Every finding on record at Glen Cove Center for Nursing and Rehabilitation

Based on observations, interviews, and record review during the Recertification Survey initiated on 12/11/2025 and completed on 12/18/2025, the facility did not ensure each resident was served food that was palatable, attractive, and at a safe and appetizing temperature. This was identified for six (6) (Resident #23, Resident #39, Resident #25, Resident #8, Resident #121, Resident #129) of seven (7) residents during the Resident Council meeting. Specifically, during the Resident Council meeting held on 12/12/2025, six (6) of seven (7) alert and lucid residents in attendance complained the hot meals were served cold. On 12/16/2025, during the lunch meal service observations, the lunch meal temperatures for the hot food items were observed to be below 135 degrees Fahrenheit.The finding is:The facility's policy titled Meal Pass Distribution & Food Temperature Control dated October 2024 documented that during meal pass the hot food temperatures should be maintained at or above 135 degrees Fahrenheit.The Resident Council meeting was conducted on 12/12/2025 at 11:45 AM. Six (6) of seven (7) residents during the group interview complained they were served cold food during meals that should have been served hot.During an interview on 12/12/2025 at 12:26 PM, the Ombudsman stated residents regularly complain about hot food being served cold which affects the food palatability. The Ombudsman stated that the complaints about food are from residents throughout the facility and not just on one unit. A review of the Resident Council minutes from 6/2025 to 10/2025 revealed during each of these Resident Council meetings under the heading Old Business, there was documentation that food temperatures were improving as per residents.On 12/16//2025, during the lunch meal service, four (4) test trays were requested for four (4) (Akahai Unit, [NAME] Unit, Olakino Unit, and Imua Unit) of four (4) units in the facility.The first of the two meal trucks for the Akahai Unit arrived on the unit at 11:39 AM and the second meal truck arrived on the unit at 11:46 AM. The last meal tray on the Akahai Unit was observed to be served at 12:10 PM at which time the test tray temperature was taken in the presence of Licensed Practical Nurse #1. The temperature reading for the roast beef was 127 degrees Fahrenheit, mashed potatoes 123 degrees Fahrenheit, and green beans 121 degrees Fahrenheit.The first of the two meal trucks for the [NAME] Unit arrived on the unit at 12:00 PM and the second meal truck arrived on the unit at 12:08 PM. The last meal tray on the [NAME] Unit was observed to be served at 12:37 PM at which time the test tray temperature was taken in the presence of the Registered Nurse #2. The temperature reading for the mashed potatoes was 125.4 degrees Fahrenheit and green beans 120 degrees Fahrenheit.The second unit meal truck of two meal trucks for the Olakino Unit arrived on the unit at 12:37 PM. The last meal tray from this meal truck on the Olakino Unit was observed to be served at 12:52 PM at which time the test tray temperature was taken in the presence of Registered Nurse #1. The temperature reading for the roast beef was 129 degrees Fahrenheit and the green beans 130.5 degrees Fahrenheit.On 12/16/2025 at 12:47 PM, at the conclusion of the lunch meal observation of the tray line in the kitchen, it was observed that only 5 resident trays of approximately 18-20 resident trays sent to the Imua unit had heated pellet bottoms. The second unit meal truck of the two meal trucks for the Imua Unit arrived on the unit at 12:49 PM. The last meal tray from this meal truck on the Imua Unit was observed to be served at 12:55 PM at which time the test tray temperature was taken in the presence of Licensed Practical Nurse #2. The temperature reading for the roast beef was 124 degrees Fahrenheit and the green beans 111 degrees Fahrenheit.During an interview on 12/16/2025 at 2:00 PM, Resident #129 stated their hot meals are often served cold because it takes a long time for the staff to deliver the food to their rooms. During an interview on 12/17/2025 at 8:15 AM, Resident #8 was in bed with their breakfast tray on their overbed table. The resident stated they were not eating their breakfast because their meal was delivered cold.During an interview on 12/17/2025 at 9:25 AM, Licensed Practical Nurse #1 (Akahai Unit Manager) stated the meal trays served to residents eating in their rooms are on the same meal truck that serves the residents eating in the dining room. The dining room residents are served first, so the meal trays for the residents who eat in their rooms have to wait for their meals until the dining room service is completed. During an interview on 12/17/2025 at 10:00 AM, the Food Service Director stated approximately 13-15 heated pellet bottoms were not available for the lunch meal service for theImua unit, because they may have been left upstairs on the units from breakfast that morning. The Food Service Director stated that all the meal trays should have heated pellet bottoms to help keep the residents' meals warm. The Food Service Director stated they were unaware that there were not separate meal trucks for the Akahai and [NAME] units for those residents who eat in their rooms. The Food Service Director stated that they were aware from Resident Council Meetings there were problems with keeping the residents' hot foods at 135 degrees Fahrenheit or greater. The Food Service Director stated the residents' food is at appropriate temperature in the kitchen, but once it leaves the kitchen it is out of their hands as to what happens to the food. During an interview on 12/17/2025 at 11:40 AM, the Administrator stated they were aware the residents had concerns regarding hot meals served cold. The Administrator stated there should have been enough heated pellets for all the resident meals in the facility. The Administrator stated to prevent the food from getting cold, the residents eating in the dining room should have their meals delivered on a separate meal truck than residents who eat in their rooms. 415.14(d)(1)(2)

Based on observations, interviews, and record review during the Recertification Survey initiated on 12/11/2025 and completed on 12/18/2025 the facility did not ensure that comfortable temperature levels were maintained in the facility. This was identified for one (1) (Resident #2) of one (1) resident reviewed for the Environmental Task. Specifically, on 12/15/2025 Resident #2 complained of being cold. The room temperature was measured to be 66 degrees Fahrenheit.The finding is:The facility policy titled Ambient Temperature, dated 01/02/2018, documented the facility is to maintain the temperature within the resident areas at a safe and comfortable level. Whenever the temperature in any resident area is outside the temperature range, the nursing home shall immediately evaluate the situation and take appropriate action to ensure the health, safety and comfort of its residents. The Engineering department shall do routine temperature checks of various rooms daily and log the findings. If there is an unusual weather action, then temperature shall be monitored more frequently. Respond to temperatures in resident areas that are outside the temperature range documented: identification of available sites within or outside the nursing home to which residents can be relocated temporarily. The policy did not indicate the required temperature range required in the resident area. Resident #2 was admitted with diagnoses including non-Alzheimer's dementia, Parkinson's disease, and malnutrition. The 11/28/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status assessment score of 6, indicating the resident had severe cognitive impairment.During an observation on 12/15/2025 at 09:35 AM, while Licensed Practical Nurse #1 and Certified Nursing Assistant #2 were preparing to perform Resident #2's wound care treatment, the resident complained of being cold. The resident was in bed and was the only resident in the two-bedded room. The ambient temperature in the room felt cold. Licensed Practical Nurse #1 acknowledged the room was cold and said they would reach out to the maintenance department to turn the heat on after the wound care treatment was completed. Certified Nursing Assistant #2 stated they would get the resident another blanket. During an observation on 12/15/2025 at 11:00 AM, Resident #2 was in bed and complained that they were still cold. The resident had two blankets on. The surveyor noticed a gap in the wall above the wall-mounted air conditioning unit and there was a cold draft coming into the room above the air conditioner through the gap. On 12/15/2025 the outdoor atmospheric temperature at the time of observation was 28 degrees Fahrenheit. During an interview on 12/15/2025 at 11:05 AM, Licensed Practical Nurse #1 stated immediately after performing the wound care, they called the maintenance department to report that Resident #2's room was cold. During an observation and interview on 12/15/2025 at 11:14 AM, Resident #2 was in bed and was still complaining of being cold. At this time Maintenance Office Worker #1 arrived at Resident #2's room with an infrared thermometer and checked the room temperature, which was 66 degrees Fahrenheit. Maintenance Office Worker #1 confirmed there was a cold draft coming into the room from the gap above the air conditioner unit and that they would apply an insulated cover over the air conditioner unit. During an observation with the Director of Engineering and Environmental Service #1 on 12/15/2025 at 11:40 AM, the wall mounted air conditioning unit in Resident #2's room was now observed to be insulated. Director of Engineering and Environmental Service #1 stated that the heating unit in the resident's room was working properly. The cool temperature in Resident #2's room might be due to the location of the room as the room is located next to the stairwell and the stairwell is not heated. The temperature reading, using an infrared thermometer directed at the stairwell wall, measured 63 degrees Fahrenheit. During an observation on 12/15/2025 at 1:25 PM, the air conditioning unit now had an insulated cover on and there was no cold draft coming through; however, the resident was still in bed and complaining of being cold. The room continued to feel cold.During an observation and re-interview on 12/15/2025 at 1:40 PM, Director of Engineering and Environmental Service #1 checked Resident #2's room temperature with their infrared thermometer and the reading was 67 degrees Fahrenheit. The Director of Engineering and Environmental Service #1 stated they could not explain why the room was cold. The resident was still in bed and complaining of being cold. Director of Engineering and Environmental Service #1 stated the ambient room temperature checks (four random rooms) are taken daily in the facility and there have not been any issues identified. Even though the temperatures for rooms by the stairwell run a little cooler, the room temperatures should still be at least 71 degrees Fahrenheit.Review of the December 2025 Daily Air Temperature Log revealed that there were four random room temperature checks done daily with temperatures ranging from 71 degrees Fahrenheit to 77 degrees Fahrenheit. Resident #2's room was last checked on 12/12/2025 with a temperature reading of 71 degrees Fahrenheit.A progress note dated 12/15/2025 at 06:30 PM written by Social Work Director #1 documented Resident #2's room was changed. The reason for room change was the resident complained their room was cold; the Social Worker offered a room change and the resident agreed.During an interview on 12/18/2025 at 10:12 AM, Social Work Director #1 stated Resident #2's room was changed on 12/15/2025 at 4:00 PM.During an interview on 12/18/2025 at 10:16 AM, the Administrator stated the staff should have asked the resident if they were comfortable and if they preferred a room change. The nursing staff should have alerted the maintenance department right away when the resident complained of being cold and the room temperature was found to be below the required range. The facility had empty beds available on 12/15/2025 and there was no reason that it took all day for the resident to be moved to another room. 10 NYCRR 415.5(h)(4)

Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 12/11/2025 and completed on 12/18/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, the floor of the kitchen's walk-in freezer was observed soiled with food debris and frozen brownish substance during the initial kitchen tour on 12/11/2025. On follow-up kitchen observation on 12/12/2025, the floor in the walk-in freezer remained dirty and soiled with the unknown brown substance stuck to the floor. Additionally, a bag of frozen chopped spinach was observed on the floor, wedged behind the foot of the shelf and the corner of the walk-in freezer.The finding is: The facility's policy and procedure titled General Sanitation of the Kitchen effective 04/2022 documented that food and nutrition staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The frequency of cleaning for each task will be defined. Method and materials/cleaning compounds to be used for cleaning/sanitizing will be written for each task. Employees will be trained on how to perform cleaning tasks. Employees will initial and date when the tasks are completed. A review of the Kitchen Daily Cleaning Log documented that daily cleaning of the walk-in freezer was designated to the Assigned Area A. The log did not include method and materials/cleaning compound to be used for cleaning/sanitizing for each task. The form was signed by [NAME] #2 from 12/01/2025 through 12/10/2025 indicating daily cleaning of the walk-in freezer. The facility's policy and procedure titled Food Receiving/ Storage Procurement and Labeling effective 06/2023 documented that staff will inspect food, food products or beverages upon receipt and ensure their proper storage, covering, labeling and dating all Potentially Hazardous Foods/Time-Temperature Control for Safety foods stored in the refrigerator or freezer as indicated. Any person(s) including food service workers, cooks and dietary aides are responsible for adhering to all the food safety requirement, always. During an initial tour of the kitchen on 12/11/2025 at 10:08 AM, the walk-in freezer was inspected with the Director of Food Services and the Food Services Supervisor. The lighting in the walk-in freezer was dim and the use of flashlight was required to visualize the contents. The Food Service Supervisor stated they did not realize how dark it was in the walk-in freezer. A moderate amount of food debris was observed on the floor below a storage shelf on the right side of the freezer. The surface of the floor was observed dirty and appeared to have a layer of an iced-over brown substance. A bag of frozen chopped spinach was also observed on the floor, wedged behind the foot of a shelf and the corner of the walk-in freezer. The Director of Food Services was immediately interviewed and stated that they would immediately assign a dietary staff to clean the walk-in freezer. During a follow up kitchen tour on 12/12/2025 at 09:25 AM, the walk-in freezer was inspected in the presence of the Food Services Supervisor. The walk-in freezer remained dimly lit and required the use of a flashlight to visualize the contents stored in the freezer. The floor under the storage shelf, on the right side of the freezer, was still dirty with the layer of an iced-over brown substance. The unknown substance was stuck to the floor and could not be easily removed. The bag of frozen chopped spinach remained wedged behind the foot of the shelf and the corner of the walk-in freezer. During an interview and observation on 12/12/2025 at 09:35 AM, the Director of Food Services stated they had assigned a staff member to clean the floor on 12/11/2025 and thought the area was cleaned that day. The Director of Food Services retrieved a mop and bucket and tried to mop the floor vigorously to remove the dirty surface. The Director of Food Services stated they tried to clean the area with water and a regular cleaning agent but were not able to clean the area; they might need to use hotter water or some other chemical to remove the brown substance. The Director of Food Services stated the walk-in freezer was scheduled to be cleaned weekly. During an interview on 12/12/2025 at 10:09 AM, [NAME] #1 stated they were regularly assigned to handle, store and stock food inventory in the refrigerator, freezer and the dry storage room. [NAME] #1 stated they cleaned the walk-in freezer every Mondays and every other weekend when there are no deliveries. [NAME] #1 stated the walk-in freezer was poorly lit, but they did not report the dim lighting to the supervisor. [NAME] #1 stated they last cleaned the walk-in freezer on 12/08/2025 and did not notice any food or dirty substances on the walk-in freezer floor. During an interview on 12/12/2025 at 10:33 AM, [NAME] #2 stated that the Director of Food Services instructed them to mop the walk-in freezer after the surveyor's observation on 12/11/2025. [NAME] #2 stated they swept and mopped the walk-in freezer floor and could not completely clean the floor surface because the debris was stuck to the floor. [NAME] #2 stated they informed the Food Service Supervisor and the Director of Food Services that they did the best they could, and the floor may require a stronger chemical sanitizer and a deep cleaning. During an interview on 12/12/2025 at 11:15 AM, the Director of Food Services stated the walk-in freezer floor should be clean and free of any debris including food. The Director of Food Services stated if staff are not able to perform a thorough cleaning of the walk-in freezer with regular cleaning agent, they should notify their supervisor. The Director of Food Services stated they may have to purchase a non-freezing cleaning agent for cleaning the walk-in freezer. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during the Recertification Survey initiated on 12/11/2025 and completed on 12/18/2025, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #110) of three residents reviewed for Transmission Based Precautions. Specifically, Resident #110 was placed on Contact Isolation precautions for Methicillin-Resistant Staphylococcus Aureus (MRSA-a contagious bacterial infection) of the nares(nostril). Certified Nursing Assistant #1 was observed entering Resident #110's room without wearing appropriate Personal Protective Equipment including a gown and gloves. Certified Nursing Assistant #1 did not perform hand hygiene before entering Resident #110's room.The finding is:The facility's policy titled Transmission-Based Precautions, last revised on 09/11/2024, documented the facility will use Transmission-Based Precautions to manage specific, highly transmissible, or epidemiologically important pathogens based on the mode of transmission: contact, droplet and airborne. Contact Precautions will be used when there is evidence of multidrug-resistant organisms or other epidemiologically significant organisms causing clinical symptoms. Residents on Transmission Based Precaution will have isolation signage posted outside the resident's room. A yellow signage for contact precaution is used for residents on contact precautions for Methicillin-Resistant Staphylococcus Aureus (MRSA) that indicates requiring Personal Protective Equipment (PPE) including gloves, surgical mask, gown and goggles/eye shield if splashing is expected.Resident #110 was admitted with the diagnoses of sepsis, pulmonary embolism and atrial fibrillation. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #110 had intact cognition. The Annual Minimum Data Set assessment documented that Resident #110 had an active diagnosis of asthma, chronic obstructive pulmonary disease or chronic lung disease.A nose culture diagnostic test dated 12/1/2025 documented that Methicillin-Resistant Staphylococcus Aureus (MRSA) on the nose was detected at the hospital before admission to the facility.A follow up nose culture test dated 12/13/2025 documented that Methicillin-Resistant Staphylococcus Aureus (MRSA) continue to be positive on the nose.A Physician Order dated 12/04/2025 documented Strict Single Room Isolation-Contact Precautions for Methicillin-Resistant Staphylococcus Aureus (MRSA) of nares.A Physician Order dated 12/04/2025 documented Mupirocin two (2) percent apply by topical route in both nostrils once daily for seven (7) days.A Comprehensive Care Plan (CCP) titled, Isolation/Contact Precautions: Methicillin-Resistant Staphylococcus Aureus (MRSA) dated 12/04/2025 documented interventions including isolation precautions as per Physician's order, maintain isolation precautions at all times, and administer medications as per physician orders. During the breakfast meal observation on 12/02/2025 at 8:29 AM, a sign posted outside Resident #110's room read Contact Precautions. The sign instructed that everyone must clean their hands before and after entering and when leaving the room. The sign also instructed to use Personal Protective Equipment including wearing a gown and gloves. Certified Nursing Assistant #1 was observed entering Resident #110's room to deliver the breakfast tray to the resident without putting on a gown and gloves. Certified Nursing Assistant #1 did not perform hand hygiene before entering Resident #110's room.During an interview on 12/12/2025 at 8:40 AM, Certified Nursing Assistant #1 stated that they entered Resident #110's room to deliver their breakfast tray. Certified Nursing Assistant #1 stated they were in a hurry and did not see the signage outside Resident #110's room. Certified Nursing Assistant #1 stated they should have followed the sign outside Resident #110's room which included performing hand hygiene and wearing a gown and gloves before entering the room.During an interview on 12/12/2025 at 9:00 AM, Registered Nurse #1, Unit Manager stated that Certified Nursing Assistant #1 should have followed the sign outside Resident #110's room. Registered Nurse #1 stated that anyone entering Resident #110's room should perform hand hygiene before and after leaving the room, wear proper Personal Protective Equipment which included gown and gloves to prevent spread of infection.During an interview on 12/16/2025 at 10:22 AM, the Infection Preventionist stated that everyone must follow the facility's infection prevention policy and procedures. The Infection Preventionist stated that Certified Nursing Assistant #1 should have read the sign outside Resident #110's room, followed the instructions about wearing proper Personal Protective Equipment, and performed hand hygiene before and after leaving Resident #110's room. The Infection Preventionist stated that staff were provided education annually and as needed regarding infection control prevention.During an interview on 12/17/2025 at 8:42 AM, the Director of Nursing Services stated that they expect all staff to follow the facility's policy on infection control and prevention. The Director of Nursing Services stated that the signage outside the resident's door is a guidance for the staff to follow the process in preventing further spread of infection in the facility.10 NYCRR 415.19 (a) (1-3)

Based on observation, record review, and interviews conducted during the recertification survey initiated on 5/13/2024 and completed on 5/17/2024 the facility did not ensure that each resident had a call bell accessible to alert staff of the resident's needs. This was identified for one (Resident #80) of two residents reviewed for the Environmental Task. Specifically, on two occasions, Resident #80 was observed in bed with the call bell out of reach. The finding is: The facility's policy titled, Resident Call System, effective 10/2022 documented call lights are to be placed within the reach of residents. Staff will ensure the call bell is properly placed within the reach of a resident before exiting the room. Resident #80 was admitted with diagnoses that included Cerebral Infarction (Stroke), Dementia, and a History of Falls. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #80's Brief Interview for Mental Status score was four which indicated a severely impaired cognition. Resident #80 received partial/moderate assistance for bed mobility and transfers and had no impairment in functional range of motion in the upper and lower extremities. The Behavior Symptoms Care Plan initiated on 12/20/2023 and last modified on 3/20/2024 documented that Resident #80 had the potential to exhibit inappropriate behavioral problems as evidenced by wandering, poor safety awareness, physical aggression, and wearing surgical gloves. There was no documented evidence that Resident #80 exhibited the behavior of hanging the call bell on the knob of their nightstand. Resident #80 was observed laying in their bed with a sheet pulled up to their chin on 5/13/2024 at 10:08 AM. The head of the bed was elevated, and the right half-side rail was in the up position. Resident #80 had a nightstand located on the right side of the head of their bed. Resident #80's call bell was observed hanging over the top knob of their nightstand. Resident #80 stated they did not have a call bell. Resident #80 was observed laying in their bed with a sheet pulled up to their chin on 5/13/2024 at 12:38 PM. The head of Resident #80's bed was elevated, and the right half-side rail was in the up position. Resident #80 had a nightstand located on the right side of the head of their bed. Resident #80's call bell was observed hanging over the top knob of their nightstand. Resident #80 was interviewed on 5/13/2024 at 12:38 PM and stated they could not reach the call bell and did not know why the call bell was hanging on the knob of the nightstand. Resident #80 did not know where the call bell was normally placed. Certified Nursing Assistant #9 was interviewed on 5/13/2024 at 12:57 PM and stated they assisted Resident #80 with morning care and checked in on the resident at lunch. Certified Nursing Assistant #9 stated Resident #80 can use the call bell and the call bell should be within reach of the resident. Certified Nursing Assistant #9 observed Resident #80's call bell hanging over the top knob of the nightstand. Certified Nursing Assistant #9 stated Resident #80 would not be able to reach the call bell if they were lying in bed. Certified Nursing Assistant #9 stated they forgot to place the call bell next to the resident when they left the room. Certified Nursing Assistant #9 stated they should have clipped the call bell to the resident's fitted bed sheet. Licensed Practical Nurse #5 was interviewed on 5/13/2024 at 1:07 PM and stated Resident #80 was able to use the call bell and the call bell should be within reach of the resident. Licensed Practical Nurse #5 observed Resident #80's call bell hanging over the top knob of the nightstand. Licensed Practical Nurse #5 stated if Resident #80 was lying in bed and was in distress they (Resident #80) would not be able to reach the call bell. Licensed Practical Nurse #5 stated the call bell should be clipped on the sheet next to the resident while the resident is in bed. Registered Nurse #3, the Unit Manager, was interviewed on 5/14/2024 at 11:06 AM and stated the call bell should be within reach of each resident, and after providing care the call bell should be checked before a staff person exits the resident's room. The Director of Nursing Services was interviewed on 5/17/2024 at 10:51 AM and stated they expected the call bell to be within the resident's reach. The Director of Nursing Services stated if the resident is in bed, the call bell should be clipped to the bed linen or pillow. The Director of Nursing Services stated the Certified Nursing Assistant should check the call bell every two hours and as needed. 10 NYCRR 415.5(e)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 5/13/2024 and completed on 5/17/2024, the facility did not ensure that a clean, comfortable, and homelike environment was maintained for two (Resident #24 and Resident #80) of two residents reviewed for the Environmental Task. Specifically, 1) The privacy curtain in Resident #24's room was observed with large stained/soiled areas and 2) Resident #80's room had no window covering for one of the two windows observed in the room. The findings are: 1) The facility's policy titled Resident Room Terminal Cleaning, effective 8/10/2022 documented that all resident rooms receive a complete room cleaning on a rotating basis every five weeks. The maintenance will remove the privacy curtain and the laundry will launder the privacy curtain. Resident #24 was admitted with diagnoses that included Complete Intestinal Obstruction, Acute Respiratory Failure, and Muscle Wasting and Atrophy. The Admission Minimum Data Set assessment dated [DATE] documented Resident #24's Brief Interview for Mental Status score was 15 which indicated an intact cognition. A review of the maintenance logs from 4/9/2024 through 5/14/2024 did not include documentation related to the soiled privacy curtain in Resident #24's room. During an observation on 5/13/2024 at 10:38 AM the privacy curtain in Resident #24's room was observed with numerous large stains. Resident #24 was interviewed on 5/13/2024 immediately after the observation and stated the stains on the privacy curtains were present when they were admitted to the facility approximately three weeks ago. Resident #24 stated they would appreciate a clean privacy curtain. An observation of Resident #24's stained privacy curtain was made with Certified Nursing Assistant #10 on 5/14/2024 at 10:30 AM. Certified Nursing Assistant #10 stated they assisted Resident #24 with morning care and did not notice the stained privacy curtain. Certified Nursing Assistant #10 stated normally, when they observe maintenance concerns, they would report the concerns to the Unit Manager. An observation of Resident #24's stained privacy curtain was made with Registered Nurse #3 on 5/14/2024 at 10:35 AM. Registered Nurse #3 stated they were not aware that Resident #24's room had soiled curtains. If they knew of the concern, they would have reported it to the maintenance staff. Registered Nurse #3 stated resident's privacy curtain should be clean and without stains. Maintenance Mechanic #1 was interviewed on 5/14/2024 at 11:13 AM and stated they were not aware that Resident #24's privacy curtain was soiled. Maintenance Mechanic #1 stated each Resident's privacy curtain should be clean and without stains. Maintenance Mechanic #1 stated maintenance issues are generally reported to them verbally; however, there was a maintenance log on each unit at the nurse's station and they reviewed the log at the beginning of their shift. Maintenance Mechanic #1 stated when they completed a request they signed the log book to indicate the concern was addressed. Housekeeper #1 was interviewed on 5/14/2024 at 11:25 AM and stated they cleaned each resident's room daily and visually scanned the room for any soiled areas before they started their cleaning tasks. Housekeeper #1 stated they did not observe the soiled privacy curtain in Resident #24's room. The Director of Engineering and Environmental Services was interviewed on 5/16/2024 at 3:41 PM and stated the resident's privacy curtains should be clean and free of stains. The housekeeper and maintenance mechanic complete room checks daily and the privacy curtains should be part of their inspections. The Administrator was interviewed on 5/17/2024 at 10:10 AM and stated the housekeeper should have observed the stained privacy curtain during their daily rounds. The Administrator stated they expected the privacy curtains to be clean and without stains. 2) The facility's policy titled Resident Room Window Covering, effective 1/2/2024 documented the facility is responsible for maintaining resident privacy and a homelike environment with appropriate window treatments and/or blinds. The facility will maintain either window treatments or blinds in each resident's room. All blinds/window treatments will be maintained in good repair by building services. Resident #80 was admitted to the facility with diagnoses that included Cerebral Infarction (Stroke), Dementia, and a history of Falls. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #80's Brief Interview for Mental Status score was four which indicated a severely impaired cognition. A review of the maintenance logs from 4/9/2024 through 5/14/2024 did not include documentation related to a need for window covering in Resident #80's room. During an observation of Resident #80's room on 5/13/2024 at 10:08 AM, one of the two windows did not have window covering. Resident #80 stated they were not sure if they ever had a window covering for the window. An observation of Resident #80's window was made on 5/14/2024 at 10:38 AM with Certified Nursing Assistant #2. Certified Nursing Assistant #2 stated each resident's room window should have a window covering; however, they did not notice Resident #24's room window did not have a window covering. An observation of Resident #80's window was made on 5/14/2024 at 10:42 AM with Licensed Practical Nurse #5. Licensed Practical Nurse #5 observed Resident #80's window without a window covering and stated each window in a resident's room should have a window covering. Licensed Practical Nurse #5 stated they regularly came into the resident's room to administer medications on the 7:00 AM-3:00 PM shift and did not notice the window did not have a covering. An observation of Resident #80's window was made on 5/14/2024 at 11:00 AM with Registered Nurse #3, the Unit Manager. Registered Nurse #3 stated each resident should have window coverings on their windows. Registered Nurse #3 stated they would report the need for a window covering to the maintenance mechanic verbally or via the maintenance log. Maintenance Mechanic #1 was interviewed on 5/14/2024 at 11:13 AM and stated they were not aware that Resident #80's window did not have a window covering. Maintenance Mechanic #1 stated maintenance issues are generally reported to them verbally; however, they were not told about the missing window covering in Resident #24's room. Maintenance Mechanic #1 stated the unit maintenance log also did not have any documentation related to the missing window covering. Housekeeper #1 was interviewed on 5/14/2024 at 11:25 AM and stated they cleaned each resident's room daily and were not aware that Resident #80's room did not have a window covering. Housekeeper #1 stated they would have reported the missing window covering to the medication nurse. The Director of Engineering and Environmental Services was interviewed on 5/16/2024 at 3:41 PM and stated each window in a resident's room should have a window covering. The Director of Engineering and Environmental Services stated they expected the housekeeper or maintenance mechanic to ensure the resident rooms are checked during their daily rounds or during the terminal room cleaning. The Administrator was interviewed on 5/17/2024 at 10:10 AM and stated the staff persons on the unit should have observed the missing window covering during their daily rounds. The Administrator stated they expected each window in a resident's room to have a window covering. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and staff interviews during the Recertification Survey, initiated on 5/13/2024 and completed on 5/17/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for one (Resident #109) of four residents reviewed for Pressure Ulcers. Specifically, Resident #109 was admitted to the facility with a Deep Tissue Injury (a pressure injury caused by damage to the underlying soft tissues) to the sacrum (a bone at the base of the spine). The resident had a physician's order for an alternating pressure relief air mattress. During multiple observations, the adjustable weight setting for the mattress, which is meant to correspond to the resident's weight, was not set accurately. In addition, a re-assessment of the sacrum wound, by the Director of Nursing Services and the Wound Physician, did not classify the stage of the pressure ulcer. The finding is: The facility policy titled Pressure Injury-Prevention and Care, dated February 2022, documented that suspected deep tissue injury is due to damage of underlying soft tissue from pressure and/or shear. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. A Stage 2 pressure ulcer is a partial thickness loss of dermis (skin) presenting as a shallow open injury with a red, pink wound bed, without slough (defined as dead tissue containing white blood cells and wound debris). The wound care team members will weekly evaluate each pressure site for the effectiveness of treatment, improvement/healing, deterioration, or if the site remains the same. The operation manual for the Alternating Pressure System with Low Air Loss documented adjusting the mattress' internal pressure according to the resident weight by using the weight button. Resident #109 was admitted to the facility with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Hip Fracture. The 4/4/2024 Admission Minimum Data Set assessment documented no Brief Interview for Mental Status score due to the resident's severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented that the resident had one Stage 2 pressure ulcer (defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). The nursing admission assessment dated [DATE] documented that the resident had a Deep Tissue Injury at the lower back/sacrum area measuring three centimeters by two centimeters. The nursing admission assessment documented the resident's Braden Scale (a numerical system used to predict pressure ulcer risk) score was 16, which indicated the resident had a mild risk for developing pressure ulcers. A physician's order, dated 4/1/2024 and last on 4/22/2024, documented to cleanse the sacral wound with normal saline, pat dry, and apply Medihoney (a wound healing medication) topically followed by dry protective dressing twice a day and when needed for diagnosis of Stage 2 pressure ulcer of the sacral region. A physician's order dated 4/23/2024 documented Air Mattress for pressure relief, check for proper functioning and placement every shift. A Comprehensive Care Plan, titled Pressure Ulcer-Sacrum effective 4/1/2024, documented the resident was admitted with a sacral pressure ulcer and was at risk for further breakdown. An intervention documented on 4/1/2023 included providing a pressure-relieving mattress. The wound care physician consultant note dated 5/13/2024 documented the resident had a Stage 2 pressure ulcer to the sacrum. The wound measurements: 1.2 centimeters by 1.0 centimeters by 0.2 centimeters, with 100% epithelial tissue (pink or pearly white and occurs in the final stage of healing when the wound is covered by healthy skin cells) with light serous drainage (defined as a clear to yellow fluid that leaks out of a wound. This type of wound drainage is a normal). Interventions included the use of a low-air loss mattress. A review of the electronic medical record indicated Resident #109's most recent weight, dated 5/9/2024, was 108.3 pounds. On 5/13/2024 at 10:20 AM Resident #109 was observed in bed. The air mattress pump weight setting was set at 230 pounds. On 5/14/2024 at 08:05 AM Resident #109 was observed sitting in their wheelchair next to the bed. The weight setting on the air mattress pump was set at 230 pounds. Licensed Practical Nurse #3 (medication nurse) was interviewed in Resident #109's room on 05/14/2024 at 8:07 AM. Licensed Practical Nurse #3 observed the weight setting of 230 pounds on the air mattress pump and stated they were not sure who adjusts the weight setting on the air mattress. Licensed Practical Nurse #4, the charge nurse, was interviewed in Resident #109's room on 5/14/2024 at 8:59 AM. Licensed Practical Nurse #4 observed the weight setting of 230 pounds on the air mattress pump and stated the initial weight setting on the air mattress is set by the wound care nurse and the weight setting should match the resident's weight. Licensed Practical Nurse #4 attempted to adjust the weight setting but did not know how and stated they would call the maintenance staff. A review of the May 2024 Treatment Administration Record revealed that nurses have been documenting every shift that the air mattress is functioning properly as per the physician's order. The Director of Maintenance was interviewed in Resident #109's room on 5/14/2024 at 9:51 AM. The weight setting on the mattress was now set at 120 pounds. The Director of Maintenance stated they had just adjusted the weight setting on 5/14/2024 at 9:50. The Director of Maintenance stated the air mattress was not malfunctioning and that the weight adjustment on the air mattress pump was just a matter of pressing a button on the pump panel. Licensed Practical Nurse #2 (wound care nurse) was interviewed on 5/15/2024 at 8:17 AM and stated the setting on the mattress should be consistent with the resident's weight. Resident #109's air mattress should not have been set at 230 pounds. Licensed Practical Nurse #2 stated they did not recall checking the mattress weight setting during wound rounds on 5/13/2024. Licensed Practical Nurse #2 stated the unit nurses are responsible for checking the weight setting on the air mattress as per the physician's order. A wound care observation for Resident #109 was conducted on 5/15/2024 at 10:03 AM. Licensed Practical Nurse #2, the wound care nurse, administered the wound care and was assisted by Licensed Practical Nurse #4. The sacral wound appeared as a full-thickness wound (damage extends below all layers of the skin into the subcutaneous tissue or beyond). The wound bed was observed with approximately 90% granulation (healthy) tissues and 10% yellow slough (a yellow/white material in the wound bed). Licensed Practical Nurse #2 was interviewed on 5/15/2024 at 10:04 AM and stated they were not licensed to classify the staging of the sacral pressure ulcer. The Wound Physician was interviewed on 5/15/2024 at 10:57 AM and stated for Resident #109, the weight setting of 230 pounds on an air mattress would be on the firm side. The Wound Physician stated the air mattress weight setting should be consistent with the resident's weight to promote wound healing. The Director of Nursing Services was interviewed on 5/15/2024 at 12:14 PM and stated the weight setting of 230 pounds was a little high for Resident #109's air mattress. The Director of Nursing Services stated the weight setting on an air mattress should be consistent with the resident's weight to ensure optimal wound healing. An update dated 5/16/2024 to the pressure ulcer comprehensive care plan, written by the Director of Nursing Services, documented that on 5/15/2024 sacral wound was re-assessed and was noted with 95% granulation tissue and 5% yellow slough. The wound measured 2.0 centimeters in length, 1.0 centimeters in width, and 0.3 centimeters in depth. The note did not classify the sacral pressure ulcer staging. The Director of Nursing Services was re-interviewed on 5/17/2024 at 11:42 AM and stated they re-assessed Resident #109's sacral wound on 5/15/2024. The Director of Nursing Services stated during the assessment they noticed there was a change in the wound status. The wound was increased in size and there was slough present. The Director of Nursing Services stated they then called the Wound Physician to re-evaluate the wound. The Director of Nursing Services stated they do not determine the wound stages, only the Wound Physician classifies the staging of the pressure ulcer wounds. The wound Physician's progress note dated 5/17/2024 documented the wound was comprised of 95% granulation tissue and 5% slough and measured 2.0 centimeters in length, 1.0 centimeters in width, and 0.3 centimeters in depth. The wound had no foul odor, signs of infection, or purulent discharge. The wound was unavoidable secondary to the resident being at high risk for skin breakdown due to multiple comorbidities. The progress note did not classify the staging of the sacral pressure ulcer. Attempts were made to re-interview the Wound Physician on 5/17/2024. The Wound Physician was not available for an interview. 10 NYCRR 415.12(c)(1)

Based on observations, interviews, and record review during the Recertification Survey initiated on 5/13/2024 and completed on 5/17/2024, the facility did not ensure nursing staffing was posted daily and included the total number of licensed and unlicensed staff working per shift. Specifically, the facility's entrance lobby was observed on 5/13/2024 at 9:00 AM with the nursing staffing sheet dated 5/10/2024. Additionally, the nursing staffing sheets posted from 5/13/2024 to 5/16/2024 did not include the total number of licensed and unlicensed nursing staff working per shift. The finding is: A nursing staffing sheet was observed at the facility entrance by the receptionist area on 5/13/2024 at 9:00 AM. The nursing staffing sheet was dated 5/10/2024 and did not contain the number of licensed and unlicensed nursing staff directly responsible for resident care for each nursing shift: 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM. A nursing staffing sheet was observed at the facility entrance by the receptionist area on 5/14/2024 at 12:30 PM. The nursing staffing sheet was dated 5/14/2024 and did not contain the number of licensed and unlicensed nursing staff providing care for each nursing shift: 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM. A nursing staffing sheet was observed at the facility entrance by the receptionist area on 5/15/2024 at 9:23 AM. The nursing staffing sheet was dated 5/15/2024 and did not contain the number of licensed and unlicensed nursing staff providing care for each nursing shift: 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM. The Staffing Coordinator was interviewed on 5/16/2024 at 11:43 AM and stated they were responsible for completing and posting the nursing staffing sheet daily on days they are working. The Staffing Coordinator stated they were not sure who was responsible for completing and posting the nursing staffing sheets on the weekends or when they were not working. The Staffing Coordinator stated that the nursing staffing sheet should contain the date, resident census, and total number and hours worked by licensed and unlicensed nursing staff. The Staffing Coordinator further stated they were not aware why the facility's nursing staffing sheet does not include the total number of nursing staff on each shift. The Director of Nursing Services was interviewed on 5/17/2024 at 9:54 AM and stated that the night (11:00 PM-7:00 AM) Registered Nurse Supervisor is responsible for completing and posting the staff information daily, including the weekends. The Director of Nursing Services stated that they spoke with the Registered Nurse Supervisor who worked this past weekend (5/11/2024 and 5/12/2024) and the Registered Nurse Supervisor forgot to post the staffing information. The Director of Nursing Services stated they were not sure why the facility's nursing staffing sheet did not include the total number of nursing staff on each shift and would revise it to include that information. The weekend Registered Nurse Supervisor #2 was contacted on 5/17/2024 at 11:28 AM and 1:24 PM and was unable to be interviewed. 10 NYCRR 415.13

Based on record review and interviews during the Recertification Survey initiated on 5/13/2024 and completed on 5/17/2024 the facility did not ensure that each resident received the use of outside resources in a timely manner. This was identified for one (Resident #91) of five residents reviewed for Unnecessary Medications. Specifically, Resident #91 had a physician's order, dated 4/2/2024, for an initial psychiatry consult following the resident's admission to the facility on [DATE]; however, the resident did not receive their initial psychiatry consult until 5/15/2024. The finding is: The facility's policy titled, Physician Consultations effective 4/2023, documented it is the policy of this organization to ensure all residents receive medical care in a timely manner. The attending physician will indicate the appropriate time frame within which the specialist should see the resident. Resident #91 was admitted with diagnoses including Alzheimer's Disease, Parkinson's Disease, and Psychotic Disorder. The 4/8/2024 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented that the resident had frequent problems related to mood, such as little interest in doing things, trouble with sleep, trouble concentrating, and being restless. A physician's order dated 4/1/2024 documented Quetiapine (an antipsychotic medication), 25 milligrams tablet; give one tablet by oral route every 12 hours, for diagnosis of Anxiety Disorder. A physician's order, dated 4/2/2024, documented to obtain an Initial Psychiatry Consult. A Comprehensive Care Plan titled, Psychotropic Medications effective 4/2/2024, documented an intervention to obtain a psychiatry consultation as ordered. A Pharmacist medication regimen review dated 4/4/2024 documented resident was recently admitted to the facility and receiving Quetiapine with no clear diagnosis to support current use. Please consider obtaining a psychosocial work-up along with performing a medical work-up as soon as possible to assess the underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors or identification of a chronic psychiatric condition, please consider implementing a tapering schedule and/or discontinuation of the medication. The physician response, dated 4/8/2024, documented: Disagree, would observe for now. Resident with psychosis and new admission. A Pharmacist medication regimen review dated 4/13/2024 documented currently receiving Quetiapine, which can increase the risk of falls. Per clinical record, with recent falls. Please evaluate and consider tapering dose or implementing alternative treatment. The Physician's response, dated 4/15/2024, documented: Disagree: Resident still with target symptoms. Continue current dose. A physician's order dated 5/8/2024 documented Quetiapine, 25 milligrams tablet; give one tablet by oral route every 12 hours, for diagnosis of Other Psychotic Disorder not due to a Substance or Known Physiological Condition. A Comprehensive Care Plan, titled Mood State, effective 4/2/2024, documented psychiatric consult and follow-up as ordered. A note entry dated 5/8/2024 documented the interdisciplinary team discussed the resident behaviors and current management. The resident was being followed by the facility Psychiatrist due to a diagnosis of Alzheimer's Disease and Anxiety Disorder. The resident continued to have intermittent episodes of being combative and yelling during morning care. The resident will continue to be followed by the facility Psychiatrist. A review of the medical record revealed no previous evaluation by the Psychiatrist. A nursing progress note dated 5/9/2024 at 1:07 AM documented the resident pulled out their peripheral intravenous line. Attempts were made to re-insert the intravenous line, but the resident refused and was combative. The resident was trying to hit bite and pinch staff and used inappropriate words towards staff. The Primary Physician was notified, and the Psychiatrist was made aware for re-evaluation. A review of the medical record revealed no previous evaluation by the Psychiatrist. A review of the medical record revealed that there had been no documented psychiatric evaluation as of 5/15/2024. The Director of Nursing Services was interviewed on 5/15/2024 at 9:39 AM. The Director of Nursing Services stated the psychiatry consult for Resident #91 is pending and the initial consult has not been done yet. The Director of Nursing Services stated generally, the initial psychiatry consult should be done within 14 days of a new admission. Psychiatrist #1 was interviewed on 5/15/2024 at 1:00 PM. Psychiatrist #1 reviewed their notes and stated they had not seen Resident #91 yet. Psychiatrist #1 stated generally, they like to see a new resident as soon as possible, within 1-2 weeks after the resident is admitted . Psychiatrist #1 stated the facility asked them to see the resident today. Psychiatrist #1 stated when a consult is needed for newly admitted residents, the staff either texts them or puts the consult request in the consult book. Primary Physician #1 was interviewed on 5/15/2024 at 1:55 PM and stated they expect the psychiatry consult to be done rather quickly. Primary Physician #1 stated they did not change the Seroquel (Quetiapine), dosage because the resident was very aggressive and almost attacked them a couple of times. Primary Physician #1 stated they were waiting for the Psychiatrist to assess the resident because they (Primary Physician #1) are not an expert. Primary Physician #1 stated the Quetiapine order written on 4/1/2024 indicated a diagnosis of Anxiety as a reason for the medication use, which may have been an oversight. The Director of Nursing Services was re-interviewed on 5/15/2024 at 2:05 PM and stated all newly admitted residents who receive psychotropic medications are automatically referred to psychiatry services. Resident #91 is a newly admitted resident who receives antipsychotic medications and should have been seen by the Psychiatrist within 14 days of their admission to the facility. A Psychiatry consult dated 5/15/2024 documented a recommendation for a dose reduction of Quetiapine. The resident has been intermittently combative, agitated, and depressed at times, with poor sleep sometimes. The resident has been extremely confused, and unable to answer questions due to cognitive impairment. The Psychiatrist recommended to continue Seroquel 12.5 milligrams every 12 hours. 10 NYCRR 415.26(e)

Based on interviews and record review during the Recertification Survey and Abbreviated survey (NY 813) initiated on 9/6/2022 and completed on 9/13/2022, the facility did not ensure that all alleged violations are thoroughly investigated to rule out Abuse, Neglect, Exploitation, or Mistreatment. This was identified for one (Resident #208) of one resident reviewed for Change in Condition. Specifically, Resident #208 sustained a skin tear to the right forearm on 3/7/2022 and a skin tear to the left forearm on 3/8/2022. The facility did not initiate an investigation to determine the root cause of the incident and obtain pertinent statements to rule out Abuse, Neglect, Exploitation and Mistreatment. The finding is: The facility's policy, titled Risk Management: Resident/Patient Incidents and Accidents, dated 1/1/2022, documented an incident is an unexpected, unintended event that can cause a resident/patient superficial injury or no injury. Examples of incidents may include but are not limited to the following: non-injury falls, soft tissue injury or hematoma that does not disrupt structure or function of affected part of body, and superficial scratches, scrapes, blisters, abrasions, skin tears, or lacerations not requiring closure, resulting from actual occurrences. For all occurrences the Registered Nurse (RN) will examine the resident and perform a complete physical assessment; the charge nurse in collaboration with the nurse manager/supervisor will notify the physician and complete the accident/incident report; the Director of Nursing Services (DNS) will be notified immediately if suspicion of abuse/neglect exists; and within 24 hours the completed accident/incident investigation will be forwarded to the DNS. Resident #208 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/26/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that there were no ulcers, wounds, or skin problems. The 48-hour care plan, dated 2/25/2022-2/26/2022, documented under skin ulcers/wound, fragile skin: skin tear-treatment as indicated, gentle handling. A facility investigation dated 3/2/2022 documented that Resident #208 sustained a skin tear to the neck while the resident's pillow was being adjusted by a Certified Nursing Assistant (CNA). The outcome from the investigation was for the CNA to receive an inservice on gentle handling of residents. The Registered Nurse (RN) Supervisor progress note, written by RN #3 dated 3/7/2022 at 3:23 PM, documented the Primary Care Nurse, who was Licensed Practical Nurse (LPN) #1, advised RN #3 that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . After evaluating the injury, the matter was reported to the wound care nurse who evaluated the left arm [right arm per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide the Accident/Incident report, or an investigation related to the skin tear to Resident #208's right arm, which was identified on 3/7/2022. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed no accompanying progress notes for the 3/8/2022 left arm wound. The Director of Nursing Services (DNS) was interviewed on 9/9/2022 at 9:00 AM and stated as per the RN Risk Manager, there was no incident investigations for the 3/7/2022 or 3/8/2022 skin tears. RN #3 was interviewed on 9/9/2022 at 10:18 AM regarding Resident #208's right forearm skin tear identified on 3/7/2022. RN #3 stated they (RN #3) were told about the skin tear by LPN #1. RN #3 stated they reported the skin tear to the wound care RN (RN #4). RN #3 stated they (RN #3) would have expected an investigation to have been done for the skin tear unless there was a discussion with the wound care RN and the wound care RN felt an investigation was not necessary. RN #4 (wound care nurse) was interviewed on 9/9/2022 at 10:27 AM and stated usually the incident investigation is done by the RN Risk Manager (RN #1). RN #4 stated they (RN #4) saw the right arm skin tear on 3/7/2022 and do not know why an investigation was not done. RN #4 stated they (RN #4) did not make a decision that an investigation was not necessary. RN #4 stated they (RN #4) did not remember the left arm skin tear that was identified on 3/8/2022 for Resident #208. RN #1 who was the Risk Manager/Assistant Director of Nursing Services (ADNS) was interviewed on 9/9/2022 at 10:59 AM and stated the resident had very fragile skin. RN #1 stated they (RN #1) did not do an investigation for the 3/7/2022 right arm skin tear because the skin tear occurred from the aide taking care of the resident during regular hygiene care, so a report was not necessary. RN #1 stated they did not speak to the aide who provided the hygiene care but learned about the skin tear from other staff. RN #1 stated they did not know about the wound that occurred on 3/8/2022 to the left arm. RN #1 stated that in their opinion since the resident had fragile skin, an investigation for the skin tears was not necessary. LPN #1 was interviewed on 9/9/2022 at 11:17 AM and stated they did not remember which CNA told them (LPN #1) about the skin tear on the right forearm on 3/7/2022. The DNS was interviewed on 9/9/2022 at 1:29 PM and stated if the origin of an injury is known then the investigation is not really needed. The DNS stated they (DNS) were not aware of the skin tears to the arms, only the neck wound. The DNS stated the skin tears to the arms may have happened because the CNAs were not that gentle, and the resident had fragile skin. 415.4(b)(3)

Based on record review and interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for two (Resident #30 and Resident #86) of three residents reviewed for Nutrition. Specifically, 1) Resident #30 had a 5% significant weight loss in July 2022 which was not addressed by their Primary Care Physician in their progress note and 2) Resident #86 had an 8.6% significant weight loss in 3 months identified in May 2022 which was not addressed by the Primary Care Physician in their progress note, a 17.1% significant weight loss in 6 months identified in June 2022 which was not addressed by the Primary Care Physician in their progress note, and a 10.8% significant weight loss in 6 months identified in August 2022 which was not addressed by the Primary Care Physician in their progress notes. The findings are: The facility's policy titled, Notification of MD of Residents Change in Condition last revised on 8/24/2022 documented that any change in the resident's baseline status observed by any staff of the facility will be reported to the Unit Managers/Licensed Nursing Staff. Unit Managers/Licensed Nursing Staff will assess the resident's condition and determine if the Attending Physician needs to be contacted. Once the resident has been observed by the Unit Managers/Licensed Nursing Staff, the resident's Attending Physician will be notified. Changes that warrant notification of the Attending Physician included but were not limited to weight loss/gain. 1) Resident #30 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #30 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required supervision with setup help only with eating. The resident's height was 60 inches and they weighed 144 pounds. No weight loss was identified on this MDS. The resident's Weight Monitoring Report documented that on 6/1/2022 the resident weighed 144.4 pounds (lbs) and on 7/13/2022 the resident weighed 136.8 lbs which indicated a 7.6 lb or a 5.26% significant weight loss over one month. The Dietary Progress Note and Comprehensive Care Plan (CCP) titled Nutrition/Hydration dated 7/26/2022 documented that the resident had a recent weight decline that month due to being diagnosed with COVID-19 infection on 6/29/2022. The note documented that the resident's usual body weight (UBW) range was 144-147 lbs over the past 6 months. The resident's current weight (CW) was 136.8 lbs which reflected a 7.2 lbs or 5% weight decline that month. Review of the resident's Electronic Medical Record (EMR) revealed no Physician (MD) Monthly Visit for July 2022. The MD Monthly Visit dated 8/13/2022 documented, WT (weight) stable. The resident's current diet orders dated 8/13/2022 documented Diet Type: No Added Salt (NAS), Diet Consistency: Soft, and Fluid Consistency: Thin/regular Liquids. A nutritional supplement of Ensure Plus 237 milliliters by mouth twice daily was ordered on 9/2/2022. The Registered Nurse (RN) Unit Manager (RN #5) was interviewed on 9/9/2022 at 3:05 PM and stated there has been a change in the Dietician employed by the facility since August 2022. RN #5 stated they (RN #5) were unsure if Resident #30 had a significant weight loss in July. RN #5 stated since the new Registered Dietician (RD)'s arrival a meeting is held after the morning report to discuss the weight losses in the facility, including the interventions. RN #5 stated they (RN #5) were not aware if the resident's Primary Physician was notified of the significant weight loss in July 2022 because the previous RDs were the ones responsible for making the Physician's aware of significant weight losses. The resident's Primary Care (Attending) Physician was contacted for an interview on 9/9/2022 at 3:30 PM and declined to speak to the Surveyor. The facility's Medical Director was interviewed on 9/09/2022 at 4:00 PM and stated that the Physicians in the facility have a protocol they follow when a resident has weight loss. The Medical Director stated that when a Physician sees a resident, they should look at their weight and if a weight loss is seen, the Physician should write a note documenting if the weight loss is desirable or undesirable. The Medical Director stated that sometimes a resident is receiving [MEDICATION(S)] (a diuretic medication) for [CONDITION(S)] then the weight loss is medically related and desirable. The Medical Director stated that the Physician should know if the weight loss is due to a decrease in the resident's intake. The Chief Clinical RD was interviewed on 9/9/2022 at 4:30 PM and stated that their first day of work was 7/5/2022. The RD stated that they (RD) gather the weight record from each unit on a weekly or monthly basis and analyze it. The RD stated that they (RD) report any weight changes that trigger a significant weight loss, after obtaining a reweigh for accuracy, to the Nurses and then the Nurses notify the Physicians. The Director of Nursing Services (DNS) was interviewed on 9/9/2022 at 4:55 PM and stated that Nursing reports to the Physician when a resident has a significant weight loss. The DNS stated significant changes in weight are also discussed in morning report between two departments, Nursing and Dietary. 2) Resident #86 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] documented Resident #86 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severely impaired cognition. The resident was totally dependent on the assistance of one person for eating. The resident's height was 66 inches and they weighed 114 pounds. The MDS documented that the resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a Physician-prescribed weight-loss regimen. The resident's Weight Monitoring Report documented that on 1/24/2022 the resident weighed 133.1 pounds (lbs) and on 5/6/2022 the resident weighed 121.7 lbs indicating 11.4 lbs or an 8.6% significant weight loss over 3 months. The resident's Weight Monitoring Report documented that on 12/1/2021 the resident weighed 137. 3 lbs and on 6/1/2022 the resident weighed 117.3 lbs indicating 20 lbs or a 17.1 significant weight loss over 6 months. The resident's Weight Monitoring Report documented that on 2/1/2022 the resident weighed 129.2 lbs and on 8/5/2022 the resident weighed 117 lbs indicating 12.2 lbs or 10.8% significant weight loss over 6 months. The Dietary Progress Note and Comprehensive Care Plan (CCP) titled Nutrition/Hydration Monitoring/Evaluation Note dated 5/6/2022 documented that the resident's current weight (CW) was 121.7 lbs which reflected 11.4 lbs or 8.6% significant weight loss over the past 3 months. The CCP titled Nutrition/Hydration Monitoring/Evaluation Note dated 6/14/2022 and the Significant Weight Change Dietary Progress Note dated 6/24/2022 documented that the resident's current body weight (CBW) triggered 17.1% significant weight loss over 6 months. The Significant Weight Change Dietary Progress Note dated 8/5/2022 and the CCP titled Nutrition/Hydration Monitoring/Evaluation Note dated 8/5/2022 documented that the resident's CBW triggered 10.8% significant weight loss over 6 months. A review of the Monthly Physician's Visit progress notes, dated 5/24/2022, 6/18/2022, and 8/13/2022 revealed no documented evidence that the resident's Primary Care Physician was aware of the resident's significant weight loss. The resident's current diet orders dated 8/13/2022 documented Diet Type: Regular, Diet Consistency: Puree, and Fluid Consistency: Thin/regular Liquids. The resident's nutritional supplement of Ensure Plus 237 milliliters by mouth twice daily was ordered on 8/26/2022. The Registered Nurse (RN) Unit Manager (RN #8) was interviewed on 9/9/2022 at 2:45 PM and stated that the Dietitian gets the weights from them (RN #8) from the weight book and then enters the weights into the computer. RN # 8 stated that the Dietitian who no longer worked at the facility would inform them (RN #8) and the resident's Physician when a resident had a significant weight loss, what the plan was, and that the resident needed to be put on weekly weights. RN #8 stated that they (RN #8) were not aware if the previously employed RD had informed the Physician of the resident's significant weight loss. RN #8 stated that they (RN #8) did not recall discussing with the resident's Physician about the resident losing weight. RN #8 stated that the Dietitian is the one who works closely with the Physician about the resident's diets and weights. The resident's Primary Care (Attending) Physician was contacted for an interview on 9/9/2022 at 3:30 PM and declined to speak to the Surveyor. The facility's Medical Director was interviewed on 9/09/2022 at 4:00 PM and stated that the Physicians in the facility have a protocol they follow when a resident has weight loss. The Medical Director stated that when a Physician sees a resident, they should look at their weight and if a weight loss is seen, the Physician should write a note documenting if the weight loss is desirable or undesirable. The Medical Director stated that sometimes a resident is receiving [MEDICATION(S)] (a diuretic medication) for [CONDITION(S)] then the weight loss is medically related and desirable. The Medical Director stated that the Physician should know if the weight loss is due to a decrease in the resident's intake. The Chief Clinical RD was interviewed on 9/9/2022 at 4:30 PM and stated that their first day of work was 7/5/2022. The RD stated that they (RD) gather the weight record from each unit on a weekly or monthly basis and analyze it. The RD stated that they (RD) report any weight changes that trigger a significant weight loss, after obtaining a reweigh for accuracy, to the Nurses and then the Nurses notify the Physicians. The Director of Nursing Services (DNS) was interviewed on 9/9/2022 at 4:55 PM and stated that Nursing reports to the Physician when a resident has a significant weight loss. The DNS stated significant changes in weight are also discussed in the morning report between two departments, Nursing and Dietary. 415.15(b)(1)(i)(ii)

Based on observation, interview, and record review, during a COVID-19 Focused Infection Control Survey conducted on 10/21/2020, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19 and infections for 2 (Resident #4, Resident #5 who were both on Contact/Droplet precautions) of 6 Residents reviewed. Specifically, Employee #1 was observed wearing personal protective equipment (PPE) when entering Resident #5's room. Employee #1 then exited Resident #5's room without removing the PPE and entered Resident #4's room, wearing the same PPE. The finding is: The facility Infection Control Isolation General Principles policy dated 8/2020 documented that hands must be washed with antimicrobial soap, before and after resident/patient contact. Gowns, masks, and gloves are disposable and should be used only once and discarded in the receptacle provided in each resident's room. Staff will adhere to the following techniques for a resident on isolation: Don (put on) proper attire as indicated on door sign, remove attire (Doff) in the proper manner, and wash hands following the proper technique. Resident #4 was readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) Score of 7, indicating severely impaired cognition. A Contact/Droplet precaution sign dated 10/09/20 was observed outside Resident #4's room. Resident #5 was readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment dated [DATE] documented Resident #5 had a BIMS Score of 13, indicating intact cognition. A Contact/Droplet precaution sign dated 10/12/20 was observed outside Resident #5's room. The Contact/Droplet Precautions sign outside Resident #4 and #5 room read: stop, Contact/Droplet precautions, surgical mask (and N95 optional), goggles/face shield, and gown. Providers and staff must wash hands before entering and when leaving the room. Put on gloves before room entry. Discard gloves before the room exit. Put on a new gown before room entry. Discard gown before room exit. Remove surgical mask, face protection/all in one face shield mask before room exit. Do not wear the same gown and gloves for the care of more than one person. Clean and disinfect reusable equipment. Clean and disinfect reusable equipment before use on another person. Employee #1/Guest Relations was observed on 10/21/20 at 11:05 AM on the new admission/readmission unit. Employee #1 was observed in the hall wearing a blue gown, a surgical mask over an N95 mask, a face shield, and gloves. Employee #1 entered Resident #5's room and gave a cup of water to Resident# 5. Employee #1 then came out of the room with the same blue gown, gloves, surgical mask over an N95 mask and face shield. Employee #1 changed the gloves only and then entered Resident #4's room and handed Resident #4 a cup of water while wearing the same gown, surgical mask and N95 mask, and face shield. Employee #1 was interviewed on 10/21/20 at 11:15 AM and stated that he has been working Monday to Friday 8 AM-4 PM for the past 3 weeks. He stated he was not sure if he was in-serviced on infection control. Employee #1 stated that he is aware that the sign outside the resident's door meant he must wear a gown, gloves, face shield, and double mask. He stated he is supposed to wear an apron on top of the gown then remove the apron and gown before leaving the room. He stated that he changes the gown when going in between units but not between resident rooms. Employee #1 stated he would ask the Infection Control Preventionist if the apron is not available. The Registered Nurse Manager (RNM) #1 was interviewed on 10/21/20 at 11:20 AM. RNM #1 stated when an employee goes into the resident's room, they are expected to wear a blue gown, face mask, face shield, and gloves. They must remove the gown and gloves and wash their hands before leaving the room. RNM #1 stated she spoke to Employee #1 and he stated he was not sure what to do. The Infection Control Preventionist (ICP) was interviewed concurrently with the Director of Nursing Services (DNS) on 10/21/20 at 4:35 PM. The admission/readmission unit requires droplet precautions and the staff is required to Don and Doff PPE in between rooms. Employees are expected to put on a gown and before they leave, they must remove the gown regardless of the care provided. Employees should Don and Doff the PPE as per the signage. Employee #1 should have removed the gown and gloves, washed his hands, and put on another gown and gloves before entering another room. The ICP stated that she does the mandatory in-services for COVID-19 at Orientation. The Staff Attendance Record Documented Employee #1 received Infection Prevention education on 9/22/20. Personal Protective Equipment (PPE) competency dated 9/22/20 documented that Employee #1 demonstrated competency in donning and doffing gowns, masks, goggles, gloves. The Administrator was interviewed concurrently with DON on 10/21/20 at 5:40 PM. The Administrator stated that the facility does not want to cause potential cross-contamination between new admission/readmission residents coming in and those who were already on the unit, so they did not want to extend the use of PPE. New admission/readmission resident rooms are not grouped to a specific section within the unit so staff going from room to room should Don and Doff PPE in between each room. The employees should be reading the signage and should follow the procedure for donning and doffing of PPE as per the signage. 415.19(a) (1-2)

Based on observations, record reviews, and staff interviews during an abbreviated survey (complaint #NY 262) on 10/21/2020, the facility did not maintain an effective pest control program. Specifically, that indicate an ongoing mouse infestation within the facility. There were no observations noted of a mice infestation, but glue traps were observed throughout the facility at the time of the investigation. The findings are: A review of the facility's extermination logbook from the Okalino Unit revealed mouse sightings were recorded by staff on 2/23/20 to the most recent recorded sightings was on 10/13/2020. A review of the facility's extermination logbook from the Imua Unit revealed mouse sightings were recorded by staff in resident room 106 on 10/16/20. A review of the facility's extermination logbook from the [NAME] Unit revealed recorded mice feces in room 235 on 09/30/20, and the most recent recorded mouse sightings on 10/10/2020. A review of the facility's extermination logbook from the Akahi Unit revealed recorded mouse sightings on 10/24/19 to the most recent recorded mouse sightings as of 10/17/2020. A review of the kitchen extermination logbook revealed documented evidence of mouse droppings in the kitchen storeroom (documented dates not legible). A review of the extermination service report that is kept at the front desk documented mouse in the infestation found column dated 03/4/20 to the most recent date of 10/16/20. The facility's policies and procedures for pest control with an effective date of 10/2018 was reviewed and documented that The facility is to have an ongoing pest control program to prevent, control pest activity, and infestation. The procedure indicated that the facility is to contract a pest control company to 'spray all areas of the facility and that services with be prformed once a week and as needed. If there is a concern with pests that mainteience would be contacted and follow through with the exterminating company. Doors, screens, windows and all possible entryways shall be kept in good repair. During the observations glue traps were noted in the kitchen, in resident room 129 of the Olakino Unit, and in resident room 231 of the [NAME] Unit. Additional observations indicated the presence of bait stations placed around the perimeter of the building. During the interview with the Director of Maintenance at 9:50am he stated that there was an ongoing problem with mice in the facility for the past month and a half that he can recall. The pest control company has increased the frequencies of treatment from once a week to two times per week and as needed. Glue traps were placed within the affected resident rooms and additional bait stations have been placed at the perimeter of the building. The maintenance department had checked all perimeter doors for proper sealing and also checked for entry holes and window screens and sealed or repaired as necessary to prevent rodent entry (completed about a month and a half ago). There were some holes found within the kitchen storeroom that were filled with pest blocking foam. During an interview with the Food Service Director at 10:07am he stated that there was evidence of mouse sightings and droppings within the food storage room about a month ago. The issue was reported to the maintenance department, and the maintenance department checked and sealed some holes within the ceiling and the wall of the food storage room. The pest control company has since rendered pest control services in the kitchen 2-4 times per week and that there was no evidence of mice in the kitchen for the past week and a half. During an interview at 11:10am with the wound care nurse that works on all units in the facility, she stated that a mouse was seen downstairs a couple of weeks ago. It was then reported to maintenance, and the exterminators came in. There have not been any mouse sightings since. The facility's infection control preventionist was interviewed at 1:30pm and stated that there was an issue with mice in the laundry. During an interview with the Administrator at 4:45pm he stated that a quality assurance review was completed for an alleged mice infestation and that the pest control company has been rendering treatments twice a week and as needed. Additional glue traps and bait stations were added as enhanced treatment methods to address the mice concerns. Another pest control company was consulted and didn't recommend any new treatment methods. Some residents were storing food in their rooms and were subsequently given Tupperware to properly store their food. 415.29(j)(5)

Based on observation, record review and interviews during the Recertification Survey, the interdisciplinary team did not revise the Comprehensive Care Plans (CCP) for each resident to reflect resident specific interventions to address the resident's specific needs. This was evident for one (Resident #79) of six residents reviewed for Unnecessary Medications and one (Resident #96) of one resident reviewed for Advanced Directives. Specifically, 1) Resident #79 had multiple increases in the Antipsychotic and Antidepressant medications used to treat the [DIAGNOSES REDACTED]. 2) Resident #96 had a Do Not Resuscitate (DNR) physician's orders [REDACTED]. There was no updated documentation in the resident's CCP for Advance Directives that the DNR had been rescinded and changed to full cardiopulmonary resuscitation. The findings are: 1) The facility Policy and Procedure titled Comprehensive Care Plans (CCP) and Resident/Patient Meeting effective date ,[DATE] documented information obtained from the Comprehensive Assessment and staff interviews enable the facility staff to plan care that focuses on the resident's ability to achieve his/her highest practicable mode of functioning that includes but, is not limited to the following: (h) Mental and Psychosocial needs, (k) Activities potential and preferences (m) Cognitive status (n) Drug Therapy.CCP's will be revised or new care plans will be developed quarterly, annually and as needed, within seven days of completion of MDS. Resident #79 is [AGE] years old with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 15, indicating the resident was cognitively intact. The MDS documented the resident's Mood Score was 1, indicating the resident was feeling down, depressed or hopeless one day over the 14 assessment period. The resident's activity preferences, which were somewhat important to the resident, included reading, music, doing things outdoors and doing favorite activities. The MDS documented the resident was administered Antipsychotic and Antidepressant medications for seven of the seven days of the assessment period and that the Physician documented a Gradual Dose Reduction (GDR) as clinically contraindicated. The resident had increases of the antidepressant medication Trazadone on [DATE] and [DATE] and of the antipsychotic medication [MEDICATION NAME] on [DATE]. The CCPs for [MEDICAL CONDITION] Drugs initiated [DATE] and last updated [DATE]; Mood State initiated [DATE] and last updated [DATE]; and Behavior Symptoms effective [DATE] and last updated [DATE]; and the Recreation CCP dated [DATE] and last updated [DATE], did not include resident specific, non-pharmacological interventions or were not reviewed for potential revisions to the plan of care. The resident was observed and interviewed on [DATE] at 11:35 AM. The resident was alert and in bed. There were no books, magazines, or pictures in the resident's room. The resident stated that she likes painting, used to go to art galleries, and would like to paint. The Activity Director was interviewed on [DATE] at 3:05 PM. The Director stated that the interdisciplinary team meets for the care plan meeting and reviews the resident's entire plan of care. The Director stated that the resident often refuses interventions and stated that even though the resident may refuse interventions, it should be reviewed and documented on the CCP. The Registered Nurse (RN)/Unit Coordinator was interviewed on [DATE] at 10:45 AM. The RN stated that the care plan meeting includes the entire interdisciplinary team and that discussion is always initiated before medication is increased. The RN stated that the team was unaware of some of the resident's preferences and that any member of the team can document on the CCP. 2) The facility policy titled Advance Directives dated [DATE] documented that all Advanced Directives will have a corresponding care plan. Resident #96 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for mental Status (BIMS) score of 5, indicating severe cognitive impairment. The Comprehensive Care Plan (CCP) titled Advance Directives, effective [DATE] and last updated [DATE], documented the resident was being assessed for a quarterly review, the advanced directives were reviewed and the resident has a DNR order in place. Goals remain appropriate and to continue the CCP times (x) 90 days. The Social Service Department Re-Admission assessment dated [DATE] documented the resident's Do Not Resuscitate Order was rescinded by the resident's family member on [DATE]. The physician's orders [REDACTED]. The Registered Nurse (RN)/Unit Coordinator was interviewed on [DATE] at 10:41 AM and confirmed the resident had an order for [REDACTED].>The Social Work Director was interviewed on [DATE] at 2:00 PM and stated the CCP for Advance Directives was incorrect and should have been updated with the change in the resident's order for CPR. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that each resident was offered sufficient fluid intake to maintain proper hydration. This was identified for one (Resident #296) of one resident reviewed for Hydration. Specifically, Resident #296 was admitted to the facility with a [DIAGNOSES REDACTED]. However, there was no plan in place to ensure that the resident remained properly hydrated with the aspiration precautions in place. The finding is: The facility's undated policy and procedure titled Hydration documented that the Registered Dietician (RD) will make nutritional recommendations including fluid needs based on individual assessment and will ensure that fluids provided via the diet meet established needs. The facility's policy and procedure titled Aspiration Precautions dated 4/8/19 documented that the Speech Language Pathologist (SLP) will evaluate those residents with history, diagnosis, or signs of Dysphagia on admission. Upon completion of evaluation determine if resident is at risk for aspiration and initiate an order for [REDACTED]. Resident #296 has was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/11/19 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented the resident required total dependence of one staff member for eating and drinking. A physician's orders [REDACTED]. Administer water only via teaspoon before meals and 60 minutes after meals. No other fluids allowed. A physician's orders [REDACTED]. Do not give with fluid, only with apple sauce. A Nutritional assessment dated [DATE] documented that the estimated daily requirement for fluids was 1450-1740 cubic centimeters (cc), which equals 6-7 cups. Documentation in the nutritional assessment included that the resident had a Modified [MEDICATION NAME] Swallow Study (MBSS) prior to admission and the recommendation was for nothing by mouth (NPO). The facility received informed consent from the resident's health care proxy (HCP) for a puree diet and thin water only via teaspoon. A Comprehensive Care Plan (CCP) titled Nutrition/Hydration effective 12/11/19 documented that the resident had a fluid intake restriction of 1500 milliliter (ml) per day. The CCP had interventions for puree solid consistency foods at meals, thin water only via teaspoon prior to meal times and 60 minutes after meals, all meals must be consumed out of bed in an upright position and under nursing supervision. Additional interventions in the CCP included to provide fluids with meals, medications, snacks, assess need for increased fluids and encourage and assist as needed. A CCP titled Dysphagia effective 12/11/19 documented that the resident presents with severe dysphagia/aspiration risk with interventions of no straw, medications to be crushed, and upright 30 minutes post PO (intake by mouth). A late-entry dated 12/10/19 was added by the Speech Therapist (ST) to the Dysphagia care plan on 12/16/19. The update documented that an ethics meeting was held with the resident and his health care proxy (HCP) upon admission on 12/10/19. The risks of by mouth (PO) intake were explained. The HCP signed an informed consent form that the resident would receive meals and fluids by mouth. The recommendation by the ST was puree solid consistency at meals. Thin water only via teaspoon prior to meal times and 60 minutes after meals. All meals must be consumed out of bed in an upright position and under nursing supervision. The ST documented that nursing staff was inserviced on safe feeding techniques and PO recommendations and inservice communication form was signed and placed in patient's chart. A nursing note dated 12/14/19 at 7:58 PM documented the resident has to be watched carefully, that he will pick up a drink from anywhere and drink it. Resident #296 was interviewed on 12/16/19 at 11:26 AM. The resident was lying in bed and stated that he is thirsty all the time. Resident #296 was observed in the hallway by the nursing station on 12/16/19 at 12:10 PM. The resident had an empty plastic cup in his hand. There was no teaspoon in the cup. The Registered Nurse (RN) unit manager was interviewed on 12/16/19 at 12:12 PM. She stated that the resident had a small cup of ice chips. She stated that the resident is allowed to have ice chips. Resident #296 was observed in the hallway by the nursing station on 12/16/19 at 12:29 PM. He had a cup of ice chips and was observed drinking from the cup and frequently clearing his throat. The resident was observed taking sips repeatedly from the cup and not using a teaspoon. A physician's orders [REDACTED]. On 12/17/19 at 7:50 AM Resident #296 was observed in the hallway being administered ice chips by the ST with a teaspoon. The ST was interviewed on 12/17/19 at 8:34 AM. The ST stated there was no limit to the amount of liquid the resident can have. She stated the order is specific regarding before meals and 60 minutes after a meal so the water does not mix with food. She stated a Certified Nursing Assistant (CNA) or the nurse can administer the water. She stated someone needs to be present with him while he is eating or drinking. The ST provided the inservice sign-in sheets titled, Safe Feeding Techniques for Resident #296 dated 12/10/19 and 12/11/19. There were a total number of four staff members inserviced (two nurses and two CNAs). The resident's regularly assigned CNA was interviewed on 12/17/19 at 10:35 AM. She stated the resident is on aspiration precautions and the resident is only allowed to have one teaspoon of water at a time. She stated he can feed himself but with supervision. She stated she has not been with him while he is eating or drinking because she does not feel comfortable. She stated that the resident asks for ice chips but she just refers him to the nurse. She stated she was not sure if there was a schedule for the resident to get water and stated she did not receive training for safe feeding techniques for the resident because she was off when the training was provided. Review of the CNA Accountability Record (CNAAR) revealed documentation for intermittent supervision/assist for eating. There was no documentation regarding the specialized feeding and drinking precautions that were ordered for the resident. The resident was re-interviewed on 12/17/19 at 1:23 PM. He stated he was thirsty and did not understand the order of teaspoons of water before meals and 60 minutes later. He stated he had asked for ice prior to yesterday (12/16/19) but it was very difficult to get. The Licensed Practical Nurse (LPN) who wrote the 12/14/19 nursing note was interviewed on 12/18/19 at 12:28 PM. He stated that the resident has an urge to put something in his mouth and that he would pick up empty cups. The LPN stated that he gave the resident thickened water in a cup because the resident was asking for water and the resident drank it himself. He stated the resident drank from the cup and a spoon was not provided. The Registered Dietician (RD) was interviewed on 12/18/19 at 12:52 PM. She stated that the resident can get as much water as he wants and was not on a fluid restriction. She stated the Nutrition/Hydration CCP was incorrect in documenting a restriction of 1500 ml and to provide fluids with meals. She stated the resident can get thin water only, not thickened. She stated the resident cannot drink from a cup and he must receive his fluids via teaspoon. She stated whenever the resident asks for ice he gets it and stated laboratory results are monitored closely because the resident is very high risk for dehydration. She stated the resident is able to tell us when he is thirsty. Review of laboratory reports dated 12/11/19 revealed that the blood urea nitrogen (BUN) level was 21 (above the reference range of 8-20), creatinine was 1.16 (within the reference range of 0.64-1.27), and sodium was 141 (within the range of 136-144). Review of laboratory reports dated 12/18/19, received at 10:55 AM, revealed that the BUN was 57, creatinine was 2.31, and sodium was 147. A nursing note dated 12/18/19 at 12:54 PM documented that the Physician was called regarding the 12/18/19 laboratory reports. A nursing note dated 12/18/19 at 2:07 PM documented that a telephone order was received to start intravenous (IV) fluids. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Water must be provided only before meals and 60 minutes after meals. No other fluids allowed. The RN Inservice Coordinator was interviewed on 12/19/19 at 9:32 AM and provided additional undated inservice sheets. She stated when she found out that the Speech Therapist did not complete the safe feeding inservice for Resident #296, she began inservicing everyone else on the unit. The Administrator, Director of Nursing Services (DNS), and the RD were interviewed concurrently on 12/20/19 at 9:20 AM. They stated that a copy of the instructions regarding safe feeding techniques for Resident #296 was placed in the CNAAR binder after the Speech Therapist did the inservice. They stated the staff could have followed those instructions. A copy of the instructions was provided by the Administrator, which was the inservice that was provided by the Speech Therapist and was signed by four staff members. The DNS also stated that ice chips were the same as water and felt that the original order, which stated thin water via teaspoon only, was clear and there was no need to specify that ice chips were allowable. 415.12(i)(1)

Based on record review and staff interview during the recertification survey, the facility did not develop and implement a Behavior/ Mood Comprehensive Care Plan (CCP) which included goals and interventions specific to the resident's needs and behaviors. This was evident for one resident who was being administered [MEDICAL CONDITION] Drugs for documented behavior problems. Specifically Resident # 8, being administered [MEDICAL CONDITION] Medications for [DIAGNOSES REDACTED]. The findings is: Resident # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severely impaired cognition. The Physician's admission orders [REDACTED]. The Physician's Admission History and Physical dated 3/7/18 documented the resident's [DIAGNOSES REDACTED]. The facility's Baseline Care Plan (BCP) dated 3/6/18 through 3/8/18 did not include initiation of a Behavior Care Plan. There were no behaviorial symptoms identified on the BCP and no immediate interventions. The BCP for [MEDICAL CONDITION] Drug Use documented that the resident will show improvement in Mood/Behavior. There was no further documentation addressing the resident's potential Mood or Behavior problems. The CCP titled [MEDICAL CONDITION] Drugs dated 3/7/18 documented that the resident's mood and behavior was to be monitored and to assess the ongoing need for Psychoactive medications. There were no mood and behavior symptoms documented and no specific behavioral interventions documented. There was no further documentation on the BCP including specifics of the behaviors or resident's mood including interventions or goals until 8/23/18. The Director of Nursing Services (DNS)/Registered Nurse (RN) was interviewed on 9/14/18 at 11:00 AM. The DNS stated that the BCP did not document behavior symptoms or a behavior plan because there were no behaviors at the time of admission. The DNS stated that the CCP for Behavior was initiated on 8/23/18 because that was when the resident was exhibiting behaviors that warranted interventions. 415.11

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that a comprehensive person centered care plan (CCP) was developed in a timely manner to meet the resident's current need. This was evident for one (Resident #107) of two residents reviewed for mood and behavior. Specifically, Resident #107 had a physician's orders [REDACTED]. The finding is: Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 10 which indicated moderate cognitive impairment. The resident had no mood or behavior problems and required supervision to extensive assist of one staff member for all areas of activities of daily living (ADLs). The resident received Antipsychotic, Antianxiety ,and Antidepressant medication for seven of seven days prior to this assessment. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The original order date for [MEDICATION NAME] was 3/29/18. A CCP for Behavior dated 8/14/18 documented the resident had the potential for exhibiting inappropriate behavior problems related to wandering, and the resident was attempting to remove a wander guard. The goals were for behavior not to interfere with care, not put others at risk for physical injury, and will not be at significant risk for physical injury. The intervention was to encourage family involvement in care. A CCP dated 9/12/18 for the use of [MEDICAL CONDITION] medication documented the resident was at risk for complication/negative outcome related to use of Antipsychotic, Antianxiety, Antidepressant medication. The goals were that the resident will not have side effects from the medications. The interventions included to assess for ongoing need for psychoactive medication, to attempt non-pharmacological interventions and to obtain psychiatry consult as ordered. A Review of the resident's electronic medical record revealed there was no CCP developed for the use of the Antipsychotic, Antianxiety ,and the Antidepressant medications prior to 9/12/18. During an interview conducted on 9/14/18 at 12:10 PM with the Registered Nurse (RN) Manager, she stated that the RN Managers were responsible for initiating the CCPs and that a CCP should have been developed for the use of the [MEDICAL CONDITION] medications at the time the medications were ordered. The RN further stated the CCP should be updated with any changes in the dosage of the medication. Additionally, a review of the resident's medical record was conducted by the RN and revealed there were no CCPs developed prior to 9/12/18 for the use of the [MEDICAL CONDITION] medications. The RN stated that it was an oversight. During an interview with the Director of Nursing Services (DNS) on 9/14/18 at 3:44 PM she stated the RN Managers were responsible for initiating and updating the care plans. The DNS stated the expectation was that a CCP for [MEDICAL CONDITION] Medication use is initiated at the time of the physician's orders [REDACTED]. 415.11(c)(1)

Based on record review and staff interviews during the recertification survey the facility did not ensure that comprehensive care plans were reviewed and revised after each assessment for 1 (Resident #108) of 5 residents reviewed for unnecessary medications. Specifically, Resident #108's comprehensive care plans were not updated to reflect behaviors related to refusing to have a suprapubic catheter changed and newly prescribed medications to treat the behaviors. The finding is: Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/5/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The MDS documented the resident had an indwelling catheter and had received antipsychotic medications on a routine basis. A Comprehensive Care Plan (CCP) titled Behavioral Symptoms-Noncompliance, effective 9/26/2016 and last updated 9/11/2018, addressed the resident's refusal of medications and use of a hand-roll. The CCP did not address the resident's refusal to have the suprapubic catheter changed. A CCP titled [MEDICAL CONDITION] Drug Use, effective 6/28/2016 and last updated 9/12/2018, has an intervention for non-pharmacological interventions. The CCP documented the dosage for [MEDICATION NAME], an antipsychotic medication, was increased on 1/22/2018, but it does not say what the dosage was. Also, the CCP does not document when the medication was started or what non-pharmacological interventions were used before starting and increasing the dosage. A CCP titled Urinary Incontinence and Indwelling Catheter, effective 6/28/2016 and last updated 9/12/2018, documented that the resident refused to have the catheter changed on 1/11/2018, but did not document that the resident also refused to have the catheter changed on 1/18/2018. A nursing note dated 1/11/2018 documented that the resident had refused to have the suprapubic catheter changed at the urologist's office on 1/11/2018, and the family would be meeting with the resident. This was noted in the Urinary Incontinence and Indwelling Catheter CCP. A Nursing note dated 1/17/2018 documented that the psychiatrist was notified about the resident saying the doctor is trying to kill him and the resident's refusal to have the suprapubic catheter changed. A telephone order was received from the psychiatrist for a new medication, [MEDICATION NAME], 2.5 milligrams (mg) once a day at bedtime. This new medication was not documented in the [MEDICAL CONDITION] CCP. In addition, there were no non-pharmacological interventions documented in the nursing notes or the [MEDICAL CONDITION] CCP prior to starting [MEDICATION NAME]. The refusal of the suprapubic catheter change was not documented in the behavior care plan. A Medical Director note dated 1/19/2018 documented that the resident refused to have his suprapubic catheter changed on 1/11/2018 and 1/18/2018 due to delusional behaviors. In addition, the note documented that the dosage of [MEDICATION NAME] may need to be increased and that it was ok to change the suprapubic catheter next month (February). The 1/18/2018 refusal was not documented in the Urinary Incontinence and Indwelling Catheter CCP. A nursing note dated 1/21/2018 documented the resident was seen by the psychiatrist and the dosage of [MEDICATION NAME] was increased to 5 mg. Non-pharmacological interventions were not documented prior to the increase in dosage in the [MEDICAL CONDITION] CCP or in nursing notes. The Director of Nursing Services (DNS) was interviewed on 9/14/2018 at 3:45 PM. She stated the Registered Nurse (RN) unit manager is responsible for updating care plans and that the care plans should have been updated. 415.11(c)(2)(i-iii)

Based on record review and staff interview during the recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. This was evident for three (Resident #68, #8 and #95) of eight residents reviewed for Unnecessary Medications. Specifically, 1) Resident #68's [MEDICATION NAME] (an antidepressant medication) was tripled over an eleven day period without any documented clinical symptoms of Depression; 2) Resident #8, with a primary [DIAGNOSES REDACTED].#95 was receiving an antipsychotic medication in conjunction with antidepressant medication since admission and in the absence of clinical symptoms without an attempt at a Gradual Dose Reduction (GDR). The findings are: The facility's undated Policies, Procedures and Information #NS-104 Psychoactive Medications # 1-When a physician writes an order for [REDACTED].# 6- A STAT order is permissible in the event that the resident/patient is a threat to themselves or others. 1) Resident #68 has diagnoses which include Diabetes Mellitus and [MEDICAL CONDITION]. The resident was admitted to the facility on [DATE]. The 60-day Minimum Data Set ((MDS) dated [DATE] documented the resident was understood and could usually understand. The resident had a Brief Interview for Mental Status score of 9 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The Physician order [REDACTED]. The Nursing Progress Note dated 7/4/18 documented that the resident was very confused with periods of agitation, accusing nursing staff of stealing his dentures and using inappropriate language towards the nursing staff. A Psychiatry Consultation was requested. The Psychiatry Report of Consultation dated 7/20/18 revealed that the reason for the consult was that the resident had episodes of confusion and forgetfulness. The [DIAGNOSES REDACTED]. Part of the Assessment/Plan documented to increase the resident's [MEDICATION NAME] to 100 mg every AM (morning). The Consultation also documented that the resident had been having episodes of agitation and was physically aggressive to staff. The Physician order [REDACTED]. The Psychiatry Report of Consultation dated 7/27/18 revealed that the reason for the consult was increased agitation with periods of confusion. The [DIAGNOSES REDACTED]. Part of the Assessment/Plan documented to continue the resident's [MEDICATION NAME] to 100 mg every AM and start [MEDICATION NAME] 50 mg every 6 PM. The Physician order [REDACTED]. Review of Nursing Progress Notes from the resident's admission on 6/13/18 to the present on 9/13/18 revealed no documentation of the resident being agitated or aggressive other than for the incident noted on 7/4/18. The resident's 7:00 AM - 3:00 PM Certified Nursing Assistant (CNA #1) who fills in when the resident's regular scheduled CNA is off, was interviewed on 9/14/18 at 1:00 PM and stated that the resident was nice and did whatever she asked him to do. CNA #1 also stated that the resident had never cursed at her or been aggressive with her and she has taken care of him once or twice a week since his admission. The resident's Primary Care Physician (PCP) was interviewed on 9/14/18 at 1:35 PM and stated that he could only answer about the resident's medical condition and he defers all psychiatric issues to the Psychiatrist as that is his expertise. The PCP also stated that it was very rare that he would override a Psychiatrist's recommendation and that he, as a PCP, defers all adjustments in [MEDICAL CONDITION] medications to the Psychiatric specialist. The resident's Registered Nurse (RN #3) Unit Manager was interviewed on 9/14/18 at 2:25 PM and stated that the resident would call out from his room at times, but was never verbally abusive. RN #3 stated that the resident always took his medication, was cooperative, friendly, pleasant, and able to make his needs known. RN #3 also stated that the resident was sometimes forgetful such as when he speaks to his wife on the phone and then wants to call her again because he forgot he spoke to her. The facility's Medical Director was interviewed on 9/14/18 at 3:15 PM and stated that he could not make any judgment on the increase in the resident's [MEDICATION NAME] medication and that the PCP was responsible for everything related to the resident, not just the medical portion. The 3:00 PM - 11:00 PM Licensed Practical Nurse (LPN #1) who wrote the Nursing Progress Note on 7/4/18 was interviewed on 9/14/18 at 3:25 PM. The LPN stated that it was close to dinnertime that night and the resident was in the dining room when the resident accused him of stealing his dentures. LPN #1 stated that the resident started to yell in the dining room and he moved the resident out of the dining room because he was causing chaos. The LPN stated that the resident's wife just happened to call at that time and spoke to the resident which calmed him down. LPN #1 stated that the resident will yell sometimes because he wants attention, calling nurses at random. LPN #1 further stated that he has learned to deal with the resident's attention seeking behavior by visiting him in his room when he has the time. The Director of Nursing Services (DNS) was interviewed on 9/14/18 at 4:00 PM and stated that the PCP was responsible for the resident's total plan of care. The facility's Psychiatrist was unavailable for interview. 2) Resident #8 was admitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The Physician's (MD) admission orders [REDACTED]. The MD order dated 3/7/18 documented [MEDICATION NAME] 12.5 mg twice daily by oral route for indication of Anxiety Disorder and [MEDICATION NAME] (an antidepressive medication) 7.5 mg by oral route daily at bedtime for indication of Anxiety disorder. The CCP for [MEDICAL CONDITION] Medications dated 3/7/18 documented that the resident was being administered Antipsychotic and Antidepressive medications, however there were no diagnoses documented. There were no documented behavior problems or depressive symptoms documented on the updates to the CCP 4/10/18 through 9/4/18. The Psychiatric Consultation dated 4/10/18 documented that the resident was lethargic but arousable with no agitation and had a [DIAGNOSES REDACTED]. A Nursing Progress Note (P/N) dated 8/6/18 at (no time indicated) documented that the resident was agitated with aggression and confusion. There was no description of the agitated and aggressive behaviors exhibited. The Nursing P/N dated 8/6/18 3:00 PM-11:00 PM shift stated that the resident was medicated, as ordered, and would be monitored. The progress note had no behavioral interventions and no monitoring documented in the medical record. The Psychiatric follow up dated 8/17/18 documented the resident has been agitated and accusatory of staff. The [MEDICATION NAME] was increased from 12.5 twice daily to 25 mg twice daily and 50 mg at hour of sleep. A Nursing P/N dated 8/17/18 documented that the resident was examined by the Psychiatrist and the [MEDICATION NAME] was increased from 12.5 mg twice daily to 25 mg twice daily without any further documentation of behaviors. Review of the Nursing Progress Notes (P/N) 7/29/18 through 8/17/18 and the CCP for [MEDICAL CONDITION] Medications, updated 8/20/18, documented that the medication was increased without any further documentation. A Nursing P/N dated 8/23/18 documented that at 3:30 AM the resident seemed to be confused. The P/N documented the resident had also refused all medications. A Nursing P/N dated 8/23/18 at 7:00 AM documented the resident was agitated, aggressive and accusing staff of dealing with husband. The P/N documented that the resident calmed down with emotional support. At 8:00 AM the P/N documented the resident continued accusing staff and was very agitated. The resident was offered breakfast and consumed about 20 %. The P/N further described that the resident was agitated and propelling the wheelchair up and down the hallway, emotional support given with results not documented. The 8/23/18 Nursing P/N documented that at 8:15 AM the resident continued to yell and was accusatory to staff. The Attending Physician was called and a telephone order for [MEDICATION NAME] (an antipsychotic) 2 mg Intra muscular (IM) stat (immediate) for restlessness and agitation was obtained. There was no specific diagnoses. The Nursing P/N dated 8/23/18 documented that the resident refused all her medications, the Psychiatrist/MD was called at 9:45 AM and gave a telephone order for an immediate dose of [MEDICATION NAME] 25 mg without a specific diagnosed and documented condition. The Psychiatrist also increased the daily MD order of [MEDICATION NAME] from 25 mg twice daily to 50 mg twice daily and added [MEDICATION NAME] 75 mg at hour of sleep. There was no documented follow up visit or assessment by the Psychiatrist following the telephone order. The 8/23/18 CCP developed for Behavior Symptoms documented the resident was accusatory and aggressive, and there was no psychiatric [DIAGNOSES REDACTED]. The 8/23/18 CCP for Behavioral Symptoms for non-compliance did not document specific behaviors of non-compliance, interventions or [DIAGNOSES REDACTED]. The Registered Nurse (RN)/Manager was interviewed on 9/12/18 at 11:00 AM. The RN stated the resident was very agitated and was accusatory to staff regarding the husband. The RN stated that the resident was not a danger to herself or others, but she was very agitated and resistive to care. The resident's Attending Physician/Medical Director (MD) was interviewed on 9/14/18 at 11:30 AM. The MD stated that the stat dose of [MEDICATION NAME] IM for this resident was appropriate as the resident is the most disruptive resident in the building. The MD stated that the resident's second, immediate dose of [MEDICATION NAME] ordered by the Psychiatrist was appropriate and that the increase in [MEDICAL CONDITION] Medications for resident's refusal on all types of medications was acceptable to him. The MD stated that non-pharmacological interventions should be attempted first and that the Interdisciplinary Team should be reviewing and documenting the resident's behavior plan. The resident's regular CNA on the 7 AM-3 PM shift was interviewed on 9/14/18 at 1:45 PM. The CNA stated the resident participates in all care and has never refused care with her. The CNA stated the resident has not been agitated during care with her in the last several months. If agitated, she would inform the nurse and return later. The CNA stated that she has never observed the resident aggressive, has had no problems when the husband was visiting and that she has never observed the resident as a danger to herself or to others. The resident was observed on 9/14/18 between 1:41 PM and 2:45 PM. The resident was observed outdoors, being propelled in her wheelchair and conversing with her husband. The resident appeared calm and was without agitation. The Director of Nursing Services (DNS)/Registered Nurse (RN) was interviewed on 9/14/18 at 11:00 AM. The DNS stated that the Attending Physician should have been notified when the resident was refusing medications. The DNS stated that the resident has had very disruptive behaviors on the unit and the Psychiatrist will assess the resident on the next follow-up visit. The Psychiatrist was not available for interview. 3) Resident #95 was admitted on [DATE] with [DIAGNOSES REDACTED]. There were no behaviors or mood score (no symptoms of depression) during the assessment period. Additionally, the MDS documented that the resident was receiving Antipsychotic Medication on a routine basis without a Gradual Dose reduction (GDR). The MDS dated [DATE] documented that the resident had no mood score or behavior symptoms during the assessment period. The MDS documented that the resident was receiving daily Antidepressive and Antipsychotic medication on a routine basis without a GDR. The [MEDICAL CONDITION] Medications CCP dated 6/16/17 and updated 6/4/18, documented that the resident was continued on [MEDICATION NAME] with no behavioral issues. The Behavioral Symptoms Non-Compliance CCP, dated 6/16/17 and updated 6/4/18, documented that there have been no issues of non-compliance and no behavioral issues documented for the quarter. The Activities CCP, dated 6/16/17 and updated 8/14/18, documented that the resident was socially active and responds well to his favorite programs. The Behavior CCP updated on 8/21/18 documented that the resident was pending a routine Psychiatric Evaluation, all resident's goals met and to continue the plan of care. The Psychiatric Consultation dated 8/22/18 documented that the resident had diagnoses of Dementia with [MEDICAL CONDITION]. The medications included an increase in [MEDICATION NAME] (an antidepressive medication) and added Klonopin (an antianxiety medication). The Psychiatrist documented to continue the [MEDICATION NAME] 100 mg twice daily. The MD orders dated 8/22/18 documented Quetiapine ([MEDICATION NAME] an antipsychotic) 100 mg by oral route twice daily for Major [MEDICAL CONDITION] (initiated 6/15/17), [MEDICATION NAME] 15 mg by oral route daily at bedtime for Major [MEDICAL CONDITION] and Klonopin (an antianxiety medication) 0.5 mg by oral route once daily at bedtime for Major [MEDICAL CONDITION]. Review of the Nursing Progress Note (P/N) from 3/21/18 through 9/11/18 did not contain any documentation that the resident had signs of Depression. There were no behaviors documented. The resident was observed on 9/11/18 at 10:30 PM. The resident was in bed and able to communicate with sounds and gestures. The resident was smiling and laughing during the conversation. There were no behavior issues observed at that time. The RN/Manager was interviewed on 9/12/18 at 2:16 PM. The RN stated that the resident's behavior is controlled and there has been no changes in his behaviors since admission. The RN stated that there has been no recent aggression or resistance to care. A second resident observation was conducted on 09/12/18 at 2:22 PM. The resident was sitting in day room participating in a table top activity, pleasant, smiling and well groomed. The resident's Attending Physician/Medical Director (MD) was interviewed on 9/14/18 at 11:37 AM. The MD stated that the resident has fluctuating behaviors which included a decreased appetite and occasional agitation. The MD stated that a GDR would be considered for the resident. The resident's regular 7:00 AM-3:00 PM CNA was interviewed on 9/14/18 at 12:17 PM. The CNA stated that the resident participates in his activities of daily living without any problem. The CNA stated that there has been no agitation, no aggression and the resident has a a good appetite. The CNA stated that the resident does attend activities, is pleasant and that the family frequently visits and has not been any danger to himself or others. The Psychiatrist was not available for interview. 415.12(l)(2)(ii)

Based on observations, interviews and record review during the recertification survey, the facility did not ensure that garbage was disposed of and contained in an appropriate manner. Specifically, during the initial tour of the facility grounds, there was a build-up of bagged garbage lying directly on the ground surrounding a dumpster container. The finding is: An undated policy for Waste Management documented that a carting company shall be used to provide an approved waste container on the property to receive all non-hazardous waste in accordance with local codes and guidelines. The container pick-up shall be weekly or as needed. The area around the container shall be kept clean and clear. Observation after the kitchen tour on 9/10/18 at 8:30 AM revealed: There was a partially loaded dumpster container situated outside the kitchen door approximately 30 feet from the kitchen exterior side door. The dumpster container door (push) used to move the garbage into the dumpster was not working when tested by the Assistant Director of Maintenance on 9/10/18 at 8:45 AM. There were full large garbage bags directly on the ground surrounding the dumpster container. These garbage bags were piled as high and as wide as the dumpster. In addition, there was some isolated garbage, dirty gloves and food containers on the ground near to the bagged garbage. A review of the current contract dated 8/15/17 with the carting company documented the size of container as a 35 yard compactor container. An interview was conducted with the Assistant Director of Maintenance on 9/10/18 at 9:00 AM. He stated that the dumpster company was made aware on Friday, 9/7/18, and Saturday, 9/8/18, that the door used to push the garbage into the container was not working. The company reported they would have it repaired. An interview was conducted with the Food Service Director (FSD) on 9/11/18 at 2:20 PM who stated that he would rely on the dietary staff, or the porter, to report any problems with the dumpster during the weekend. The FSD further stated that the porter should have reported the problem to a Food Service Supervisor who would alert the Maintenance Department. An interview was conducted with the Director of Maintenance on 9/11/18 at 2:55 PM. He stated that he was made aware of the dumpster problem on Friday, 9/7/18. He further stated the owner of the dumpster company came on site and reported the problem as a reset button which was fixed. The Director further stated this problem has happened once or twice before. The Director also stated that the facility staff did not report the dumpster problem to him during this past weekend and should have. 415.14(h)

Based on record review and staff interviews during an abbreviated survey, the facility did not ensure that a physician and a resident's representative/family member were notified when the resident had a significant change in condition. Specifically one (Resident #1) of three residents reviewed for pressure sores, developed a pressure sore and was admitted to the hospital from the nursing home with an Unstageable decubitus ulcer (pressure sore) on the Coccyx, or an open blister on the Sacral area and an open wound to the posterior right lower leg. Resident #1's medical record lacked documented evidence that the resident's Attending Physician or Representative/family member were notified of a significant change in her condition (skin breakdown) . This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 921 Findings include: The Facility's Policy and Procedure for Family Notification of Resident/Patient Status Change dated 04/01/2002, documented that it is the responsibility of the primary care physician, and in his/her absence, the physician on call, to notify a resident/patient's family. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's medical record lacked documented evidence of the presence of a pressure sore to the Coccyx or Sacral area or development of a Comprehensive Care Plan (CCP) for a Coccyx or Sacral pressure sore. Additionally, there were no Physician treatment orders for Coccyx or Sacral pressure sores. Resident #1's medical record lacked documented evidence that a representative/family member or the Attending Physician were notified that Resident #1 developed a Coccyx or Sacral pressure sore. The Untitled Hospital Document dated 03/26/2015 at 2:24 AM documented an Unstageable decubitus ulcer on the Coccyx area measuring 8.5cm (centimeters) x 5.0cm x 3.0cm with wound bed covered in yellow slough, an open blister measuring 3.0cm x 3.0cm on the Sacral area with some intact blisters, and a 2.5cm x 2.0cm open wound to the posterior right lower leg. The Hospital Discharge Summary dated 04/03/2015 documented that the resident was at subacute rehab and developed a Sacral decubitus with increasing Leukocytosis (white blood cell count) suggestive of infection of the decubitus, and this was confirmed by Infectious Disease and Wound Care consultants. The resident had local bedside debridement x 2, cultures [MEDICAL CONDITION], and resident completed intravenous [MEDICATION NAME] (an antibiotic). The Facility's Investigation Summary dated 05/04/2015 documented that on 03/17/2015 a CNA (Certified Nursing Assistant) noticed a black spot on the resident's sacral area and reported her findings to the nurse. The nurse notified the acting Wound Care Nurse (WCN) who looked at it (the sacral area) and called the (former) ADON (Assistant Director of Nursing) who concurred that it looked like a hematoma/blood blister. The following day wound rounds were made and the acting WCN along with the wound care physician concurred that it was a hematoma/blood blister. Upon review of the resident's medical record, there was no documentation regarding the hematoma/blood blister. During a telephone interview on 09/23/2015 at 11:32 AM with the acting WCN, she stated that she did not notify Resident #1's family of her findings when she initially saw the resident's sacral area. I would assume that is the Unit Manger's position to do that. During a telephone interview on 09/23/2015 at 01:34 PM with the Attending Physician (AP), the AP stated that he was not aware that the resident had developed a sacral pressure ulcer (pressure sore) while at the facility, and that when the resident was admitted to the emergency room the pressure ulcer was discovered and then he became aware. The AP stated that the facility should have notified him when the findings were initially discovered, and had he known he would have ordered a wound care consult, and preliminary treatment and labwork. 415.3(e)(2)(ii)(b)

Based on record review and staff interviews during an abbreviated survey, the facility did not ensure that each resident having pressure sores received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Specifically one (Resident #1) of three residents, reviewed for pressure sores, was admitted to the hospital from the nursing home with an Unstageable decubitus ulcer (pressure sore) on the Coccyx, an open blister on the Sacral area and an open wound to the posterior right lower leg. Resident #1's nursing home medical record lacked documented evidence of Coccyx or Sacral pressure sores, and a comprehensive assessment to include measurements, staging, wound characteristics or treatment. There is no documented evidence that Resident #1's physician or family was notified about the presence of a Coccyx or Sacral pressure sore. The nursing home conducted an investigation after a Department of Health (DOH) onsite visit which concluded that upon completion of the investigation the results are inconclusive as to how the resident obtained a suspected infected sacral wound. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 921 Findings include: The facility's Policy and Procedure for Pressure Ulcer - Prevention and Care dated 04/01/2002, documented all pressure ulcers noted on admission and newly developed must be reported to the Unit Nurse Manager and Wound Care Nurse(WCN), and a Pressure Ulcer Assessment Form is to be initiated at the time the ulcer is noted. The Policy and Procedure lacked documented evidence related to physician notification. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Assessment and Psychosocial History dated 03/04/2015 documented the Resident #1's cognitive status as being intact. The Initial Nursing assessment dated [DATE] documented a Skin Assessment was completed and that the resident was a low risk for developing pressure ulcers. The Assessment lacked documented evidence that the resident had a pressure sore to the Coccyx or Sacral area. The Admission Care Plan for Pressure Sores/Skin Care dated 03/03/2015 documented the interventions put in place including preventative measures: wheelchair cushion and anti-decubitus mattress. The Initial history and physical examination [REDACTED]. The Skin Assessments dated 03/09/2015 and 03/16/2015 documented that Resident #1 was low risk for developing pressure sores. The Nursing Progress Note dated 3/25/2015 at 2:45 PM documented that the resident had abnormal lab results; WBC of 38.1. A telephone order from the physician was received to send the resident to the hospital for further evaluation. Resident #1's medical record lacked documented evidence of the presence of a pressure sore to the Coccyx or Sacral area or development of a Comprehensive Care Plan (CCP) for a Coccyx or Sacral pressure sore. Additionally, there were no Physician treatment orders or a Treatment Administration Record (TAR) for Coccyx or Sacral pressure sores. The Untitled Hospital Document dated 03/26/2015 at 2:24 AM documented an unstageable decubitus ulcer on the Coccyx area measuring 8.5cm (centimeters) x 5.0cm x 3.0cm with wound bed covered in yellow slough, an open blister measuring 3.0cm x 3.0cm on the Sacral area with some intact blisters, and a 2.5cm x 2.0cm open wound to the posterior right lower leg. The Hospital Discharge Summary dated 04/03/2015 documented that the resident was at subacute rehab and developed a Sacral decubitus with increasing Leukocytosis (white blood cell count) suggestive of infection of the decubitus, and this was confirmed by Infectious Disease and Wound Care consultants. The resident had local bedside debridement x 2, cultures [MEDICAL CONDITION], and resident completed intravenous [MEDICATION NAME] (an antibiotic). The Facility's Untitled Document (Investigation), undated, by the former Director of Nursing (DON) documented that the former DON notified the Administrator regarding the complaint and expressed concern that there was no record of an ulcer or incident on file. Upon completion of the investigation the results are inconclusive as to how the resident obtained a suspected infected sacral wound. The Facility's Investigation Summary dated 05/04/2015 documented that on 03/17/2015 a CNA (Certified Nursing Assistant) noticed a black spot on the resident's sacral area and reported her findings to the nurse. The nurse notified the acting Wound Care Nurse (WCN) who looked at it (the sacral area) and called the (former) ADON (Assistant Director of Nursing) who concurred that it looked like a hematoma/blood blister. The following day wound rounds were made and the acting WCN along with the wound care physician concurred that it was a hematoma/blood blister. Upon review of the chart, there was no documentation regarding the hematoma/blood blister. During an interview on 08/07/2015 at 04:18 PM with the former DON, who stated that when he was first made aware of the complaint, he reviewed Resident #1's chart and spoke with the Administrator because there was no documentation of any open area on the resident's sacral area. The former DON stated that he gets weekly reports from the WCN and the resident was not on any of the reports either. The former DON stated that primary staff that cared for the resident were interviewed, and the staff said the resident had a hematoma or blood blister, and that he could not conclude that the resident had a pressure ulcer based upon staff interviews. Even if the resident had a hematoma or blood blister, the staff should have documented and followed it. The former DON stated that someone; a staff member, saw something on the resident's sacrum and may not have been sure what they saw, and should have notified the physician. The former DON stated that a wound care consult and treatment orders should have been obtained from the attending physician, and that there were no orders for any treatment to the sacrum and no documentation of any treatment on the resident's TAR, There was a breakdown of the system; the staff did not do what they were supposed to do. During a telephone interview on 09/16/2015 at 12:12 PM with the former ADON, who stated that when the CNA reported her findings of the resident's sacral area, it was reported to the acting WCN, and the acting WCN asked him to go with her to see the resident. I'm not big on wounds but I looked at the wound and didn't know what it was. The former ADON stated that he recommended applying Dermamed and turning and positioning the resident every 2 hours, and told the acting WCN to call the wound care physician. The former ADON stated that it is up to the WCN as to which physician is to be notified, and he does not know what the policy of the facility was regarding notifying the resident's primary physician. The ADON stated that the acting WCN never reported anything to him after they initially saw the resident together. During a telephone interview on 09/16/2015 at 12:46 PM with the Registered Nurse (RN) acting WCN, who stated that the CNA's findings of Resident #1's sacral area were reported to her by the Licensed Practical Nurse (LPN). The acting WCN stated that she went to see the resident with the assigned CNA and that there was an area on the coccyx area that appeared bloody but the skin wasn't damaged. It looked superficial not like a DTI (Deep Tissue Injury). The acting WCN stated that she went to the former ADON because she was not sure what to do about the procedure for documenting in-house acquired pressure ulcers. The acting WCN stated I was overwhelmed and he said he would take care of it, so I never checked to see what orders were being carried out on the resident. The acting WCN stated that the Unit Manager was made aware by the LPN, and that notifying the resident's physician was the Unit Manager's responsibility. The acting WCN stated that one day (03/18/2015) while making wound rounds with the wound care physician, she asked the physician to look at the area on the resident's coccyx area. The wound care physician said it looked like a hematoma and at that time she felt that it looked the same as when she initially saw it. The WCN stated that the resident was being followed for a pressure ulcer on her heel and on 03/23/2015 while making wound rounds she decided to look at the resident's sacral area and it had deteriorated, looked dusky, had an odor and did not look viable, and reported it to the former ADON because he was treating it. During a telephone interview on 09/16/2015 at 01:12 PM with the RN former Unit Manager (UM), who stated that she does not know how the resident's wound was found or who was following it. The former RNUM stated she was responsible for knowing which of her residents had pressure ulcers, but was not aware that the resident had a pressure ulcer. During a telephone interview on 09/16/2015 at 02:28 PM with the 07:00 AM - 03:00 PM shift CNA, who stated that she was the primary CNA for the resident and that on 03/17/2015 she had the resident in the bathroom and when she went to wipe the resident she saw a black spot on the bottom of the resident's spine, and told the nurse (LPN) right away. The CNA stated that she cared for the resident after that time and that the area didn't look good, she had a hole in the area. During a telephone interview on 09/16/2015 at 02:44 PM with the 07:00 AM - 03:00 PM shift LPN Medication Nurse, the LPN stated that the CNA came to her one day and said the resident had a purple area over her sacral area. The LPN stated when she saw the area it was purple in color and was not open, and that the (acting) WCN and (former) ADON were made aware. During a telephone interview on 09/23/2015 at 01:34 PM with the Attending Physician (AP), who stated that he was not aware that the resident had developed a sacral pressure ulcer while at the facility, and that when the resident was admitted to the emergency room the pressure ulcer was discovered and then he became aware. The AP stated that someone, unable to recall whom, said that initially the resident had a hematoma on the sacral area. The AP stated that there were no reports of the resident falling to justify the resident sustaining a hematoma. The AP stated that the facility should have notified him when the findings were initially discovered, and he would have ordered a wound care consult, and preliminary treatment and labwork. 415.12(c)(1)

Based on observation, staff interview and record review during an abbreviated and partial extended survey the facility failed to maintain a safe environment to protect the health and safety for one (Resident #1) of 5 residents reviewed for environmental safety. Specifically on 7/26/14 the fire alarm activated at 2:01AM on the second floor, the facility staff initially responded to the basement based on their misinterpretation of the fire alarm bell code. The fire was discovered in a room on the second floor at 2:10:27AM (nine minutes later) where Resident # 1 was discovered in his bed on fire. He suffered second and third degree burns to 12% of his body surface area. Additionally the facility failed to effectively train staff on response to the fire alarm. The facility fire plan did not include the use of the coded fire bell system that identified the fire location. In addition, the facility staff did not follow the existing plan to check the fire panels to determine the location of the fire. This resulted in actual harm with the potential for widespread harm that is Immediate Jeopardy and Substandard Quality of Care to resident health and safety. The Immediate Jeopardy was removed on 9/25/14 prior to the completion of the survey. Complaint ID Number: NY 258 The finding is: An undated Facility policy titled Fire Safety documented for a response to a fire area: activate the fire alarm and shout out doctor red and location three times; Assign one member to check the fireboard for the type of alarm noted (i.e. smoke detector, pull alarm). The facility policy lacked documented evidence of guidance to staff regarding fire bell code and procedure to respond to same. Fire Alarm code sheet documented fire codes 3-3-5 for basement exit to garden and 3-2-5 for East hall stairs #3 (rooms 234-242) (the fire alarm code list indicates the fire bell codes, the location of the pull station and the floor where the alarms gets activated). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Care Plan and Progress notes dated 7/11/14 documented that the resident was alert and oriented x3. The Nursing Care Plan and Progress Notes dated 7/26/14 at 2:40 AM documented "the fire alarm sounded, staff called code Red, fire team raced to the room, removed resident and his roommate. The Fire Department arrived within minutes and the resident was removed from the facility and transferred to the hospital by EMS on scene. Unable to assess resident's body secondary to EMS removal. The resident was awake upon transfer." The Fire Marshall's Office Incident Report dated 8/12/14 documented that the examination of the scene was conducted and revealed the following: the interior of Resident#1's room sustained severe fire damage to mattress located on "B" bed which was located against the west wall of the room. Moderate smoke damage to the interior of the room The fire system activity report dated 7/26/14 documented activation of fire alarm at 2:01:54. The facility generated Synopsis of fire incident dated July 28th, 2014 lacked documented evidence of conclusion of the investigation (the initial staff statements (written or interview) did not reveal that they responded to the basement). Revision of fire incident (7/26/14) dated 9/25/14 documented there was a delay in staff response to fire, secondary to inability to determine exact location of fire. During an interview with 11PM-7AM assigned Certified Nursing Assistant (CNA#3) on 09/25/14 at 6:35AM, she stated that she had the fire assignment for her assigned unit but was covering for another CNA on another unit at the time when the fire alarm activated. CNA#3 stated that she counted the bell codes which indicated the fire in the basement. (During a previous interview on 7/29/14, CNA#3 did not reveal this information). CNA#3 further stated that when she heard the fire alarm system, she continued checking on her covered unit and then went to check on her assigned unit. When she discovered the fire, she stated that she yelled "Dr. Red" and gave the location of the fire. She stated that the unit was filled with smoke and that staff immediately responded and removed the resident from the affected room. She also stated that she did not understand the fire bell codes at that time of the incident. During an observation of the video surveillance system on 9/24/14 at 7:12AM revealed flashing strobe lights at the nursing station at 2:02AM on 7/26/14. Facility staff were observed appearing on the second floor at 2:10AM. Smoke was observed coming through the smoke barrier doors by the nursing station. Throughout the video surveillance LPN#1 was observed either sitting at the nursing station or standing by the medication cart and going away from the medication cart. During a telephone interview with the 11PM-7AM float Licensed Practical Nurse (LPN#1) on 09/24/14 at approximately 7:20am, LPN#1 stated that he was in a resident's room providing care with the Registered Nurse Supervisor (RNS#1). After the fire alarm system was activated he was instructed by RNS#1 to stay with the sick resident. LPN#1 stated that he did not track the fire bells and did not conduct the room search as RNS#1 instructed him to stay on the unit and monitor the sick resident. LPN#1 further stated that while the fire alarm was sounding he administered his "as needed" (PRN) medications. LPN#1 could not recall if there was an assigned staff on the unit to respond to fire alarm (LPN#1 did not reveal information regarding staff not assigned to respond to the fire). During an interview with the 11:00PM-7:00AM RNS#1on 09/24/14 at 7:20am, he stated that after the fire alarm system was activated, he did not look at the panel (fire alarm codes sheet) on the second floor and went to check the panel list (fire alarm codes sheet) on the 1st floor. He stated that he panicked and misinterpreted the fire bells and thought the fire was in the basement. RNS#1 stated that he went to the basement with CNA#1 and checked the entire basement. RNS#1 recounted the bells and corresponded the bell code to the second floor. Upon reaching the second floor CNA#3 was screaming Dr Red and the affected room number. RNS#1 further stated that he left the second floor to open the main entrance door for the fire department. RNS#1 denied going to the fire panel located at the facility entrance door and the copy room on the first floor to ascertain exact location of the fire. (During an interview on 7/29/14 and 8/8/14 RNS#1 did not reveal his initial response to the basement after he heard the fire alarm). During a telephone interview with the 11PM-7AM CNA#1 on 7/25/14 at 6:14AM, CNA#1 stated that he was on duty on 7/26/14 assigned to the first floor. The fire alarm went off approximately at 1:30AM-1:45AM, he proceeded to check the fire alarm bell list while counting the bells, RNS#1 was also present on the first floor. They determined the fire alarm bells corresponded to a location in the basement. RNS#1 instructed CNA#1 to accompany him to the basement. Both of them searched the basement, there was no fire in the basement. They recounted the fire bell alarms again and this time they corresponded the alarm bell combination to the second floor. " I think the first bell combination was wrong, because all three of us (RNS#1, CNA#1 and first floor charge nurse) stood there and counted the bells which guided us to go to the basement." CNA#1 further stated that when he reached the second floor all the automatic fire doors were closed, there were three staff members present in the hallway towards the location of the alarm. The affected room door was half open and the entire unit appeared dark. He proceeded to go in to the affected room and observed Resident#1 in bed; the bed was on fire; Resident#1 got out of bed, he was on fire too. CNA#1 stated that he started shooting the extinguisher towards the fire and put out the fire on Resident#1. He grabbed Resident#1 and brought him out of the room. (During an interview on 7/30/14 and 8/8/14 CNA#1 did not reveal that the staff including himself initially responded to the basement prior to identifying fire on the second floor). During an interview with CNA#2 on 9/25/14 at 6:45AM, CNA#2 stated that she was on duty on 7/26/14 assigned to the first floor. After the fire bells went off she listened to the sound and tallied the number of bells with the fire bell code list on the unit. The bells corresponded with fire in the basement. "I think the bell combination kept changing." The last set of bells stayed with the fire alarm for the second floor. During an interview with LPN #2 on 09/25/14 at approximately 6:47am, LPN#2 stated that she could not decipher the fire bells codes at the time of the incident. She stated that she overheard someone saying that the fire was in the basement. She further stated that she subsequently responded to the fire scene after she heard someone shouting "Dr Red" from across the floor (second floor). During an observation on 9/25/14 the fire alarm panels were observed mounted at the facility entrance door and in the copy machine room on the first floor (the panel shows the actual zone activated by fire, smoke or sprinkler). During an interview with Director of Nursing (DON) on 9/25/14 at 10:10PM, the DON stated that the incident was investigated by the fire department, the fire was determined to be accidental and electrical in nature. Initial facility investigation including the staffs' interviews and statement did not reveal any issue or delay in response time. When the staff was interviewed they all stated that they responded to the fire on the second floor, there was no cause to believe that any abuse, mistreatment or neglect happened. After a couple of weeks the video surveillance was reviewed and a system failure was identified because of the poor response time by the facility staff. The DON stated that prior to the incident the staff was in-serviced for fire safety based on their policy. During an interview with the Administrator on 9/25/14 at 10:35AM, the Administrator stated that there was a delay in response time due to facility staffs' inability to determine the exact location of the fire. During an interview with the Director of Environmental Services (DES) on 09/25/14 at approximately 1:15pm, he stated that he usually does not activate the fire alarm system at night during the fire drills. He stated that he uses a coded announcement instead. A review of the fire drill logs indicated that fire bell codes were utilized on 12/30/13 and on 03/09/14. The DES stated that the alarm system inspection was conducted after the incident and found the system to be functional. During an interview with the Technician of the Fire Alarm Company on 09/25/14 at approximately 1:10pm, he stated that he was unable to retrieve a printout from the fire alarm system indicating the exact zone of the fire. He stated that the system is an old system and does not have the capability to do so. He further stated that the system worked as it was designed to. He further stated that he maintains the fire alarm system and to the best of his professional knowledge it was in good working condition. The technician stated that the staff should be able to go to the fire panel and determine the location (floor and hallway) of the fire. This IJ was removed prior to exit as evidenced by revision of Policy and Procedure for fire safety to include fire alarm bell code review, to check for the location of the fire on the fire alarm panels, 100% re education of staff on the fire alarm bell code and revised safety procedures, and maintenence of the system by the contracted company revealed no issues. 415.12(h)(1)(2)