08 AM, the ADNS was interviewed and stated they were made aware Resident #95 had a left wrist fracture on 10/16/21. The ADNS was unable to provide a reason the facility did not investigate the origin of Resident #95's left wrist fracture. On 04/20/22 at 2:00 PM, the DON was interviewed and stated the facility must thoroughly investigate if a resident sustains a serious injury to rule out abuse. The RN supervisor is responsible for obtaining staff statements and the ADNS formulates the conclusion of the investigation. The DON was unable to provide a reason why Resident #95's left wrist fracture was not investigated to rule out abuse. 415.4(b)(1)(i)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure assessments accurately reflected the resident's status for 1 of 32 sampled residents (Resident # 126). Specifically, the Minimum Data Set 3.0 (MDS) assessment for Resident #126 did not document the use of a wander/elopement alarm. The findings are: Resident #126 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #126 was severely cognitively impaired, required supervision when ambulating in the hallway, and a wander/elopement alarm was not used. On 04/14/22 at 10:46 AM, Resident #126 was observed with a wander-guard (WG) alarm to their right ankle. The Comprehensive Care Plan (CCP) related to behavior symptoms was last revised 06/30/2021 and documented interventions including a WG to Resident #126's right ankle. The Physician Order, initiated 06/30/21 and last renewed 3/28/22, documented the right ankle WG on Resident #126 should be checked every shift. The Medication Administration Records (MARs) documented the nursing staff checked the right ankle WG on Resident #126 every shift daily from 01/14/22 to 04/14/22. On 04/20/22 at 02:48 PM, the License Practical Nurse (LPN #1) was interviewed and stated LPN #1 is responsible for physically assessing the residents and and inputting the data into the MDS assessment. The MDS coordinator then reviews and signs the MDS. After reviewing MDS dated [DATE], LPN #1 stated it was an oversight that Resident #126 was not coded as having a WG alarm. On 04/20/22 at 03:02 PM, the MDS Director was interviewed and stated the LPN does not assess the residents. The LPN collects data that is already in the medical record. The MDS Director reviews and signs all MDS assessments. It was an oversight that Resident #126 was not coded as having a WG alarm. 415.11 (b)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure residents were involved in developing their comprehensive care plan (CCP) for 1 of 32 sampled residents (Resident #20). Specifically, Resident #20 was not invited to a CCP meeting with the interdisciplinary team (IDT). The findings are: The facility policy titled CCP dated 07/12/2020 documented Social Services notifies the resident and/or family, encourages them to attend the meeting, and provides alternate arrangements to include the resident in the CCP process. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Date Set 3.0 (MDS) assessment dated [DATE] documented Resident #20 was cognitively intact, able to make themselves understood, and participated in their assessment. Resident #20 was interviewed on 04/14/22 at 12:42 PM and stated they and their designated representative had not been invited to attend a CCP meeting with the IDT on 04/12/2022. The resident was alert and oriented but preferred the facility contact their designated representatives re: their CCP. The CCP schedule dated 1/12/2022 documented Resident # 20 's representative was invited and would attend the admission care plan meeting. The CCP schedule dated 4/12/2022 documented a meeting was scheduled for Resident #20. The Care Plan Meetings History dated 04/12/2022 documented a Registered Nurse and Physical Therapist attended the CCP meeting. There was no documented evidence Resident #20 or their designated representative was invited to attend the scheduled CCP meeting on 4/12/22 with the IDT. On 04/19/22 at 11:00 AM, the Social Worker (SW) was interviewed and stated residents/representatives were invited to initial, significant change, and annual but not quarterly CCP meetings. Residents/representative are invited a few days before the scheduled meeting. Resident #20 was cognitively intact and asked that CCP meeting invitations be handled by their representative. Resident #20 and their representative were not invited to the CCP meeting on 04/12/2022. On 04/19/22 at 12:16 PM, the Director of Social Work (DSW) was interviewed and stated residents/representatives were invited up to a week in advance of CCP meetings. Residents/representatives were not invited to the quarterly CCP meetings with the IDT. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure residents were provided with an ongoing activities program designed to meet their choices and interests. This was evident for 1 of 2 residents reviewed out of a sample of 32 residents (Resident #21). Specifically, Resident #21 was not provided with activities of their choice, including television (TV) channels in the French Creole language. The findings are: The facility policy titled Procedure for Individual Activities dated 7/1/19 documented every resident was involved in a meaningful program of activity, tailored to their individual needs and preferences. Resident #21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #21 had mild cognitive impairment, was able to understand others, made self understood, and participated in the assessment. On 04/14/22 at 11:17 AM, Resident #21 was observed sitting in a wheelchair in the hallway without on-going activity. Resident #21 was interviewed using an interpreter via phone language line and stated their native language was French Creole, they did not speak English, and they enjoyed watching TV in Creole French. Resident #21 was not asked by facility staff about their activity preferences, does not enjoy reading or writing, and does not have French Creole channels on their TV. The TV in Resident #21's room was observed and there were no French Creole channels available. A radio was not observed in the resident's room. Resident #21 was observed multiple times on 04/15/22 from 09:18 AM to 11:59 AM, 04/18/22 from 10:13 AM to 04:31 PM, 04/19/22 from 10:02 AM to 02:51 PM, 04/20/22 from 10:25 AM to 03:26 PM, and 04/21/22 at 09:50 AM sitting in a wheelchair in the hallway without ongoing activity. The Comprehensive Care Plan (CCP) related to Activities initiated 3/3/2016 documented Resident #21 had a language barrier and was at risk for isolation. Interventions documented to reevaluate Resident #21's needs, interests, and capabilities through interview and observation, and place Resident #21 in a level of functioning that best suits their needs, interests and capabilities. The Therapeutic Recreation (TR) Annual assessment dated [DATE] documented Resident #21 preferred TV and radio/music. The MDS dated [DATE] documented Resident #21 was the primary respondent for activity preferences and it was somewhat important for Resident # 21 to do their favorite activities. The TR Quarterly assessment dated [DATE] documented Resident #21 preferred TV and radio/music. The facility Television Channel List was undated and did not document French Creole channels. On 04/19/22 at 10:12 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated Resident # 21 was alert, oriented, able to make needs known, and spoke French Creole. Resident #21 did not like to participate in activities and sat in their wheelchair most of time. CNA #1 did not observe Resident #21 watching TV often and did not know wether Resident #21 had any language barrier issues. The facility did not have any French Creole TV channels available. On 04/19/22 at 10:21 AM, the TR was interviewed and stated Resident # 21 was alert, oriented, and had a language barrier because Resident #21 spoke French Creole and did not speak any English. The facility had a language line for staff to use for language interpretation with residents; however, the TR did not know how to use the language line and did not use it to communicate with Resident #21. The TR did not know Resident # 21's activity preferences, including Resident #21's preference to watch French Creole TV. On 04/20/22 at 10:10 AM, the Director of Recreation (DOR) was interviewed and stated the DOR was responsible for completing the recreation assessments but had only worked at the facility for 2 months and did not complete the assessment for Resident #21. The facility does not offer TV channels in French Creole but if the DOR was aware of Resident #21's language barrier, the DOR would have provided Resident #21 with their activity preferences. 415.5(f)(1)

Based on observation, record reviews, and staff interviews during the Recertification Survey the facility did not ensure residents were from unnecessary antipsychotic medications. Specifically, two residents were prescribed the antipsychotic medication [MEDICATION NAME] with no proper documentation of behavioral symptoms, without periodic re-evaluation for the clinical indication for the use of the antipsychotic medication, and without attempt for Gradual Dose Reduction (GDR). This was evident for 2 of 5 residents reviewed for Unnecessary Medications out of 33 sampled residents. (Resident # 156 and Resident #121). The findings are: Resident # 156 was admitted to the facility 6/2/16. The resident was admitted with [DIAGNOSES REDACTED]. The resident was in therapy to work on regulation of anger and associated dysphoria On 7/10/19 Resident # 156 was observed in her room sitting in her wheelchair calmly while getting her hair set by her private aid. Resident #156 was able to have a conversation but could not report how long she was in the facility. On 7/12/19 Resident #156 was observed in the Penthouse area of the facility with other residents. Resident was sitting calmly waiting for her lunch to be served The Significant Change Minimum Data Set (MDS) initiated for hospice care dated 3/27/19 documented the resident is cognitively impaired with no [MEDICAL CONDITION], or [MEDICAL CONDITION]. Th resident is usually understood, and usually understands others. Resident had no behavioral symptoms towards self or others. The resident did not reject care and was extensive assistance for Activities of Daily Living (ADLs). The resident used a wheelchair. Active [DIAGNOSES REDACTED]. Resident received and antipsychotic medication 7/7 days, antidepressant 7/7 days. Gradual Dose Reduction (GDR) has not been documented by a physician as clinically contraindicated. Last Quarterly MDS dated [DATE] documented the resident is cognitively impaired with no [MEDICAL CONDITION], or [MEDICAL CONDITION]. Th resident is usually understood, and usually understands others. The resident did not reject care and was extensive assistance for Activities of Daily Living (ADLs). The resident used a wheelchair. Active [DIAGNOSES REDACTED]. Resident received and antipsychotic medication 7/7 days, antidepressant 7/7 days. GDR has not been documented by a physician as clinically contraindicated. The Comprehensive Care Plan (CCP) titled Cognitive Loss/Dementia dated 6/2/16 documented- cognitive deficit related to dementia, impaired short and long term memory. Interventions include- orient resident, break activities into manageable subtasks, and provide positive reinforcement. The CCP titled ADL extensive assistance dated 8/22/18 documented the resident is unable to perform ADL functions without extensive assistance secondary to dementia and depression. Interventions included- provide ADLs, range of motion, and body positioning. The CCP titled Psychosocial well being dated 8/22/18 documented the resident had a decline in psychosocial wellbeing related to medical conditions and continued stay at the facility, and the resident is known to make false allegations against caregivers. Interventions included- psychological services as ordered, monitor for declines, and encourage consistency. The CCP titled [MEDICAL CONDITION] Drug Use dated 8/22/18 documented the resident was on psychiatric medications with potential for side effects. Interventions included- psychiatry consult annually per MD orders, monitor side effects of medications, explore non-pharmacological interventions. The CCP titled Hospice dated 3/19/19 documented the resident is on hospice related to Senile Degeneration of brain. Interventions included- assess physical cues, pain, signs and symptoms of infection, etc. asses psychological causes, medicate per MD order, provide emotional support, offer diversional activities (guided imagery, music, relaxation, etc.) A review of the physicians orders documented the resident is receiving [MEDICATION NAME] Oral Tablet 10mg (for Unspecified Dementia started on 6/2/16) twice a day, [MEDICATION NAME] Oral Tablet 20 mg ( for Major [MEDICAL CONDITION] started on 7/5/16) daily, and [MEDICATION NAME] Oral Tablet 25 mg (for Unspecified [MEDICAL CONDITION] started on 5/22/18) 0.5 tablet at bedtime. Monthly Medication Review conducted by a pharmacist dated 6/9/19 documented the Resident is currently receiving [MEDICATION NAME]. Unable to locate recent documentation of current need/effect, absence or presence of side effects, and ability or lack of ability to taper current dose in chart. Physician responded with psych consult ordered. The nursing admission note dated 6/2/16 documented no potential indicators of [MEDICAL CONDITION]. The social worker note dated 6/5/16 documented the resident was admitted with a [DIAGNOSES REDACTED]. The physician admission note dated 6/5/16 documented the resident has [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. July (YEAR)- (MONTH) 2019 progress notes were reviewed and no behavioral notes or mention of [MEDICAL CONDITION] were observed. Psychiatric consult dated 6/9/18 documented the resident was receiving [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 10 mg twice daily, and [MEDICATION NAME] 12.5 mg daily. The resident appeared sad, guarded, suspicious, depressed. Resident was reported to tell staff someone was going to murder her. Impression- [MEDICAL CONDITION]. Recommend increasing [MEDICATION NAME] 12.5 mg po daily and add [MEDICATION NAME] 25 mg po. Psychiatric consults dated 9/5/18 documented the resident was receiving [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 10 mg twice daily, and [MEDICATION NAME] 12.5 mg daily and [MEDICATION NAME] 25 mg daily. The recommendation to discontinue [MEDICATION NAME] orders and start on [MEDICATION NAME] 12.5 mg po secondary to a decrease in paranoid delusions. Psychiatric consult dated 1/14/19 documented the resident was receiving [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 10 mg twice daily, and [MEDICATION NAME] 12.5 mg daily. The resident stated she was doing ok. Decreased suicidal/homicidal thoughts and decreased audio/visual hallucinations. Memory and cognition limited. Impression- Dementia with mood disorder, memory and cognition limited. Psychiatric consult dated 3/15/19 documented the resident was receiving [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 10 mg twice daily, and [MEDICATION NAME] 12.5 mg daily. The resident is doing ok. Decreased suicidal/homicidal thoughts and decreased audio/visual hallucinations. Impression- Dementia with mood disorder. Psychology note dated 1/7/19 documented the resident was showing suicidal ideation and risk of self-harm in conversation with therapist when interviewed on 1/7/19. Resident does not recall statements. Resident is not at risk for self-harm at this time. Specific of [MEDICAL CONDITION] were not ellaborated in psychologists notes. Psychology note dated 1/31/19 documented the resident has had a cognitive decline, has delusions/hallucinations, confusion, and the resident is unaware. Unaware of what? Psychology note dated 2/7/19 documented the resident was in therapy to work on regulation of anger and associated dysphoria. Psychology note date 2/13/19 documented the resident had diagnoses of Major [MEDICAL CONDITION], and Unspecified Dementia. The resident does not recognize the provider and services will be discontinued. On 7/10/19 at 11:15 AM the Private Aid (PA) caring for the resident was interviewed. The PA stated that she has been working with the resident for the past 4 years. The PA stated she is with the resident for 12 hours a day for 4 days a week. The PA stated that the resident does have dementia and can exhibit mood swings at times. The PA stated the mood swings are when the resident is confused and can call the staff names or will ask if she is in danger or if the nursing home is safe. The PA further stated that the resident is confused and will say things that did not happen. The PA stated that the residents behavior never escalates besides the occasional name calling. The PA stated the resident has never had to be removed from a situation where she was out of control. The PA stated that sometimes the resident will go for months at a time without having an name calling. On 7/10/19 at 12:13 PM the Registered Nurse Supervisor #1 (RNS) on the resident's floor was interviewed. The RNS #1 stated that the resident is sometimes depressed, and does not really interact with other residents on the unit. The RNS #1 stated the resident will go up to the Penthouse for her meals and to socialize. RNS #1 stated she has never seen a behavior problem with the resident, further stating the resident usually stays in her room with her private aid. RNS #1 stated that the resident was started on [MEDICATION NAME] because she was screaming, but she had never seen the resident screaming. RNS #1 stated there are no behavior notes in the computer for the resident at this time. On 7/10/19 at 3:27 PM the Medical Doctor #1 (MD) for the resident was interviewed. MD #1 stated the resident has been declining and was put on hospice in March. MD #1 stated the resident is still on [MEDICATION NAME] for her [MEDICAL CONDITION], agitation, and behavioral disturbances. MD #1 stated the staff monitor how the resident behaves while eating and interacting with other residents. MD #1 stated the resident has not has any disruptive behavior since she was started on the [MEDICATION NAME] and the residents daughter is happy with the residents behavior. MD #1 stated that [MEDICATION NAME] is continued because the resident is behaviorally stable and doing well. MD #1 stated that the resident should have been seen by the psychiatrist in (MONTH) 2019. When asked to see documentation for (MONTH) 2019 psychology consult the MD provided (MONTH) 2019 consult. The MD could not provide explaination to why the resident was not seen by the psychiatrist in (MONTH) despite Medication Regimen Review comment stating psychiatry consult was ordered. The residents psychiatrist was not available for interview per the Assistant Director of Nursing (ADNS). ADNS stated the regular psychiatrist was on vaction. A phone call on was made to the covering psychiatrist on 07/11/19 at 02:54 PM. The covering psychiatrist stated he was not the regular psychiatrist for resident and did not have information on resident. The covering psychiatrist was not able to answer any questions on resident # 156 psychaitric history and prescription of antipsychotic medication. A review of the record did not document any behavioral symptoms indicating the continued use of the antipsychotic medication [MEDICATION NAME]. A review of the record did not show that periodic re-evaluation for the clinical indication for the use of the antipsychotic medication was completed. 415.18(c)(1) 2) Resident # 121 is a [AGE] years old admitted to the facility on [DATE] with diagnoses that include Unspecified dementia without behavioral disturbance, [MEDICAL CONDITION], hypertension and diabetes. On 7/09/19 the resident's medical record was reviewed. The resident's current orders and Medication Administration Record [REDACTED]. The Patient Review Instrument (PRI) dated 2/05/19 documented diagnoses of diabetes, dementia, [MEDICAL CONDITION], cerebral amyloid angiopathy. There is no [DIAGNOSES REDACTED]. The Initial Assessment documented on the MDS (Minimum Data Set 3.0) and with a reference date of 2/27/19 documented the resident with impaired cognition. It documents that the resident has no evidence of acute mental changes. The resident has no disorganized thinking, there is no altered level of consciousness and the resident has no difficulty focusing attention. There is no mood indicators documented in the initial MDS. There are no symptoms of [MEDICAL CONDITION] documented. There are no behaviors that indicate [MEDICAL CONDITION] on the MDS. There are no verbal, physical and other behavioral symptoms directed toward others. There are no delusions and no hallucinations documented in the MDS. There are no rejections of care behaviors documented in the MDS. The resident required supervision in most activities of daily living. Dementia is documented as the primary [DIAGNOSES REDACTED]. The Comprehensive Care Plan documented that the resident has impaired cognition related to dementia. The resident is alert and oriented to person and place with periods of confusion and forgetfulness. The interventions include orient resident to environment and staff during interactions, establish ADL, task segmentation, provide positive experiences and positive reinforcements, approach resident in calm gentle and therapeutic manner and involve resident in decision making. On 07/08/19 at 10:04 AM, on 07/09/19 at 11:15 AM, on 07/10/19 at 02:18 PM and on 07/12/19 at 10:23 AM, the resident was observed seating around the nursing station clamly with no signs of aggression noted. There were no signs of delusions and no signs of hallucinations noted. Nursing notes dated 2/18/19 to 2/24/19 documented the resident was physically aggressive when approached by staff. The resident only speaks Russian. The resident has a language barrier. The primary care physician was notified, and the Primary Care Physician ordered that the resident start [MEDICATION NAME] 25 mg at bedtime. Nursing notes from 3/11/19 to 3/20/19 documented no aggressive behaviors. The behavior notes do not document that Resident #121 has exhibited any inappropriate behaviors that would indicate [MEDICAL CONDITION]. Nursing notes dated 4/2/19 to 4/15/19 documented that resident # 121 is refusing to take showers. The resident became combative when the nursing assistant tried to change her clothes. The resident becomes physically aggressive due to language barrier. The behavior notes do not document that Resident #121 has exhibited any inappropriate behavior that would indicate [MEDICAL CONDITION]. Nursing notes dated 5/1/19 to 5/24/19 documented no behavior problems. The resident gets agitated when she is approached by staff. The behavior notes do not document that Resident #121 has exhibited any inappropriate behavior that would indicate [MEDICAL CONDITION]. Nursing noted dated 6/7/19 to 6/21/19 documented no behavior problems. The resident refused to wear wander guard which was ordered for use while in the facility. The behavior notes do not document that Resident #121 has exhibited any wandering behavior nor inappropriate behaviors that would indicate [MEDICAL CONDITION]. Physician evaluation dated 3/7/19 documented diagnoses of dementia without behavior disturbance, [MEDICAL CONDITION], anxiety disorder, [MEDICAL CONDITION] and coronary [MEDICAL CONDITION]. The resident is at risk of worsening mental and emotional problems. The plan is for the resident to continue present psychiatric evaluations to adjust medications. [MEDICAL CONDITION] was not mentioned in the physician evaluation. Pharmacy Review dated 3/11/19 documented that the resident was recently admitted on [MEDICATION NAME] with no clear [DIAGNOSES REDACTED]. The Pharm Consultant wrote, Please consider obtaining a psychosocial work up along with performing a medical work up as soon as possible. Should the workups and nursing behavioral monitoring reveal no significant behaviors or identification of a chronic psychiatric condition, please consider implementing a tapering schedule or discontinue. The physician's documented response agreed with recommendations. Psychiatry consult dated 3/11/19 documented low mood and poor appetite. The resident is depressed. The resident denied hallucinations. Physician evaluations dated 4/5/19, 5/2/19, 5/31/19 and 6/29/19 documented the resident's mood and behavior has improved. The resident is compliant with medical regimen. The physician notes also documented that the resident is on [MEDICATION NAME] 25 mg at bedtime (antipsychotic). The physician's progress notes did not document that the resident is currently displaying problematic behaviors or exhibited signs of [MEDICAL CONDITION]. There is no documentation supporting the use of [MEDICATION NAME] and whether it was necessary to treat the resident's medical condition. There was no evidence that an evaluation was conducted by either the attending physician or a psychiatrist to weigh the benefits of this medication against the risk of use to the resident. There was no documented evidence that a Gradual dose reduction was considered by the physician and the psychiatrist as recommended by the pharmacist on 3/11/19. On 07/11/19 at 12:34 PM, CNA # 3 stated that at times, resident # 121 would become aggressive to prevent new staff from going into her room. The resident does not exhibit any behaviors when she is being assisted by a staff member she is familiar with. CNA #1 also stated that the resident does not exhibit any behaviors when she is assisting the resident with activities of daily living. On 07/11/19 at 12:42 PM, LPN # 3 stated that resident # 121 was non-compliant with following rules at first. The resident would become very aggressive and annoyed when the staff would try to redirect her. The resident is currently calm. The resident has adjusted to the unit. There has not being any aggression noted the past few weeks. LPN # 3 further stated that the resident is not showing any signs of delusions nor hallucinations. On 07/11/19 at 12:48 PM, RN Nursing Supervisor # 2 stated that resident # 121 was aggressive at first. The resident had behavior problems the day after she was admitted to the facility which was 2/16/19. Resident # 121 is currently calm. The resident was put on [MEDICATION NAME] on 2/18/19 due to aggressive behaviors. The resident would get aggressive when staff that she is not familiar with approach her. The resident has adjusted to the unit. The resident has calmed down. There have not been any aggression behaviors noted on the unit the past few weeks. On 07/11/19 at 03:38 PM, Physician # 2 stated that the resident was very aggressive, psychotic, uncooperative and confused in the beginning. Physician # 2 stated that the nursing staff reported to him that the resident was being aggressive toward staff. Physician # 2 stated he immediately prescribed [MEDICATION NAME] 25 mg at bedtime. Physician # 2 further stated that [MEDICATION NAME] was chosen due to the resident's severe [MEDICAL CONDITION]. Physician # 2 also stated that currently the resident condition is controlled. Physician # 2 also stated that the resident has been mentally stable the past few weeks. Physician # 2 also stated he is familiar with the antipsychotic drug Black box warning. Physician # 2 also stated that he chose to prescribe [MEDICATION NAME] to resident # 121 because [MEDICATION NAME] is considered a safe drug. Physician # 2 further stated he did not initiate a gradual dose reduction for the [MEDICATION NAME] because he usually tries to keep the residents on anti-psychotic medications for three to six months to ensure the medication is working. Physician # 2 stated that the resident is not currently exhibiting any problematic behaviors. Physician monthly evaluations and progress notes from (MONTH) 2019 to (MONTH) 2019 were reviewed. There is no documentation supporting the use of [MEDICATION NAME] was necessary to treat the resident's medical condition. There is no documentation supporting how the IDT team determined that the resident needed to continue to take [MEDICATION NAME] which is an antipsychotic medication several weeks after the resident's behaviors has improved. There was no evidence that an evaluation was conducted by either the attending physician or a psychiatrist to weigh the benefits of this medication against the risk of use to the resident. There is no documented evidence that a Gradual dose reduction was considered by the physician and the psychiatrist as recommended by the pharmacist on 3/11/19. 415.15(b) (2) (iii)

Based on observations, interviews and the facility did not ensure a safe, sanitary and comfortable environment to prevent the transmission of infections and communicable diseases. Specifically, a resident's oxygen tubing was observed on two occasions coming into contact with and laying on the floor. (Resident #122). The findings are: A Quarterly Minimum Data set ((MDS) dated [DATE] documented that Resident # 122 was severely impaired in cognition and has a [DIAGNOSES REDACTED]. Resident is on hospice. On 7/8/19 at 8:57 AM and 10:34 AM, Resident # 122 was observed in his room with private aid at bed side. Residents oxygen tubing was noted to be coming into contact with and laying on the floor next to the oxygen machine and right next to the residents bed. On 7/10/19 at 10:31 AM, Resident #122 was observed in a reclined wheel chair in the day room with oxygen machine at side. The nasal canula was still inserted in the resident's nose with the slack of the oxygen tubing laying on the floor between the resident's wheelchair and the oxygen concentrator positioned beside the wheelchair. On 07/10/19 at 11:00 AM, the Private Aid #2 (PA) was interviewed. PA #2 stated she is a companion and does not provide care to the resident. PA #2 stated that the Certified Nursing Assistants (CNA) perform all daily care, which involves moving the resident from the bed to the chair and putting the nasal cannula in the resident's nose for oxygen. PA #2 stated that if the resident's oxygen tubing is on the floor she will tell the nurse. On 07/10/19 at 11:28 AM, CNA #1 was interviewed. CNA # 1 stated the resident is total care with ALDs. CNA # 1 stated the resident is on oxygen therapy. CNA # 1 stated for oxygen we make sure the oxygen is on, we make sure it is always in his nose, make sure with the oxygen we make sure everything is in place because sometimes the resident removes the nasal cannula. CNA # 1 stated she will set the oxygen up when the resident transfers from the bed to the chair. CNA # 1 stated sometimes the oxygen come off and is on the floor and when we notice we get a new tubing. CNA # 1 stated when the resident is in the wheel chair the tubing never stays wrapped up and it falls out and when that happens we don't put it back on him. CNA # 1 stated the CNAs get infection control in servicing for oxygen. CNA # 1 stated she was not aware that the residents oxygen tubing had been observed on the floor on multiple occasions. On 07/10/19 at 11:47 AM, the Licensed Practical Nurse (LPN ) # 1 was interviewed. LPN #1 stated that she is the staff who will replace the oxygen tubing if it touches the floor. LPN #1 stated that the nurse secures the oxygen tubing when the resident is placed in the chair or in bed. LPN #1 stated the oxygen tubing will slip out onto the floor. LPN #1 stated she did not notice the residents oxygen tubing was laying on the floor underneath the residents wheelchair. 415.19 (a)(1-3)

Based on observation, interviews and records review, conducted during the recertification survey; the facility did not develop a comprehensive person-centered care plan resident. Specifically 1) Resident #155 has hearing difficulty and uses a hearing aid. There was no comprehensive care plan that identified the resident has having hearing difficulty or lists hearing aid device as an intervention. There was no instruction for which discipline would be responsible for ensuring hearing aid was properly maintained and worn by resident. This was evident for 1 out of 33 sampled residents. (Resident #155) The facility's undated policy/procedure Comprehensive Care Plan document an initial comprehensive care plan is initiated upon admission and developed on the 21st day after admission and reassessed quarterly or more often as determined by the resident's condition. The findings are: Resident #155 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. MDS dated [DATE] documented resident #155 hearing as adequate, no difficulty in normal conversation and has hearing aids. It also documented that the resident has intact cognition. On 07/11/19 at 09:22 AM, an interview was conducted with Resident #155 who stated she wears hearing aids and entered the facility with her personal hearing aids. Resident #155 stated staff is aware that she wears a hearing aid. Review of Resident #155 records did not contain a comprehensive person-centered care plan identifying that resident requires the use of hearing aid to enable hearing. There is no instruction in the record indicating which discipline would be responsible for ensuring the device is maintained and working properly, or if resident is responsible or capable of hearing aid maintenance. On 07/11/19 at 02:44 PM an interview was conducted with Registered Nurse (RN #2). The RN stated that the condition: Hard of Hearing would be listed in general orders and not necessarily in the Physician Orders. RN #2 stated that care plans would be developed for residents with hearing aids, but was not sure that it was picked up that Resident#2 had a hearing aid. RN#2 stated the admission note does state that the resident has a hearing aid. RN#2 stated the evening nurse generates the care plan , because residents are generally admitted in the evening. RN #2 stated that the care plan for hearing/hearing aid would need to be initiated manually. On 07/11/19 at 02:53 PM an interview was conducted with the Certified Nursing Assistant (CNA #2) who stated the resident has a hearing aid in one ear. CNA #2 stated the resident takes care of the hearing aid herself and is alert and oriented to person, place, and time. CNA #2 stated the resident does not have difficulty hearing while wearing hearing aid. 415.11(c)(1)

Based on observations, and staff interview during the recertificatrion survey, the facility did not ensure that adequate housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior for 6 of 6 resident nursing units. This was evident for 6 units observed during the initial tour and ongoing observations during the survey. The findings included but were not limited to: walls in need of painting due to multiple black/gray scuffed marks in resident rooms; areas of cove molding pulled away from wall/and or badly soiled, areas of wallpaper in hallways peeling and/or pulled away from walls; privacy curtains stained, torn, or off the hooks; multiple resident bedside floor mats torn and hallway doors that were heavily soiled or in disrepair. There were also areas of plastered wall that were not painted, holes observed in doors and walls. A small box attached to wires, measuring approximately 4 inches by 3 inches, was observed hanging out of the wall in room 509. The findings include but are not limited to: During the initial tour on 8/15/2016 AM between 8:15 AM and 10:00 AM, and throughout the survey process through 8/19/16 the following were noted: Examples of rooms in need of painting: Unit 1: Rooms: 104, 106, 111 Unit 2 Rooms: 203, 206, 207 Unit 3 Rooms: 300, 302, 305 Unit 4 Rooms: 404, 407, 410 Unit 5 Rooms: 506, 509, 511 Unit 6 Rooms: 602, 604, 606 Example of cove molding heavily soiled or in disrepair: Unit 1: Room 104 the cove molding across from the resident's beds was pulled away from the wall; Rooms 105,106, 107 cove molding across from resident's beds and area under sink heavily soiled; Unit 2: Rooms 202 and 204 the cove molding was pulled away from wall across from the resident's bed; Rooms 206, 207 the cove molding under the sinks was heavily soiled; Unit 3: Room 300 the cove molding at the bottom of the wall to the right of the door frame was separating from the wall; Rooms 305, 309 the cove molding was heavily soiled. Unit 4: Room 409 the cove molding to the left of the door was separating from the wall Unit 5: Room 508 cove molding to the left of the door separating from the wall and room 509 the cove molding to left of window was separating from the wall; Room 511 a portion of cove molding was missing. Unit 6: Room 606 the cove molding to the left of the door was separating, room 607 the cove molding between the sink and the bathroom was separating from the wall, room 612 the cove molding between the sink and the bathroom was separating from the wall. Examples of wallpaper ripped, and or lifting from the wall: The wallpaper in the hallway to the right and left of room 307 was peeling; The wallpaper was ripped between the storage room and the shower room and the wall between the elevator and the bathroom on the 4th floor. Examples of privacy curtains that were off their hooks, torn, or stained: Rooms 309, 509, 511, and 513, Examples of ripped bedside floor mats/bolsters: Rooms 213, 312, 313, 406, 407, 408, 409, 410, 413, and 513. Examples of heavily soiled hallway doors: Unit 3: There were layers of separation on the bottom of the shower room door between rooms 311 and 312. The porters closet door, the utility room door and the shower room doors were heavily soiled at the lower 1/3rd of the doors. Unit 4 The shower room/tub room door, porters closet door, the utility room door and the clean linen closet door were heavily soiled at the lower 1/3rd of the doors. Unit 5 The tub room door had peeling paint and there were layers of separation on the bottom of the door. Unit 6 The porters closet door, the utility room door, the shower room doors, the clean linen room door were all observed to be heavily soiled at the lower 1/3rd of the doors. In room 610 there was an area of unpainted plaster and a small hole, approximately 2 x 2.5 inches in the wall to the left of the windows. In room 503 there was a hole in the bathroom door approximately 2 and 1/2 inches x 2 inches, and the door was detached from the frame. In room 509 the wall under the window was in disrepair and there was an area of unpainted plaster noted to the right of the window measuring approximately 1 and 1/2 feet x 1 foot. In room 509 there was a small hole measuring approximately 2 inches in the bathroom door. In room 509 a small box measuring approximately 4 inches x 3 inches and attached by wires to a wall plate, at the lower 1/3 of the wall, was observed hanging out from the wall across from the bed by the window. In room 513 there was a broken switch plate cover near the bathroom. 08/19/2016 at 12:30 PM the Director of Housekeeping was not available for interview. On 08/19/2016 between 12:40 and 1:45 PM the Assistant Administrator accompanied the surveyor on tour of the facility. The Assistant Administrator was interviewed on 8/19/16 at 1:45 PM and stated that the areas of concern observed would all be corrected. He stated that care of the facility is an ongoing process and that he would review the concerns with the maintenance and housekeeping departments. The Assistant Administrator further stated that he would make arrangements to begin to have the resident rooms painted. 415.5(h)(2)

Based on observation, record review and staff interview conducted during the recertification survey, it was determined the facility did not thoroughly develop, review, and revise comprehensive care plans (CCPs) for 1 of 25 sampled residents (Resident #235). Specifically, the Urinary CCP for Resident #235 was not updated to reflect a decline in urinary status and interventions used to prevent further decline. The Finding is: Resident #235 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Admission assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 to indicate the resident was cognitively intact. The MDS also documented that the resident was always continent of bowel and bladder and received extensive assistance of two staff for toilet use. The MDS Significant Change assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 to indicate the resident was cognitively intact. The MDS also documented that the resident was occasionally incontinent of urine and received extensive assistance of one staff for toilet use. The Comprehensive Care Plan (CCP) developed for Urinary- Continent, Needs Assistance for Toileting initiated 3/31/16 had no update as of 8/17/16. The care plan documented the resident as being continent of both bowel and bladder. The Resident's urinary status of occasionally incontinent of bladder was not reflected in this or any other care plan. Resident #235 was interviewed on 8/17/16 at 1:10 PM. She stated that she toilets herself during the day and is given disposable diapers at night which she occasionally will wet. The use and provision of disposable diapers were not reflected in the 3/31/16 Urinary Care Plan. On 8/17/16 at 1:20 PM the Assistant Director of Nursing was interviewed. He stated that the Nursing Supervisor on the unit is responsible for updating the care plans following a change in status or MDS update. He stated that the resident's change in urinary status should have been reflected in the care plans and on the CNA (Certified Nursing Aide) Accountability Sheets. The CNA Accountability Sheets for the months of June 2016, July 2016 and August 2016 were reviewed and did not reflect diaper or occasional incontinence status. On 8/17/16 at 1:30 PM the MDS Coordinator was interviewed via telephone. He stated that he completes the continence section of the MDS and obtained his information from staff interviews. On 8/17/16 at 2:05 PM the resident's 7-3 Certified Nursing Aide was interviewed. She stated that the resident is known to be continent during the day and occasionally incontinent at night. She stated that she was aware that the resident was receiving disposable diapers from the staff at night. On 8/17/16 at 2:10 PM the Licensed Practical Nurse on the unit was interviewed. She stated that the resident is known to be continent during the day and occasionally incontinent at night. She stated that she was aware that the resident was receiving disposable diapers from the staff at night. On 8/19/16 at 11:10 AM the Registered Nursing Supervisor was interviewed. She stated that the resident was on her unit during the time of the 5/27/16 MDS completion. She stated that she could not recall being notified of that particular MDS but was aware of the resident using disposable diapers at night and her episodic incontinence. She stated that she is responsible for updating the care plans and the CNA accountability sheets but could not recall doing so. 415.11(c)(1)

Based on record review, staff interview and observation during the recertification survey, the facility did not ensure that each resident was free from a significant medication error. This was evident for 1 of 5 residents reviewed for Unnecessary Drugs in a total Stage 2 sample of 25 residents. Specifically, Resident # 181 was administered two antipsychotic medications twice daily in error from 4/19/16 through 6/2/16. The finding is: Resident # 181 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for short term rehabilitation. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 7, indicating severe cognitive deficit. The MDS documented that there resident had a Mood Score of 7, which indicated mild depression. There were no behaviors documented on the MDS. The MDS documented that the resident requires staff assistance in all activities of daily living and was fully continent of bowel and bladder. The resident was examined by the Psychiatrist/Medical Doctor (MD) on 4/25/16. The MD documented that the resident was currently on [MEDICATION NAME] (an antipsychotic) 25 mg PO at 2 PM and [MEDICATION NAME] 12.5 PO (by mouth) twice daily, Klonopin (an antianxiety) 0.5 mg PO daily, and [MEDICATION NAME] (an antidepressive) 60 mg PO daily for Depression. The Psychiatrist documented that the resident was positive for Paranoid Ideation and recommended to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] (an antipsychotic) 1 mg PO twice daily. Review of the Medication Administration Record [REDACTED]. On 6/2/16 the Psychiatric follow up Consultation documented to discontinue the [MEDICATION NAME] and increase the [MEDICATION NAME] to 1 mg twice daily. The attending Physician was on vacation not available for interview. Resident #181 was observed on 08/18/2016 at 12:14 PM during the lunch meal. The resident was sitting at the lunch table, with tray in front of her. A staff member was attempting to feed the resident. The resident had her eyes closed and would not accept any food or open her eyes to respond to the staff member. The Psychiatrist was interviewed on 08/19/2016 at 12:00 PM. The Psychiatrist stated that Resident #181 was not responding to [MEDICATION NAME] that is why he discontinued the [MEDICATION NAME] and put the resident on [MEDICATION NAME]. The Psychiatrist stated that the resident was not supposed to receive both the [MEDICATION NAME] and the [MEDICATION NAME]. The Psychiatrist stated that this was an error and that the attending Physician was to discontinue the [MEDICATION NAME] and order the [MEDICATION NAME]. The Medical Director (MD) was interviewed on 08/19/2016 at 12:15: PM. The MD stated that the [MEDICATION NAME] should have been discontinued and the resident should not have been receiving two antipsychotic medications daily. The Registered Nurse (RN)/Assistant Director of Nursing was interviewed on 8/19/16 at 1:00 PM and stated that the orders and discontinuations are input directly by the physician into the Electronic Medical Record (EMR) and the order automatically becomes part of the MAR. The RN stated that apparently the order for [MEDICATION NAME] was not discontinued in the EMR. The RN stated that the nurses are notified on the computer that there is a new order and then the medication is administered according to the MAR. 415.12(m)(2)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that each residents' drug regimen was free from unnecessary drugs. This was evident for two of five residents reviewed for Unnecessary Medication in a Stage two sample of 25 residents. Specifically, 1) (a) Resident # 181 was receiving multiple [MEDICAL CONDITION] medications without a clear Psychiatric Diagnosis. In addition, there was no documented evidence that the Interdisciplinary Team (IDT) appropriately reviewed the use of the [MEDICAL CONDITION] drugs or initiated a complete and resident specific behavior plan. (b) In addition, Resident # 181 was administered four doses of an antipsychotic medication for behavior problems without specific, individualized non-pharmacological interventions documented as attempted prior to the administration of the medication. 2) Resident # 94 was receiving [MEDICATION NAME] (an antipsychotic medication) 1 milligram (mg) Intramuscular (IM) every 12 hours and [MEDICATION NAME] an (antipsychotic medication) 0.5 mg IM twice a day without any documented attempt at non -pharmacological interventions. The findings are: 1) Resident # 181 is [AGE] years of age and was admitted to the facility on [DATE] for short term rehabilitation with [DIAGNOSES REDACTED]. The Physician's Referral Findings/Medication Regime Review dated 2/22/16 recommended that a medical work-up should be considered to assess underlying causes of the resident's agitated behaviors, The referral documented that there was no clear psychiatric [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 7, indicating severe cognitive impairment. The MDS documented that the resident's Mood Score was 7, indicating mild Depression. The MDS also documented that the resident required staff assistance in all activities of daily living and was continent of both bowel and bladder. In addition, the MDS documented that the resident was receiving Antianxiety and Antidepressant medications only. The resident was transferred to the hospital on [DATE] and readmitted on [DATE]. The MDO included [MEDICATION NAME] 1 mg PO HS for Depression (with instructions to hold for lethargy), [MEDICATION NAME] 60 mg PO daily for Depression, [MEDICATION NAME] (an antianxiety medication) 0.5 mg PO at bedtime for Depression (with instructions to hold for lethargy) and [MEDICATION NAME] 25 mg PO daily at 2:00 PM for Delusions and 12.5 mg PO twice daily for Depression. The Nursing PN dated 3/16/16 at 6:40 PM documented that the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The NPN documented that the resident was weak, unable to walk or stand, was agitated and restless. The NPN documented that the resident was on multiple psychoactive medications for Behavior Problems. The Physician was notified and admission orders [REDACTED] The NPN dated 3/21/16 at 9:24 PM documented that the resident was given [MEDICATION NAME] (an antipsychotic medication) Intramuscularly (IM) for disruptive, agitated and restless behavior. The NPN documented that the behavior would be monitored. There was no monitoring documented in the medical record. A NPN dated 3/23/16 at 7:45 PM documented the the resident was shouting at times, combative with staff. [MEDICATION NAME] 1 mg IM was administered. No prior non-pharmacological behavior interventions specific to the resident were documented. The NPN dated 3/27/16 at 9:27 PM documented that the resident was restless and screaming and attempting to get out of the chair. An MD Order dated 3/28/16 documented the administration of an antibiotic to the resident for a [DIAGNOSES REDACTED]. The NPN dated 4/7/16 documented that the resident was yelling and screaming and put herself on the floor. The Resident was complaining of knee pain to both knees. The Physician was notified and [MEDICATION NAME] 1 mg IM was administered stat (immediately) for agitation. There was no documented evidence that prior non-pharmacological interventions were attempted or that consideration was given as to the cause of the resident's agitation. A NPN documented on 4/11/16 at 3:15 PM that the resident was seen by the Psychiatrist for agitated behavior and the [MEDICATION NAME] was increased. On 4/19/16 the NPN documented at 12:29 PM the resident had an episode of resident unsteadiness with a period of lethargy. The Physician was notified. At 2:25 PM the NPN documented that the resident became combative and agitated. The NPN documented at 7:33 PM the physician was called and 2 mg of IM [MEDICATION NAME] was administered. The Psychiatrist follow up dated 4/25/16 documented to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] 1 mg twice daily and to continue the Klonopin and [MEDICATION NAME]. The physician's orders [REDACTED]. The [MEDICATION NAME] was not discontinued and administered in error from 4/25/16 through 6/2/16 giving the resident two antipsychotic medications at the same time without Psychiatric [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] did not document any [MEDICAL CONDITION] or Behavior issues during the assessment period. There was no Psychiatric [DIAGNOSES REDACTED]. On 6/2/16 a Psychiatric follow up consultation documented that per nursing staff the resident continues to have periods of agitation in the afternoon. The recommendation was to discontinue the [MEDICATION NAME] and increased the [MEDICATION NAME] t 1 mg three times daily. The 7/5/16 Psychiatry follow up documented that the resident continues to get agitated on a daily basis and recommended that the prior [MEDICATION NAME] order be discontinued and changed to [MEDICATION NAME] 1 mg daily in am and at bedtime and 2 mg daily at bedtime for Agitation. The Pharmacy Medication Regime Review on 7/26/16 documented that the resident is receiving [MEDICATION NAME] in a dose which exceeds the daily dose threshold and trial tapering should be considered. Review of the available medical record from 5/1/16 through 8/18/16 documented continued, sporadic periods of confusion, agitation and restlessness. The resident was observed on 8/15/16 at 9:30 AM in the day room. Resident was sitting in the chair, elbows on table and facing the wall. The resident did not respond to the greeting and did not make eye contact. The resident's Social Worker (SW) was interviewed on 08/18/2016 at 11:40 AM. The SW stated that team reviews the resident's plan of care and the behaviors and drug regime are discussed with the team. The resident's CNA on the 7-3 Shift was interviewed on 8/18/2016 at 11:52 AM. The CNA stated that the resident's behavior usually happens after lunch. The CNA stated that the resident responds to ice water and coffee and she will calm down. The CNA stated that the resident's behavior has slightly improved lately. The resident was observed for a second time on 08/18/2016 at 12:14 PM. The resident was observed during the lunch meal. The resident was sitting at her table with a food tray in front of her. A staff member was attending to her, stroking her and encouraging her to open her eyes. The resident had her eyes closed and was not accepting food or responding to the stimulus. The Attending Physician was on vacation and not available for interview. During the interview with the Registered Nurse(RN)/Supervisor on 08/19/2016 at 11:35 AM, the RN stated that the resident's agitation and combative behaviors were not the result of any underlying medical problems such as Pain. The RN stated that the resident is known very well by the RN and that the behaviors were extreme and not easily redirected. The Psychiatrist was interviewed on 08/19/2016 at 12:05 PM. The Psychiatrist stated that the resident was not responding to [MEDICATION NAME] and that is why he discontinued the [MEDICATION NAME] and put the resident on [MEDICATION NAME], which already had been giving positive results. The Psychiatrist stated that is why discontinued the [MEDICATION NAME] and ordered the [MEDICATION NAME]. The Psychiatrist further stated that he did not want the resident to receive the [MEDICATION NAME] and [MEDICATION NAME] together and he was unaware that the attending physician had not discontinued the order of [MEDICATION NAME]. The Medical Director (MD) was interviewed on 08/19/2016 at 12:15: PM. The MD stated that the [MEDICATION NAME] should have been discontinued and the resident should not have been receiving two antipsychotic medications daily. 2) Resident # 94 is a [AGE] year old who was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. The MDS also documented that the resident had a mood score of 7 documenting that the resident was depressed, had a poor appetite and trouble concentrating. Additionally, the MDS documented that the resident exhibited other behavior symptoms not directed towards others. The physician's orders [REDACTED]. A nursing progress notes dated 6/15/16 at 5:16:PM documented that the resident was alert responsive but confused. The note further documented that the resident was combative with staff and [MEDICATION NAME] was administered On 6/16/16 the resident was seen in consultation with the Psychiatrist. The Psychiatrist documented that the resident had been spitting out her medications, was uncooperative and the psychiatrist was unable to perform a mental status exam. The Psychiatrist documented a [DIAGNOSES REDACTED]. The updated Diagnostic and Statistical Manual of Mental Disorders DSM-5 replaces the term Dementia with major and mild Neurocognitive Disorders as referenced in the Diagnostic and Statistical Manual of Mental Disorders DSM-5). Additionally, the Psychiatrist documented that the resident was to receive [MEDICATION NAME] 1 mg Intramuscularly (IM) every 12 hours and [MEDICATION NAME] 0.5 mg IM twice a day. The physician's orders [REDACTED]. On 6/19/16 at 2:50 PM the resident was found lying on the floor in a prone position next to her bed. The resident was noted with a 2 centimeter (cm) linear laceration above the right eyebrow. The resident was transferred to the hospital for evaluation. According to the Accident/Incident Report Summary this event is directly related to the resident's agitated and restless behaviors. The Medication Administration Record [REDACTED]. The Comprehensive Care Plan for [MEDICAL CONDITION] Drug Use dated 6/14/16 documented to explore non- pharmacological interventions. The resident's attending Physician was not available for interview. The Assistant Director of Nursing (ADNS)/Registered Nurse (RN) was interviewed on 8/19/16 at 11:45 PM. The ADNS stated that the staff use non-pharmacological interventions all the time for the residents. The ADNS stated that staff does not always document what they attempted. On 8/19/16 at 12:00 PM the Psychiatrist was interviewed. The Psychiatrist stated that he would have expected non pharmacological interventions to have been documented in the medical record when the resident's behavior escalated. The Policy Titled Use of [MEDICAL CONDITION] Medications Policy and Procedure undated documented that the primary care physician shall order psychoactive medications only to treat specific conditions. 415.12(1)(1)

Based on record review, staff interview and observation during the recertification survey, the facility did not provide adequate pain management or accurately assess the resident's pain levels. This was evident for one of five resident's reviewed for Unnecessary Drugs in a total Stage 2 sample of 25 residents. Specifically, Resident #181 exhibited signs and symptoms of pain and made complaints of pain without reassessment of the pain level and the need for review of the resident's pain management needs. The finding is: Resident #181 was admitted to the facility on [DATE] for short term rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 7, indicating that the resident had severely impaired cognition. The MDS documented that the resident's Mood Score was 7, indicating mild Depression. The MDS documented that the resident required staff assistance in all activities of daily living. The MDS Staff Assessment for should have been completed for this resident and it was not. The resident was hosptalized on [DATE] for [MEDICAL CONDITION] and lethargy and returned on 3/9/16. On 3/10/16 the resident was again sent to the hospital for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. In addition, the PO documented that the resident was to be administered [MEDICATION NAME] Oral Tablets 325 milligrams (mg) two tablets by mouth every six hours, as needed (PRN) for pain. The PO documented that the resident was to have pain monitored and pain medication was to be administered when level of pain was greater then one. In addition, the PO documented that the resident was being administered [MEDICATION NAME] Oral Tablet (an antianxiety medication) 1 mg three times daily, [MEDICATION NAME] Oral Capsule (an antidepressant medication) 60 mg daily and [MEDICATION NAME] (an antipsychotic medication) 12.5 mg twice daily. The Comprehensive Care Plan (CCP) for Pain dated 3/16/16 documented that the resident was to received [MEDICATION NAME] (Tylenol) 650 mgs every 6 hours PRN for pain. The Medication Administration Record (MAR) documented that the resident was given Tylenol for pain on 3/20/16 at 1:51 AM and was effective. The level of pain prior to the administration of the medication and the level of pain indicating the effectiveness level following administration, were not documented. The MAR documented that the resident was administered Tylenol per orders on 3/23/16 at 4:01 PM, 3/24/16 at 3:22 PM, 3/26/16 at 3:39 PM, 3/27/16 at 8:38 AM and 8:17 PM, and 3/29/16 at 8:57 PM. Prior assessment of the pain level and reassessment of the pain level including effectiveness of the medication was not documented on the MAR or found in the medical record. A Progress Note (PN) dated 3/21/16 at 9:24 PM documented that the resident became disruptive, agitated and combative. The Physician (MD) was called and ordered [MEDICATION NAME] (an antipsychotic medication) 1 mg Intramuscularly (IM) stat. Again, on 3/23/16 at 7:25 PM the PN documented that the resident was administered IM [MEDICATION NAME] 1 mg Stat for agitation. There was no documentation in the medical record to determine the cause or the resident's agitation or to assess for pain. A Nursing PN dated 4/7/16 at 2:19 PM documented that the resident was yelling and screaming and put self down onto the floor. The PN documented that the resident was complaining of pain to both knees and was restless and disruptive. The PN documented that the MD was notified and an order for [REDACTED]. The MD ordered X-Rays of both knees. The stat X-Ray of both knees completed on 4/7/16 documented that the resident had advanced [MEDICAL CONDITION] Changes in both knees. The Accident/Incident Report Summary dated 4/8/16 documented that the resident is alert and verbal and has decreased cognition with episodic behaviors. The summary documented that the resident had a new complaint of pain to both upper arms. The Nurse Practitioner (NP) examined the resident on 4/8/16 and documented that the resident had complained of pain to the upper arms, X-Rays were ordered. A PN documented the resident had a fall on 4/16/16 at 8:26 PM. The resident was given Tylenol for complaints of right buttock pain. There is no documentation in the medical record as to the what the level of pain was and what the effectiveness of the Tylenol was. The CCP for Pain updated 5/6/16 documented that the resident was to be monitored for verbal and non-verbal complaints of pain. The CCP documented that the resident was to be assessed for location, severity and intensity. The evaluation dated 5/6/16 documented that the resident is on Tylenol every 6 hours PRN. Goals and interventions are maintained. There is no documentation of an updated Pain Assessment in the medical record since admission or from the 4/7/16 incident. The MAR documented on 5/31/16, 6/26/16, 7/9/16, 7/11/16, 7/15/16, 7/25/16 and 8/16/16 Tylenol 650 mg was administered for Pain without any documented assessment as to the Pain levels or medication effectiveness. The NP was not available for interview and is no longer working for the facility. The Attending Physician was on vacation and not available for interview. The Certified Nurse Assistant (CNA) for the resident on the 7 AM-3 PM shift was interviewed on 8/18/2016 at 11:52 AM. The CNA stated that the resident's behavior has improved recently. The resident has been resistive to care, at times, but will respond to offers of coffee and ice water. Resident #181 was observed on 08/18/2016 at 12:14 PM during the lunch meal. The resident was sitting at the lunch table,with a tray in front of her. A staff member was attempting to feed the resident. The resident had her eyes closed and would not accept any food or open her eyes to respond to the staff member. The Registered Nurse (RN)/Assistant Director of Nursing (ADNS) was interviewed on 08/19/2016 at 11:23 AM. The RN stated that the Physician should have been when the resident complained of knee pain and arm pain and the pain management should have been discussed. The level of pain and the effectiveness should be documented on the MAR where indicated and not just given a check mark. The Medical Director (MD) was interviewed on 08/19/2016 at 12:15 PM. The MD stated that the resident should have been reassessed for pain after the complaints of pain and when examined by the NP. The facility's current Policy and Procedure for Pain Assessment and Pain Management documents that: .All residents will be assessed for pain upon admission, at any time when pain is recognized and not less then quarterly thereafter.with each significant change in condition or noted changes in behavior. 415.12

Based on record review and staff interview during the recertification survey, the facility's Minimum Data Set (MDS) Assessment did not completely and accurately reflect the resident status. This was evident for one of twenty five resident's MDS reviewed during Stage 2. Specifically, Resident # 181 had incomplete [DIAGNOSES REDACTED]. The Finding is: Resident # 181 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for short term rehabilitation. The Physician's admission orders [REDACTED]. The MDS Admission assessment dated [DATE] did not include the administration of the antipsychotic drugs or the [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MDS Quarterly assessment dated [DATE] did not document that the resident was receiving an antianxiety drug daily and did not document the [DIAGNOSES REDACTED]. The only active [DIAGNOSES REDACTED]. The MDS Coordinator/Registered Nurse (RN) was interviewed on 8/18/16 at 11:27 AM. The RN stated that the information for the MDS was obtained mainly from staff interview and resident observation on the units. The RN stated that the CNA and Nursing staff are the primary sources of information for the MDS. 415.11(b)

Based on record review and staff interview during the recertification survey, the facility did not consider a resident with a general decline in condition for a Significant Change Assessment. This was evident for 1 of twenty five residents' Minimum Data Set (MDS) Assessments reviewed during Stage 2 of the survey. Specifically, Resident # 181 had a significant decline in Behavior with the administration of antipsychotic drugs, a decline in Urinary Continency and a Significant Weight Loss without an Interdisciplinary Team review for determination of a significant change to review and revise of the plan of care, as needed. The finding is: Resident # 181 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] for short term rehabilitation. The Admission MDS assessment dated ,[DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 7, indicating severely impaired cognition. The MDS documented that the Mood score was 7, indicating mild Depression. The MDS documented that the resident required staff assistance in all activities of daily living and was always continent of bowel and bladder. According to the MDS, the resident was receiving Antianxiety and Antidepressant medications daily. The resident's weight was documented at 152 pounds. The resident was discharged to the hospital on [DATE] and readmitted on [DATE]; again on 3/10/16 and readmitted on [DATE] and discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The Nursing Progress Notes (NPN) for those discharge date s documented that the resident was lethargic, weak and hypotensive. The Nursing Progress Notes (NPN) dated 3/23/16, 4/7/16, 4/11/16, 4/19/16 and 4/26/16 documented the the resident was agitated and combative, restless at times, screaming and resistive to care. The resident was administered Intramuscular (IM) doses of [MEDICATION NAME] (an Antipsychotic) to control the behavior. The Quarterly MDS dated [DATE] documented that the resident BIMS was 5 with a Mood Score of 11, indicating a slight decrease in cognition and an increase in depressive symptoms from mild to moderate. The MDS documented that the resident was always incontinent of bowl and bladder, declining from former fully continent status. The resident lost weight as evidenced by the resident's weight record which documented the following: 5/19/16-141 pounds (lbs), 6/25/16-139 lbs and 8/10/16-124 lbs. A Dietary Progress Note (PN) documented on 6/10/16 and again on 8/15/16 that the resident was showing a significant loss of weight. The MDS Coordinator/Registered Nurse (RN) was interviewed on 8/18/16 at 11:27 AM. The RN stated that the Interdisciplinary Team (IDT) meets during Care Plan Meeting and will determine if a Significant Change Assessment should be initiated. They IDT would have discussed the resident's changes and would make updates to the plan of care. The RN further stated that if the CNA accountability records need of revisions, however, the determination is made with conference with the CNAs. The resident's Social Worker (SW) was interviewed on 08/18/2016 at 11:40 AM. The SW stated that the team reviews the resident plan of care and discusses the changes. At the Care Plan Meeting the team reviews behaviors and medications and updates the plan of care. The RN/Supervisor for the unit was interviewed on 8/19/16 at 7:39 AM. The RN stated that with regard to significant change when any team member sees a change the MDS Coordinator is notified about the concerns. It is the communication between the team, the unit nurses and the MDS Coordinator that can discuss the possibility of a Significant Change Assessment. 415.11(a)(3)(ii)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that resident incidents were thoroughly investigated to rule out mistreatment, neglect or abuse. This was evident for one of five residents reviewed for Unnecessary Medications in a Stage two sample of 25 residents. Specifically, Resident # 21 did not have a thorough investigation completed when the resident was found with a [MEDICAL CONDITION]. The finding is: Resident # 21 was admitted to the facility on [DATE]. The resident has [DIAGNOSES REDACTED]. The resident was also noted to be Russian speaking. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) conducted with a translator. The resident scored a 12 indicating moderately impaired cognition. The MDS also documented that the resident was a two person assist for bed mobility, transfer, and toilet use. A progress note dated 2/25/16 at 7:50 PM written by the Registered Nurse (RN) Supervisor documented that she was called to the unit to evaluate Resident # 21. The progress note documented that the resident was observed by the Certified Nursing Assistant (CNA) during care with the left foot flaccid and painful to touch. The progress note also documented that the left foot had limitation of movements and a bluish discoloration of the left groin with shortening and external rotation of the left foot. The physician was notified and the resident was transferred to the hospital for evaluation. The Accident/Incident (A/I) Report dated 2/25/16 at 7:55 PM documented in the Resident Version section of the A/I that she was unable to communicate to the staff what had happened as she speaks a Ukraine language. The A/I Report documented in statements from CNAs that the resident was taken out of bed at 10:45 AM and returned to bed at 7:55 PM. The two day shift CNAs (#1, #2) documented on their statement of the occurrence dated 2/26/16 that the resident was transferred out of the bed in the morning after morning care was performed. The CNAs documented that the resident was brought via wheelchair to the dining room until visited by her niece and where she remained from after lunch for the rest of the afternoon. There was no documented evidence in the medical record that the resident had been toileted on the day shift. The two CNAs (#3,#4) documented on their statements of occurrence dated 2/25/16 that when they had transferred the resident into the bed they immediately noticed that the resident's left leg was weak. The CNA daily care plan and accountability record dated February 2016 documented that the resident was in the penthouse floor where activities take place through 3:00 PM. On 8/19/16 at 9:30 AM the Assistant Director of Nursing (ADNS) was interviewed. The ADNS stated that at the time of the incident he felt a complete investigation had been completed. The ADNS also stated that there was no Russian speaking employee working on the 3:00 PM-11:00 PM shift on 2/25/16. On 8/19/16 at 10:30 AM the Administrator was interviewed. The Administrator stated that he had no recall of the incident for Resident # 21 at this time. The Administrator did state that the Director of Nursing (DNS) and Assistant Director of Nursing (ADNS) would often discuss with him the Accident/ Incident Report and the need to report to the Department of Health (DOH). On 8/19/16 at 10:40 AM the DNS was interviewed. The DNS stated that the ADNS completes the investigation for all A/I's. The DNS stated that she reviews and signs all completed A/I's. The DNS stated that in the investigation of Resident # 21 she did not feel any additional information was necessary. The DNS stated that she now agrees that additional statements and more indepth information should have been obtained. 415.4(b)(1)(ii)

Based on record review and staff interviews during the recertification survey the facility did not ensure that Resident # 21 was questioned in her language when she was observed with a rotated left hip. This was evident for 1 of 1 resident reviewed for Resident's Rights in a Stage two sample of 25 residents. Specifically, Resident # 21 was observed with swelling, discoloration and slight shortening of the left leg and there was no documented evidence in the medical record that the resident was every interviewed as to what might have occurred. The finding is: Resident # 21 was admitted to the facility on [DATE]. The resident has [DIAGNOSES REDACTED]. The resident was also noted to be Russian speaking. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) conducted with a translator. The resident scored a 12 indicating moderately impaired cognition. The MDS also documented that the resident was a two person assist for bed mobility, transfer, and toilet use and that the resident was frequently incontinent of of bowel and bladder. A progress note dated 2/25/16 at 7:50 PM written by the Registered Nurse (RN) Supervisor documented that she was called to the unit to evaluate Resident # 21. The progress note documented that the resident was observed by the Certified Nursing Assistant (CNA) during care with the left leg flaccid and painful to touch. The progress note also documented that the left foot had limitation of movements and a bluish discoloration of the left groin with shortening and external rotation of the left foot. The physician was notified and the resident was transferred to the hospital for evaluation. The Accident/Incident (A/I) Report dated 2/25/16 at 7:55 PM documented in the Resident Version section of the A/I that she was unable to communicate to the staff what had happened as she speaks a Ukraine language. On 8/19/16 at 9:00 AM the Social Worker (SW) was interviewed. The SW stated that it is not always easy to engage in conversation with Resident # 21. The SW stated that she will often just wave her hand or not answer staff when questioned. The SW further stated that if Russian speaking staff are not available then there is a Language Line Personal Interpreter Service. On 8/19/16 at 9:30 AM the Assistant Director of Nursing Services (ADNS) was interviewed. The ADNS stated that on 2/25/16 at 8:00 PM there was no Russian speaking employee scheduled to work. The ADNS further stated that the facility should have made an effort to have the resident give an explanation in her language. 415.3(e)(1)(i)

Based on observation, and staff interview, it was determined that the facility did not ensure that the two toilet rooms located on resident floors 2 through 5 along the corridor and made accessible to the residents were equipped with nurse calling system. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings include: On 7/29/13, between 8:30 M to 4:00 PM, it was observed that the facility has one toilet facility on each resident floor from the 2nd floor to the 5th floor labeled as " staff " toilet. These toilet facilities were unlocked and also accessible to residents. There were no provisions for nurse calling system in these toilet facilities. On 7/29/13, at approximately 2:30 PM, the Director of facility management stated that either these toilet facilities will be kept locked with keys available at the nurses' station or nurse calling system will be installed. 713-2.22 (g) (2)

Based on observation interview and record review the facility did not ensure the Right of a Resident to refuse care or treatment. This was evident for one (1) of twenty four (24) sampled Residents. (Resident # 12). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 12 is an alert and oriented male admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set was not due for completion given the admission time frame. On 08/20/12 at 7:35 AM the Registered Nurse (RN) was observed during a medication pass for this Resident. The RN was observed removing two (2) tablets of [MEDICATION NAME]/[MEDICATION NAME] (Antiparkinson medication) 25/250 milligram (mg) from its' blister pack and dropping it into a medication cup. The RN was observed removing one (1) tablet of Requip (Antiparkinson medication) 1 mg from its' blister pack and dropped it into the same medication cup. The RN also prepoured "[MEDICATION NAME] 100 mg one (1) tablet; [MEDICATION NAME] 25/200 mg one tablet; [MEDICATION NAME] 50 mg one tablet; and [MEDICATION NAME] 100 mg one (1) tablet into the same medication cup. The RN poured water into an 8 ounce cup and walked towards the Resident, in his room. The resident was in bed, he sat up and was wearing glasses's. The RN after identifying the Resident by his wrist band, informed the Resident that he had his medications for the Resident to take. The Resident took the cup of pills and examined them with his finger and stated, "I took them already." "The other nurse already gave them to me." The RN stated, "No" "you could not have taken them before", and that "I would not be doing my job if you don't take them." The Resident repeatedly refused to take his medications, while still holding the cup in his hand and examining them with his finger. The RN repeatedly insisted that the Resident take his medications and that he must be mistaking about having already taken them earlier today. The Resident told the nurse, "I took them already. The nurse before gave them to me." The nurse responded by saying, " No you could not have." "Please take your pills." The Resident repeated his same statement, " I took them already." This exchange between the Resident and the RN's took placee over a perion of approximately five minutes. At approximately 7:55 AM the State Agency surveyor checked the Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At this time the SA stopped the RN from insisting that the Resident take his medications. The RN was interviewed and stated that the 7:00 AM signature on the MAR indicated [REDACTED]. The RN stated that by looking at the MAR indicated [REDACTED]. The RN stated that he did not look at the MAR indicated [REDACTED]. The RN stated that when a resident refuses his job is to teach and educate and not argue with the Resident and inform the doctor, also that looking at the MAR prior to administering of medication is a standard of practice as a nurse. The RN stated that it looks like the Resident received all of his [MEDICAL CONDITION] medication at 7:00 AM. The RN discarded the medications and began another prepour of medications at 8:05 AM for the Resident's scheduled 9:00 AM medications. The Resident was observed looking at his medications and said, "you finally got it right" and took his medications. A review of the MAR indicated [REDACTED]. A review of the physician's orders [REDACTED]." "[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME])25/250 mg 2 (two) tablets by mouth at 7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM." On 08/20/12 at 10:00 AM the Resident was interviewed and he stated that he knows his medications and that he was not going to take them over again. "I know what I take, they should listen to me." "It is very frustrating and makes me upset when people don't get it right." 415.3(e)(1)(ii)