Every finding on record at Highbridge Woodycrest Center

Based on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety. This deficiency was evident in one (1) of four (4) kitchen refrigerators and two (2) of four (4) unit pantry refrigerators observed during the survey. Specifically, the kitchen walk-in refrigerator contained expired deli meat products, and the Unit 3 and Unit 4 pantry refrigerators contained unlabeled, undated, expired, and decomposing food items. The findings include:The facility's Labeling and Dating System Protocol with a revised date of 10/12/2025 directed staff to follow manufacturers' expiration dates for all unopened products, including deli meats. The protocol further required opened and sliced deli meats to be discarded after three (3) days and requires all food items to be labeled, dated, covered, and marked with the date received and opened.The facility's Unit Pantry Refrigerators policy with a revised date of 01/2026 required all opened food items to be labeled with the date opened and use-by date. Food brought in by family members must be labeled with the resident's name, date received, and use-by date. The policy further stated that all items must be covered, labeled, dated, and that expired items are to be discarded.The facility's Food Brought from Outside policy with a revised date of 05/06/2026 required perishable foods brought by family members or visitors to be labeled with the resident's name, food item, and use-by date, stored appropriately in the refrigerator, and discarded on or before the use-by date. Foods exhibiting signs of spoilage or potential foodborne hazards such as mold growth or foul odor are to be discarded immediately.1. On 05/13/2026 at 9:20 AM, an initial kitchen observation was conducted with the Food Service Director. The kitchen walk-in refrigerator contained:One (1) opened whole turkey breast deli meat dated 05/09/2026 with a manufacturer's use-by date of 04/27/2026.One (1) unopened whole smoked ham received on 05/11/2026 with a manufacturer's use-by date of 04/03/2026.The opened turkey breast was not stored in a drip pan and was observed leaking when handled. 2. On 05/13/2026 at 10:50 AM, the Unit 4 pantry refrigerator contained unlabeled and undated food items, including:One (1) smoked turkey drumstick in a sealed plastic container.One (1) decomposing onion in a sealed plastic container.One (1) half head of romaine lettuce in a plastic bag.Sliced Swiss cheese in a deli package stamped 04/16/2026. 3. On 05/13/2026 at 11:01 AM, the Unit 3 pantry refrigerator contained unlabeled and undated food items, including:One (1) salami sandwich in a paper bag.One (1) Styrofoam plate dated 05/07/2026 containing partially consumed chicken, collard greens, rice with gravy, and macaroni and cheese. On 05/13/2026 at 11:09 AM, Certified Nursing Assistant #1 stated during an interview that resident food should be stored in the unit pantry refrigerator for no longer than three (3) days and should be labeled with the resident's name and the date placed in the refrigerator. The Certified Nursing Assistant further stated that unlabeled, undated, or expired food should be discarded by nursing or dietary staff.During an interview on 05/18/2026 at 3:29 PM, the Director of Nursing stated responsibility for monitoring unit pantry refrigerators is shared by nursing and food service staff. Food service staff are expected to inspect refrigerators daily while recording temperatures and verify that food items are labeled with the resident's name, room number, and date. Unlabeled, undated, or expired food items should be discarded immediately, and nursing staff should conduct rounds to ensure compliance.On 05/20/2026 at 10:45 AM, the Food Service Director stated during an interview that food should be inspected upon receipt for freshness and manufacturer expiration dates. The Food Service Director further stated the opened turkey breast should have been discarded after three (3) days and stored in a drip pan. Both the turkey breast and smoked ham should not have been placed in the refrigerator because they were beyond the manufacturer's use-by dates. The Food Service Director stated staff should have separated the items and contacted the food supplier for return or disposal. The Food Service Director also stated that unit pantry refrigerators are inspected daily and that unlabeled, undated, or expired food should be discarded. The Food Service Director acknowledged that daily rounds to monitor food storage, labeling, and dating had not been conducted on the date of the survey observations.On 05/20/2026 at 1:30 PM, the Administrator stated during an interview that kitchen staff should not have stored the expired meat products in the walk-in refrigerator. The Administrator further stated food should be inspected upon receipt and either discarded or identified as unusable if expired. The Administrator confirmed that responsibility for monitoring unit pantry refrigerators is shared between food service and nursing staff and that unlabeled, undated, and expired food items should have been discarded.10 New York Codes, Rules and Regulations 415.14(h)

483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control S483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. S483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: S483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.70(e) and following accepted national standards; S483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. S483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. S483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. S483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. Observations: Based on record review and interview conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. This was evident during review of the Water Management Plan for Legionella. Specifically, the facility did not have a facility-specific water management plan for Legionella with mandatory components including but not limited to a description of the facility's water distribution system; temperature profile of the water system; control measures, and actions to be taken if control measures are not met. The findings are: The facility policy titled Legionella Water Management Program with a revised date of 06/13/2024 documented that the facility would maintain and monitor the facility's water system for Legionella. There was no documentation within the policy to indicate the document served as a site-specific water management plan for Legionella. Statements of prevention, surveillance, and reporting did not account for the actual design and operation of the facility's water system. The facility's Water Management Plan for Legionella had the following missing components: a description of the facility's water distribution system; temperature profile of the water system; facility-specific personnel roles and responsibilities; and control measures and actions to be taken if control measures not met. An environmental risk assessment form was not available for review. During an interview on 07/11/2024 at 1:50 PM, the Administrator stated they would ensure that the water management plan includes all the required components. 10 NYCRR 415.19(a)(1-3)

Based on record review and interviews conducted during the Recertification Survey from 07/09/2024 through 07/16/2024, the facility did not ensure that the Infection Preventionist had completed specialized training in infection prevention and control. This was evident during the review of the Infection Control Task. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. The findings are: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality Safety by Oversight Group Ref: QSO-19-10-NH dated 03/11/2019 documented that effective 11/28/2019 the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's infection prevention and control program. The facility's policy titled Infection Preventionist with a reviewed date of 02/01/2024 documented that the Infection Preventionist is responsible for coordinating the implementation and updating of the facility's established infection prevention and control policies and practices. The Infection Preventionist's must have completed a specialized training for infection preventionists such as specialized Infection Control Training for New York state Healthcare Professionals. There was no documented evidence that the facility's Infection Preventionist had completed specialized training in infection prevention and control. During an interview on 07/15/2024 at 12:07 PM, the Director of Nursing, who was also the acting Infection Preventionist stated their full time Infection Preventionist had been out sick for 4 months. They stated they both had taken 4 contact hours of infection control training in October 2022. The Director of Nursing stated they are not aware they have to complete a specialized infection prevention and control training. During an interview on 07/16/2024 at 12:12 PM, the Administrator stated they were not aware that the Infection Preventionist need more than 4 contact hours to function as Infection Preventionist for the facility. 10 NYCRR 415.19

Based on observation, interviews, and record review conducted during the Recertification survey from 09/27/22 to 10/06/22, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during review of the Infection Control Task. Specifically, the facility did not have a qualified IP with specialized education, training, experience, or certification and in infection prevention and control. The findings are: The facility policy titled Infection Control-General dated 10/27/18 and last revised on 03/29/22 documented the facility has established and maintains an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. The Infection Control Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data and implementation. On 09/29/22 at 09:52 AM and 09/30/2022 at 11:34 AM, the Director of Nursing (DON) was interviewed and stated Registered Nurse (RN) #3 was the facility IP responsible for overseeing the facility's IPCP. The DON was aware that specialized infection control training was required but not aware of the date IPs were required to have the training completed. The DON was interviewed and stated that they know that training is required but do not know the deadline. The facility's IP did not have the required ICPC training and certification. On 10/04/2022 at 11:34 AM, RN #3 was interviewed and stated they are responsible for training and inservicing the facility staff re: infection control and ensuring facility staff adhere to infection control protocols. RN #3 was informed they were the facility IP at the beginning of the recertification survey. RN #3 informed the Administrator that the facility's designated IP was required to complete the proper training. On 10/04/2022 at 11:43 AM, a follow-up interview was conducted with the DON who stated the DON and RN #3 are the facility's IPs and have not received specialized education, ICPC training, and did not receive the required certification. The facility's former IP left the position, and the facility is unable to hire a replacement. On 10/06/2022 at 4:08 PM, the Administrator was interviewed and stated that the DON is the facility's IP. The Administrator was not aware an IP required specialized education, training, and certification to qualify as the IP for the facility. The Administrator was not aware the DON did not have the necessary training and certification to be the facility's IP. 415.19

Based on observation, record review and interview conducted during a Recertification survey from 9/29/22 to 10/06/22, the facility did not ensure resident were free of accident hazards. This was evident for 2 (Resident #35 and #40) of 25 sampled residents. Specifically, Residents #35 and #40 resided in a shared room with a tampered bathroom doorknob that could not be opened in an emergency. The findings are: The facility policy titled Fall and Accident Preventions dated 04/1/2019 and last revised 06/01/22 documented the facility ensures the resident's environment remains as free of accident hazards as is possible, and each resident receives adequate supervision. Resident #35 had diagnoses of non-Alzheimer's dementia and psychotic disorder. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #35 had mild cognitive impairments and was independent in Activities of Daily Living (ADL). Resident #40 had diagnoses of anxiety disorder and depression. The MDS dated [DATE] documented Resident #40 was cognitively intact and independent in ADLs. Comprehensive care plan (CCP) related substance abuse initiated 3/25/22 documented Resident #40 had a history of substance abuse. On 10/04/22 at 03:20 PM, the shared bathroom door in Resident #35 and #40's room was observed with a tampered doorknob. The inner cylinder containing a mechanism to unlock the door was not present. The bathroom door handle was locked from the outside of the bathroom and could not be pressed down to open the door from the outside of the bathroom. Certified Nursing Assistant (CNA) #4 was present during the observation and stated this bathroom door has always been like that, and they were not sure if they had reported it the maintenance director. The C.N.A stated that this door cannot be opened with a coin like the other bathroom doors in the resident rooms. On 10/04/22 at 02:14 PM, CNA #2 was interviewed and stated if the bathroom door is found locked, staff could open the bathroom door with coin. On 10/04/22 at 05:15 PM, an interview conducted with the Maintenance Director who stated resident bathroom doors can be opened with a coin in case of an emergency. The Maintenance Director became aware of the bathroom door in Resident #35 and #40's room that had a missing handle cylinder. The bathroom door handle was replaced On 10/04/22 at 05:40 PM, the Director of Nursing (DON) was interviewed and stated that there has not been any incident related to bathroom doors. There was no policy related to opening of bathroom door with coins, but all staff know what to do in an emergency. 415.12(h)(2)

Based on observation, record review and interview conducted during a Recertification and abbreviated survey (NY00294067), the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised after each assessment and as needed. This was evident for 1 (Resident #235) of 25 sampled residents. Specifically, various CCPs were not reviewed and revised upon Resident #235's quarterly assessment and improvement in functional status. The findings are: The facility policy titled Comprehensive Person-Centered Care Policy dated 10/27/2018, revised 7/29/2022 documented the CCP will be updated when there has been a significant change in the resident's condition and/or at a quarterly assessment. Resident #235 had diagnoses of psychosis and opioid abuse. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the Resident #235 was cognitively intact and required extensive assistance of 1 person to transfer. The following CCPs had revisions dated: Fall Risk, initiated 10/30/21 with no reviews or revisions. Resident's Safety: At risk for injury, harm, abuse initiated on 10/30/21 with no revision date documented. Psychosocial Well Being, initiated 11/04/21, with no revision date documented Psychiatric disorders CCP dated 11/11/2021 with no revision date documented. An Occupational Therapy note dated 3/15/22 documented that the resident was educated on fall prevention and was able to perform at edge of bed. A Physician's order dated 3/15/22 documented Resident #235 was independent in transfers. An order dated 4/5/22 documented Resident #235 may go out on pass. There was no documented evidence Resident #235's CCP related to falls, safety, psychosocial well-being, and psychiatric disorders were reviewed and revised upon MDS assessment dated [DATE] and Resident #235's improvement in transfer status. On 10/06/22 at 02:10 PM, Registered Nurse (RN #1) was interviewed and stated they were not working in the facility during Resident #235's stay and could not explain the lack of review and revision of resident's CCPs. On 10/06/22 at 03:08 PM, the Director of Nursing (DON) was interviewed and stated they were just made aware that Resident #235's CCPs were not reviewed and revised. The RNs are responsible for care plaining and ensuring the accurate documentation. The DON was not previously aware of any CCP review concerns and stated the facility needs to work on their care plan protocols to ensure this wont happen again. 415.11(c)(2)(i-iii)

Based on observation, record review and staff interviews conducted during an abbreviated survey, (NY00286640), the facility failed to ensure residents remained free from abuse. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, on 11/18/2021 Resident #1 reported that Certified Nursing Assistant (CNA) #1 hit him/her on the neck. Resident #1 was assessed and observed with superficial redness to the left side of the neck. Review of the facility surveillance video recording revealed that CNA #1 and Resident #1 were engaged in an altercation. The findings include: Resident was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and insomnia. The Minimum Data Set (MDS, a resident assessment tool) dated 10/20/2021 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and score 13/15 indicating intact cognitive response. Resident required supervision with setup help only for most areas of Activities of Daily Living (ADLs). A review of an undated facility policy titled Abuse Prevention Protocol documented that reportable incident to The Department of Health include suspicion of patient abuse, neglect, or mistreatment with or without injury. The policy documented that the requirement to report is immediately upon having 'reasonable cause' to believe that abuse has occurred. The policy documented that a complete investigation is not a requirement before reporting a reportable event. A review of the facility Incident/Accident Investigation Worksheet dated 11/18/2021 documented that at 08:02 AM Resident #1 argued with CNA #1 over removing a tray from the third floor. Resident #1 reported taking a box of cereal from the tray and throwing it on the floor. Resident #1 stated that CNA #1 hit him/her on the neck. Resident #1 was assessed and observed with superficial redness to the left side of the neck, skin intact, and no swelling. Resident #1 denied pain or discomfort. The Conclusion of Investigation documented that the investigation has revealed that there is reasonable cause to believe that alleged resident abuse, mistreatment, or neglect regarding this resident may have occurred. A review of a Resident #1's Care Follow Up dated 11/18/2021 documented that this was an unwitnessed incident. Review of the video footage showed that Resident #1 and CNA #1 had an argument in the hallway of the third floor. It also showed that CNA #1 approached Resident #1 angrily and raised his/her hand while talking to Resident #1. The alleged hitting was not captured due to their location. To ensure resident safety and to avoid further incident, CNA #1 was removed from the schedule. A review of statement by Resident #1 dated 01/18/2022 documented that he/she took a tray of food and CNA #1 snatched it from his/her hand. Resident #1 asked if he/she could have an item from the tray and CNA #1 said no and Resident #1 took the box of cereal. Resident #1 stated that CNA #1 aggressively tried to take the box of cereal back and Resident #1 threw it on the floor. Resident #1 stated that CNA #1 started yelling at him/her and then hit him/her on the neck. A review of a statement by CNA #1 dated 11/18/2021 documented that he/she left a tray, for another resident, on the table and Resident #1 took the tray. CNA #1 stated where are you going with that, and you have yours in your room. CNA #1 stated that Resident #1 responded not of my business. Resident #1 took the coffee off the tray and threw it at CNA #1. CNA #1 stated yes, it did react to them angrily. A review of an Incident Note dated 11/18/2021 documented at around 8:02 AM, Resident #1. reported that he/she was hit by the CNA #1 while taking an extra tray for breakfast. Resident #1 stated, I took the cereal from the tray and threw it on the floor, and CNA #1 hit him/her on the neck. Resident #1 was assessed for injury, superficial redness noted to the left side of the resident's neck. Resident #1 refused to press charges. The facility surveillance video recording dated 11/18/2021 was reviewed on 02/16/2022 in the presence of the Director of Nursing (DON). Video clip #1, revealed the following: At 07:58 AM, Resident #1 walked down the hallways and out of camera's view. At 07:58AM, Escort #1 sitting hallway, Resident #1 walked past Escort #1. At 07:59 AM, CNA #1 (holding a tray) walked past Escort #1 who was still sitting in the hallway. As CNA #1 was walking down the hallway, a small object was thrown behind CNA #1. (Camera does not show who threw the small object). After the object was thrown, CNA #1 turned around, took an item off the tray, that CNA #1 was carrying, and ran in the opposite direction that the object was thrown from. CNA #1 was still holding the tray in his/her hands while running down the hallway. At 7:59 AM, Escort #1 was still sitting in the hallway and made an unknown hand gesture. At 7:59 AM, LPN #1 and LPN #2 (identified by the DON) appeared in the hallway and video ended. Video clip #2, not timestamped, revealed the following: Resident #1 was observed standing in the hallway between an open door. Surveyor was unable to see exactly what had occurred, but Resident #1, while standing in between the doorway, a person's arm reached out and contacted with the left side of Resident #1's neck - between shoulder and neck. Resident #1's head jolted to the right and the resident staggered backwards. CNA #1 appeared, facing Resident #1, pointing his/her finger in proximity to Resident #1 face. LPN #1 appeared in the area where Resident #1 and CNA #1 were standing, and the video ended. During an interview on 02/16/2022 at 02:07 PM Resident #1 stated that on 11/18/2021 he/she tried to take an extra tray and CNA #1 yelled at him/her. Resident #1 stated that he/she got upset and threw the cereal on the floor towards CNA #1. Resident #1 stated that CNA #1 began marching towards me, yelling, and hit me on my neck. During a telephone interview on 02/16/2022 at 02:20 PM Escort #1 stated that he/she was sitting close to the incident on 11/18/2021. Escort #1 stated that Resident #1 took a second food tray and CNA #1 asked Resident #1 to put down the tray and Resident #1 threw the coffee at CNA #1. Escort #1 stated that CNA #1 then ran towards Resident #1 and took a swing at Resident #1. Escort #1 stated that CNA #1 did not hit Resident #1. Escort #1 stated that CNA #1 was very upset about the incident. Escort #1 stated that CNA #1 was yelling at Resident #1 and Resident #1 was cursing and yelling at CNA #1. Escort #1 stated that the nurse on the unit got in between CNA #1 and Resident #1, preventing CNA #1 from hitting Resident #1. Multiple attempts were made to contact CNA #1, but all were unsuccessful. During a telephone interview on 02/16/2022 at 02:33 PM, Licensed Practical Nurse (LPN) #1 stated that on 11/18/2021 he/she was in a room with LPN #2 when they heard a commotion in the hallway. LPN #1 stated that LPN #2 went to deescalate the situation. LPN #1 stated that they did not witness any physical altercation, only verbal. LPN #1 stated that he/she does not recall exactly what was heard, just recalled hearing some yelling. During a telephone interview on 03/18/2022 at 11:45 AM, Director of Nursing (DON) #1 stated that based on review of the video footage and redness to the left side of Resident #1's neck, the facility substantiated the allegation of physical abuse. DON #1 stated that CNA #1 was terminated. During a telephone interview on 04/14/2022 at 02:33 PM, LPN #2 stated that on 11/18/2021 at the beginning of the shift, he/she witnessed Resident #1 holding a tray and speaking loudly towards CNA #1. LPN #2 stated, soon after, while he/she was at the nursing station, he/she heard some commotion in the hallway. LPN #2 stated that he/she recalled stepping out of the nursing station and witnessing Resident #1 holding a tray up towards CNA #1. LPN #2 stated that Resident #1 and CNA #1 began to have a verbal altercation. LPN #2 stated that he/she started shouting 'oh no, no, no, don't do that, stop it. LPN #2 stated that Resident #1 and CNA #1 looked like they might start fighting. LPN #2 stated that they do not recall walking over to the scene or intervening beyond the above statement. LPN #2 stated that he/she does not recall any further information about the incident. 415.4(b)(1)(i)

Based on observation, record review and staff interviews conducted during an Abbreviated Survey (NY00290284), the facility failed to report an alleged violation involving abuse immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury. This was evident for 1 out of 3 residents reviewed (Resident #2). Specifically, on 01/24/2022 at 02:05 PM, Resident #2 reported to the facility Social Worker (SW) #1 that he/she was raped by Resident #3. The facility notified the New York State Department of Health (NYSDOH) on 01/27/2022 at 03:35 PM. The findings include: Resident #2 was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia. The Minimum Data Set (MDS, a resident assessment tool) dated 01/20/2022 identified that the resident had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15 indicating intact cognitive response. Resident #2 was independent with no setup or physical help from staff for Activities of Daily Living (ADLs). A review of the facility undated policy entitled Abuse Prevention Protocol documented that reportable incident to The Department of Health include suspicion of patient abuse, neglect, or mistreatment with or without injury. The policy documented that the requirement to report is immediately upon having 'reasonable cause' to believe that abuse has occurred. The policy documented that a complete investigation is not a requirement before reporting a reportable event. The policy documented that the federal regulations require reporting of alleged abuse, neglect, or mistreatment within five (5) days of the incident. The NYSDOH however, requires, immediate reporting of abuse, neglect, and mistreatment, including injuries of unknown source, to the Administrator of the facility, and when required to the NYSDOH. Therefore, when there is reasonable cause to believe that abuse, neglect, or mistreatment has occurred, the incident must be reported to the NYSDOH without delay. A review of a Social Services note dated 01/24/2022 documented that on this date Resident #2 came to social services around 02:05 PM. Resident #2 expressed that they are calling 911 because he/she were raped but did not mention when. Writer spoke to Resident #2, and he/she stated that, person raped me and I saw yellowish stuff in my rectum, I know that you think that I'm crazy. A review of a Physician's Note date 01/24/2022 documented that today nurse reported Resident #2 came back from hospital and he/she endorsed that he/she was disturbed by cat image at night and some resident came to his/her room as cat and tried to rape him/her. A review of an Incident/Accident Report Form dated 01/24/2022 at 02:05 PM documented that Resident #2 alleged being raped due to yellowish stuff in rectum. The facility investigated the alleged raped and concluded that the investigation revealed that there is no reasonable cause to believe any alleged abuse, mistreatment or neglect regarding this resident has occurred. A review of a Resident Care Follow Up note dated 01/25/2022 documented that Resident #2 had made multiple calls to the Police due to paranoia, claiming that a cat lives inside of him/her and was being inappropriately touched by Resident #3. Resident #2's family verbalized that Resident #2 has been talking about this since he/she was living in the community. Resident #3 does not go to Resident #2's unit. Resident #2's room is near the nursing station. Multiple staff statements documented that Resident #3 never entered Resident #2's room. A review of an email document dated 01/28/2022, received by the DON from NYS DOH, revealed that the incident was reported and submitted to the NYS DOH on 01/27/2022 at 03:35 PM. During a telephone interview on 03/18/2022 at 11:45 AM, Director of Nursing (DON) #1 stated that they are responsible for reporting allegations of abuse including sexual abuse to the NYSDOH. DON #1 stated that as soon as he/she was informed of the allegation, he/she created an incident report and initiated the investigation. DON #1 stated that allegations of abuse including sexual abuse should be reported to the NYSDOH right away. DON #1 stated due to Resident #1's history and previous allegations, this case was treated as a behavior initially and then later DON #1 decided to inform the NYSDOH. DON #1 stated that they are aware of federal reporting requirements. 415.4(b)(1)(i)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a physician reviewed a resident's total program of care at each visit. Specifically, an attending physician did not review and document the clinical rationale for continued use of an antipsychotic medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #31). The findings are: A facility policy and procedure related to Antipsychotic Medication Monitoring was undated and documented that the Psychiatrist can prescribe an antipsychotic medication can be prescribed to treat dementia with associated psychotic and/or agitated features. The Psychiatrist is to lower the dosage when clinically indicated and documents such efforts. Resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set 3.0 ((MDS) dated [DATE] documented that the resident had intact cognition, disorganized thinking, and no behaviors. The resident received antipsychotic medication daily, and a Gradual Dose Reduction (GDR) was contraindicated. The most recent Quarterly MDS dated [DATE] documented the same assessment of the resident's cognition, behavior, diagnosis, and antipsychotic medication use as the MDS assessment dated [DATE]. The resident no longer displayed disorganized thinking. On 12/03/19 at 11:03 AM, an initial interview was conducted with Resident #31. The resident answered questions appropriately and appeared calm, interactive, and stable. The admission Patient Review Instrument (PRI) dated 6/27/19 documented that the resident had no known history of verbal disruption, physical aggression, socially inappropriate behavior, or hallucinations. An addendum to the PRI documented that the resident had questionable cognitive impairment and was on [MEDICATION NAME], and antipsychotic medication, for an unclear reason. The resident had an odd affect and poor recall with an unclear etiology, possibly from Dementia related to a medical condition. The Comprehensive Care Plan (CCP) for Psychiatric Disorders dated 6/28/19 documented that the resident had a [DIAGNOSES REDACTED]. Interventions include monitoring the resident's behavior, setting limits, and referral to psych as needed. The CCP update on 9/22/19 documented that the resident was compliant with meds and stable. A CCP related to [MEDICAL CONDITION] Drug Use was initiated on 6/28/19 and documented that the resident is receiving [MEDICATION NAME] for [MEDICAL CONDITION]. Interventions include observing for changes in mood and behavior, follow up psych consults as ordered, and evaluating the effectiveness of [MEDICAL CONDITION] meds to evaluate for med reduction by decreasing dosage. The physician's orders [REDACTED]. This medication was originally ordered on [DATE]. A Medication Regimen Review (MRR) dated 6/30/19 documented that the resident was recently admitted on [MEDICATION NAME] ([MEDICATION NAME]) with no clear [DIAGNOSES REDACTED]. The MRR documented a recommendation to consider obtaining psychosocial workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors, please consider implementing a tapering schedule and/or discontinue. The physician documented that he disagreed, but he did not document the clinical rationale. The Admission Medical Doctor (MD) Note dated 7/1/19 documented that the resident was alert and oriented X 3 and scored a 25 out of 30 on the Mini-Mental Status Exam (MMSE). The resident had a possible mental illness. The Psychiatry Assessment done by the Psychiatric Nurse Practitioner (PNP) dated 7/4/19 documented that the resident was a poor historian, uncooperative, and would not answer questions during the assessment. The resident was confused with an odd affect. The resident did not present with any hallucinations or delusions and denied any psychiatric hospitalization s in the past. The PNP recommended to continue [MEDICATION NAME] 5mg once daily for Dementia- related to a medical condition and substance abuse disorder. The MRR dated 7/11/19 documented a recommendation for clarification in the resident's record related to the [DIAGNOSES REDACTED]. The MRR documented that the [MEDICATION NAME] has been ordered to treat [MEDICAL CONDITION]; however, the most recent psychiatry consult documented that the [DIAGNOSES REDACTED]. A MD Note dated 7/29/19 documented that the resident was evaluated by psychiatry on 7/4/19. The resident denied hearing voices and stated that he was ok. The MD assessment included that Unsubstantiated mental illness was likely. On 8/29/19, the MD note documented that the resident was alert and oriented x 3 and had possible resolving [MEDICAL CONDITION] causing dementia. The Pharmacist Signature Sheet documented the Pharmacist made recommendations in the MRR done on 9/7/19, but the facility was unable to provide the report. On 10/29/19 the MD note documented that the resident had questionable organic mental illness versus personality disorder, not yet established. None of the MD notes documented any reference to inappropriate behaviors displayed by the resident or that the resident was experiencing any hallucinations, delusion, or other psychotic symptoms. The MD Notes do not contain any documented evidence that the physician evaluated the continued use of [MEDICATION NAME] for Dementia. A Psychiatry Assessment completed by the PNP on 12/2/19 documented that the resident had an uneventful last period free from behavioral issues and free from [MEDICAL CONDITION]. The PNP documented that the resident sleeps well at night and keeps to himself most of the time. The recommendation was to continue [MEDICATION NAME] 5mg once daily for dementia related to a medical condition and substance abuse disorder. There were no Social Work (SW) notes, Nursing notes, or Certified Nursing Assistant (CNA) documentation that documented any inappropriate behaviors displayed by resident since admission to the facility on [DATE]. There was no documentation in the resident's record regarding any hallucinations, delusion, or decline in activities of daily living due to displayed behaviors. An interview was conducted with the PNP on 12/04/19 at 03:51 PM. The PNP stated that she has been working for the facility for approximately 3 years and is not affiliated with a psychiatric group or a psychiatrist. The PNP stated that she does not require a collaborating physician. The PNP stated that Resident #31 is prescribed [MEDICATION NAME] to treat dementia with behavioral disturbances. The resident was admitted from the hospital on this medication and the PNP stated she determined the resident should be kept on this medication after his admission to the facility. The resident displayed psychotic behavior by not being cooperative with interviews. During the initial assessment by the PNP, the resident responded only to his name, appeared to be internally preoccupied, and had an apathetic affect. The PNP stated that Resident #31 continues to have bouts of [MEDICAL CONDITION], is only oriented to himself, and does not know the time or date. The [MEDICATION NAME] is also used to help the resident sleep and he sleeps well at night currently because of it. The PNP stated that the resident did not know where he was during her psychiatric assessment and that he had no expression on his face. The resident's eyes would look up in the air and he would answer as if he were talking to someone else. Sometimes he would look at the wall while the PNP was asking questions. The resident also has a history of substance abuse which more than likely contributed to cognitive impairments. The PNP stated that according to her assessments, the resident has severe cognitive impairment and had scored a 9-20 on Montreal Cognitive Assessment (M[NAME]A). His mental status exam score was less than 20, indicating signs of dementia were present. The PNP stated that she is not aware of whether the facility staff documented that the resident displayed any delusions or hallucinations. When the PNP assessed the resident on 12/2/19, the resident did not display any behavioral issues; however, his cognitive status remained the same as when first assessed on 7/4/19. The PNP stated that this was the reason she recommends that the resident continue to receive [MEDICATION NAME]. The PNP stated that [MEDICATION NAME] is an antipsychotic medication that is used to treat [MEDICAL CONDITION], a serotonin enhancer that helps with depression, and, at this low dose, can help with sleeping patterns. The PNP stated that she was unaware of Resident #31 having a history of depression; however, depression can usually be found in those diagnosed with [REDACTED]. The PNP stated that although she tries to taper a resident's antipsychotic medication every time, she evaluates them, Resident #31 has severe cognitive impairment and is ordered to receive such a low dose of [MEDICATION NAME], that she decided to continue prescribing the [MEDICATION NAME] to him. The PNP also stated that she evaluates Nursing Notes, talks with CNAs, assesses a resident's level of isolation, hygiene, sleep and appetite, reviews labs, and assess the resident's affect. The PNP stated that she did not ascertain whether the resident had any aggression, agitation, or decline in activities of daily living related to [MEDICAL CONDITION]. She does not recall the resident having any of these concerns. She did determine that Resident #31 had an odd affect and that there was a strange oddity about him. This could have been caused by the [DIAGNOSES REDACTED]. Nonpharmacological interventions used to address the dementia symptoms displayed by Resident #31 included having the nursing staff reorient him and talk with him. Although the PNP stated that she does usually speak with the MD regarding residents, she has not specifically spoken to the MD about Resident #31. An interview was conducted with the MD on 12/05/19 at 11:01 AM. The MD has been assigned to oversee the resident's care since his admission to the facility. The MD stated that Resident #31 has an odd personality but does not exhibit any inappropriate or negative behaviors at all. The resident is not aggressive. The MD stated that he assessed the resident's cognition when he was first admitted to the facility and the resident scored a 25 out of 30 on the mini-mental exam. There was some discussion of whether he has [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder, but this has not been determined as of yet. The resident receives a low dose of [MEDICATION NAME] and consistently does well on mini-mental exams used to test his cognitive status. The facility determined that he was safe to go Out on Pass independently without supervision or escort. The resident is complaint with his medication regime and has never exhibited or reported any delusions or hallucinations. The MD stated that the resident is just odd. The resident answered appropriately when asked what state he was currently in; but, Resident #31 responded inappropriately when asked what country he resided in. The MD stated he got the impression that the resident was playing with me. The resident was admitted from the hospital with an order for [REDACTED]. Resident #31 does not have any involved family members that the MD is aware of and was unable to provide any history of his psychiatric treatment prior to admission. The resident has a current [DIAGNOSES REDACTED]. The MD stated that the resident might have a personality disorder or a mood disorder; however, the resident does not display any symptoms of mood issues and more likely has a personality disorder because he is odd. Resident #31 has no issue with conversing with the MD when approached. The MD stated that although the resident's record indicates that the resident has a [DIAGNOSES REDACTED]. If the resident has a [DIAGNOSES REDACTED]. He does confer with the PNP but did not do so in this case. He would have communicated to the PNP that he does not believe that Resident #31 has dementia. The resident is on [MEDICATION NAME] because the PNP must have seen something during her evaluation to warrant the use of an antipsychotic medication. If the resident has not displayed any aggressive behavior or disordered thought process, then the [MEDICATION NAME] can be discontinued. According to the PNP, the [MEDICATION NAME] has been ordered for this resident to treat a [DIAGNOSES REDACTED]. The MD stated that he reviews the consults that the psychiatrist writes after seeing a resident and then determines if there should be any changes to the recommendations made; but he did not confer with the PNP in regard to Resident #31. The MD stated that [MEDICATION NAME] can be used to treat [MEDICAL CONDITION], thought disorders, and dementia with agitation, delusions. The MD stated that he reviews the monthly Medication Regimen Review (MRR) from the pharmacist. The MD then documents his response as to whether he agrees or disagrees with the MRR. The MD reviewed the MRR from 6/30/19 and stated that he disagreed with the pharmacist's recommendation to obtain a psychosocial history of the resident to determine causes of the resident's behavior and to taper the [MEDICATION NAME] if behavior monitoring reveals no significant behaviors. He stated that he disagreed because the resident was just admitted to the facility and he bases his decision on the information that he received from the hospital. The MD stated that he needs to be able to take time to evaluate the resident and then make a decision. The Pharmacist asked for the [DIAGNOSES REDACTED]. The MD stated that he assigned a [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. actually is, but he needs to put something in. The MD then stated that he disagreed with the MRR dated 7/11/19 pharmacy review recommending clarification of the condition that the [MEDICATION NAME] is being used to treat. The MRR documented that the MD ordered the [MEDICATION NAME] to treat [MEDICAL CONDITION] but the PNP documented that the [MEDICATION NAME] was being used to treat dementia. The MD stated that he disagreed because the resident could have a [DIAGNOSES REDACTED]. He further stated that even though the [MEDICAL CONDITION] is not overt, and he does not agree with the dementia diagnosis, he did not feel the need to clarify this in the MRR. The MD stated that he needs more time to evaluate the resident and make a determination. He did not order a neuropsychology exam to determine whether there was a dementia diagnosis. Since the PNP thinks there is some dementia, the MD will have to collaborate and confer with her. It may be that Resident #31 does not need an antipsychotic medication, but the MD stated that was not ready yet to say either way. The MD stated that he is now more confident that the resident does not have a [DIAGNOSES REDACTED]. The MD stated that it may be best to just take Resident #31 off the antipsychotic medication. The MD stated that he did not write a response to the MRR after he checked the disagree box because he did not feel it was warranted or necessary. 415.15(b)(2)(iii)

Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that the attending physician documented a rationale for his response to the pharmacist's Medication Regimen Review. Specifically, the physician did not document the clinical rationale for disagreeing with the Pharmacist's recommendations for a resident receiving an antipsychotic medication for an unclear diagnosis. this was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #31). The findings are: An undated policy and procedure related to Drug Regimen Review-Monthly documented that the attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible. The Prescriber or Licensed Designee shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation, and provide a brief clinical rationale if no change is to be made. Resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set 3.0 ((MDS) dated [DATE] documented that the resident had intact cognition, disorganized thinking, and no behaviors. The resident received antipsychotic medication daily, and a Gradual Dose Reduction (GDR) was contraindicated. The most recent Quarterly MDS dated [DATE] documented the same assessment of the resident's cognition, behavior, diagnosis, and antipsychotic medication use as the MDS assessment dated [DATE]. The resident no longer displayed disorganized thinking. On 12/03/19 at 11:03 AM, an initial interview was conducted with Resident #31. The resident answered questions appropriately and appeared calm, interactive, and stable. The admission Patient Review Instrument (PRI) dated 6/27/19 documented that the resident had no known history of verbal disruption, physical aggression, socially inappropriate behavior, or hallucinations. An addendum to the PRI documented that the resident had questionable cognitive impairment and was on [MEDICATION NAME], and antipsychotic medication, for an unclear reason. The resident had an odd affect and poor recall with an unclear etiology, possibly from Dementia related to a medical condition. The Comprehensive Care Plan (CCP) for Psychiatric Disorders dated 6/28/19 documented that the resident had a [DIAGNOSES REDACTED]. Interventions include monitoring the resident's behavior, setting limits, and referral to psych as needed. The CCP update on 9/22/19 documented that the resident was compliant with meds and stable. A CCP related to [MEDICAL CONDITION] Drug Use was initiated on 6/28/19 and documented that the resident is receiving [MEDICATION NAME] for [MEDICAL CONDITION]. Interventions include observing for changes in mood and behavior, follow up psych consults as ordered, and evaluating the effectiveness of [MEDICAL CONDITION] meds to evaluate for med reduction by decreasing dosage. The physician's orders [REDACTED]. This medication was originally ordered on [DATE]. A Medication Regimen Review (MRR) dated 6/30/19 documented that the resident was recently admitted on [MEDICATION NAME] ([MEDICATION NAME]) with no clear [DIAGNOSES REDACTED]. The MRR documented a recommendation to consider obtaining psychosocial workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors, please consider implementing a tapering schedule and/or discontinue. The physician documented that he disagreed, but he did not document the clinical rationale. The Admission Medical Doctor (MD) Note dated 7/1/19 documented that the resident was alert and oriented X 3 and scored a 25 out of 30 on the Mini-Mental Status Exam (MMSE). The resident had a possible mental illness. The Psychiatry Assessment done by the Psychiatric Nurse Practitioner (PNP) dated 7/4/19 documented that the resident was a poor historian, uncooperative, and would not answer questions during the assessment. The resident was confused with an odd affect. The resident did not present with any hallucinations or delusions and denied any psychiatric hospitalization s in the past. The PNP recommended to continue [MEDICATION NAME] 5mg once daily for Dementia- related to a medical condition and substance abuse disorder. The MRR dated 7/11/19 documented a recommendation for clarification in the resident's record related to the [DIAGNOSES REDACTED]. The MRR documented that the [MEDICATION NAME] has been ordered to treat [MEDICAL CONDITION]; however, the most recent psychiatry consult documented that the [DIAGNOSES REDACTED]. A MD Note dated 7/29/19 documented that the resident was evaluated by psychiatry on 7/4/19. The resident denied hearing voices and stated that he was ok. The MD assessment included that Unsubstantiated mental illness was likely. On 8/29/19, the MD note documented that the resident was alert and oriented x 3 and had possible resolving [MEDICAL CONDITION] causing dementia. The Pharmacist Signature Sheet documented the Pharmacist made recommendations in the MRR done on 9/7/19, but the facility was unable to provide the report. There were no Social Work (SW) notes, Nursing notes, or Certified Nursing Assistant (CNA) documentation that documented any inappropriate behaviors displayed by resident since admission to the facility on [DATE]. There was no documentation in the resident's record regarding any hallucinations, delusion, or decline in activities of daily living due to displayed behaviors. An interview was conducted with the PNP on 12/04/19 at 03:51 PM. The PNP stated that she has been working for the facility for approximately 3 years and was not affiliated with a psychiatric group or a psychiatrist. The PNP stated that she does not require a collaborating physician. The PNP stated that Resident #31 is prescribed [MEDICATION NAME] to treat dementia with behavioral disturbances. The resident was admitted from the hospital on this medication and the PNP stated she determined the resident should be kept on this medication after his admission to the facility. The resident displayed psychotic behavior by not being cooperative with interviews. During the initial assessment, the resident responded only to his name, appeared to be internally preoccupied, and had an apathetic affect. The PNP stated that Resident #31 continued to have bouts of [MEDICAL CONDITION], is only oriented to himself, and does not know the time or date. The [MEDICATION NAME] is also used to help the resident sleep, and he sleeps well at night because of it. The PNP stated that the resident did not know where he was during her psychiatric assessment, and that he had no expression on his face. The resident would look up in the air and he would answer as if he were talking to someone else. Sometimes he would look at the wall while the PNP was asking questions. The resident also has a history of substance abuse which more than likely contributed to the cognitive impairments. The PNP stated that according to her assessments, the resident had severe cognitive impairment and scored a 9-20 on the Montreal Cognitive Assessment (M[NAME]A). His mental status exam score was less than 20, indicating signs of dementia were present. The PNP stated that she was not aware of whether the facility staff documented that the resident displayed any delusions or hallucinations. When the PNP assessed the resident on 12/2/19, the resident did not display any behavioral issues; however, his cognitive status remained the same as when first assessed on 7/4/19. This was the reason she recommended that the resident continue to receive [MEDICATION NAME]. The PNP stated that [MEDICATION NAME] is an antipsychotic medication that is used to treat [MEDICAL CONDITION], a serotonin enhancer that helps with depression, and, at this low dose, can help with sleeping patterns. The PNP stated that she was unaware of Resident #31 having a history of depression; however, depression can usually be found in those diagnosed with [REDACTED]. The PNP stated that although she tries to taper a resident's antipsychotic medication every time, she evaluates them, Resident #31 has severe cognitive impairment and is ordered to receive such a low dose of [MEDICATION NAME], that she decided to continue prescribing the [MEDICATION NAME] to him. The PNP also stated that she evaluates Nursing Notes, talks with CNAs, assesses a resident's level of isolation, hygiene, sleep and appetite, reviews labs, and assess the resident's affect. The PNP stated that she did not ascertain whether the resident had any aggression, agitation, or decline in activities of daily living related to [MEDICAL CONDITION]. She does not recall the resident having any of these concerns. She determined that Resident #31 had an odd affect and that there was a strange oddity about him. This could have been caused by the [DIAGNOSES REDACTED]. Non-pharmacological interventions used to address the dementia symptoms displayed by Resident #31 included having the nursing staff reorient him and talk with him. Although the PNP stated that she does usually speak with the MD regarding residents, but she has not specifically spoken to the MD about Resident #31. An interview was conducted with the MD on 12/05/19 at 11:01 AM. The MD stated [MEDICATION NAME] is ordered because the PNP must have seen something during her evaluation to warrant the use of an antipsychotic medication. If the resident has not displayed any aggressive behavior or disordered thought process, then the [MEDICATION NAME] can be discontinued. According to the PNP, the [MEDICATION NAME] has been ordered for this resident to treat a [DIAGNOSES REDACTED]. The MD stated that he reviews the consults that the psychiatrist writes after seeing a resident and then determines if there should be any changes based on the recommendations made. He did not confer with the PNP about Resident #31. The MD stated that [MEDICATION NAME] can be used to treat [MEDICAL CONDITION], thought disorders, and dementia with agitation, delusions. The MD stated that he reviews the monthly Medication Regimen Review (MRR) from the pharmacist. The MD then documents his response as to whether he agrees or disagrees with the MRR. The MD reviewed the MRR from 6/30/19 and stated that he disagreed with the pharmacist's recommendation to obtain a psychosocial history of the resident to determine causes of the resident's behavior and to taper the [MEDICATION NAME] if behavior monitoring reveals no significant behaviors. He stated that he disagreed because the resident was just admitted to the facility and he bases his decision on the information that he received from the hospital. The MD stated that he needs to be able to take time to evaluate the resident and then make a decision. The MD stated that the MRR asks for an appropriate [DIAGNOSES REDACTED]. The MD stated that he assigned a [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. actually is, but the MD stated that he needs to put something in. The MD then stated that he disagreed with the MRR dated 7/11/19 recommending clarification of the condition that the [MEDICATION NAME] is being used to treat. The MRR documented that the MD ordered the [MEDICATION NAME] to treat [MEDICAL CONDITION] but the PNP documented that the [MEDICATION NAME] was being used to treat dementia. The MD stated that he disagreed because the resident could have a [DIAGNOSES REDACTED]. He further stated that even though the [MEDICAL CONDITION] was not overt and he did not agree with the dementia diagnosis, he did not feel the need to clarify this in the MRR. The MD stated that he needs more time to evaluate the resident and make a determination. He did not order a neuropsychology exam to determine whether there was a dementia diagnosis. Since the PNP thinks there is some dementia, the MD will have to collaborate and confer with her. It may be that Resident #31 does not need an antipsychotic medication, but the MD stated that was not ready yet to say either way. The MD stated that he is now more confident that the resident does not have a [DIAGNOSES REDACTED]. The MD stated that it may be best to just take Resident #31 off the antipsychotic medication. The MD stated that he did not write a response to the MRR after he checked the disagree box because he did not feel it was warranted or necessary. An interview with the Director of Nursing (DON) was conducted on 12/05/19 at 12:30 PM. The DNS stated that when there are MRR recommendations from the pharmacist regarding antipsychotic medication use and GDR, the PNP is responsible for documenting a response. The Medical Director oversees the PNP and the MD but does not review all of their documentation unless there is an identified issue. The DON stated that if a resident is not displaying any behaviors associated with a psychiatric diagnosis, then the PNP needs to question why they may be on an antipsychotic medication and justify a reason that the resident is still on it. If the MRR from pharmacist includes recommendations, then there needs to be a response from the PNP or the MD as to the reason they do not agree. An interview was conducted with the Medical Director on 12/05/19 at 01:35 PM. The Medical Director stated that the facility has decided to link with a Psychiatrist to bolster their efforts to have a Psychiatrist oversee the tapering of antipsychotic medications. Whenever the pharmacist submits a monthly MRR related to antipsychotic medications, the PNP is made aware. The PNP then communicates her recommendations with the MD. The DON and the Medical Director also get a copy. The Medical Director stated that he reviews all of the MRR. A response to the MRR must always be given in writing. The standard practice is for the MDs and/or the PNP to write a response as to why they disagree with the MRR in the same box where they check of the disagree option. The MD and/or PNP then hands the MRR back to the DON. After the Medical Director reviewed the MRR for Resident #31, he stated that there should be a response somewhere in the resident's chart since it is not written directly on the MRR. The Medical Director stated that he does review the MRR after the MD signs off on it and was under the impression that the MD documented his rationale in the chart. If there is no documentation regarding the MD's disagreement with the MRR recommendation, then it must have been missed. The Medical Director does not review the MD's progress notes unless there is an identified issue. 415.18(c)(2)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that a resident remained free of unnecessary [MEDICAL CONDITION] medication. Specifically, a rationale was not provided for the continued use of an antipsychotic medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medications (Resident #31). The findings are: A facility policy and procedure related to Antipsychotic Medication Monitoring was undated and documented that the Psychiatrist can prescribe an antipsychotic medication to treat dementia with associated psychotic and/or agitated features. The Psychiatrist is to lower the dosage when clinically indicated and document such efforts. Resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's Admission Minimum Data Set 3.0 ((MDS) dated [DATE] documented that the resident had intact cognition, disorganized thinking, and no behaviors. The resident received antipsychotic medication daily, and a Gradual Dose Reduction (GDR) was contraindicated. The most recent Quarterly MDS dated [DATE] documented the same assessment of the resident's cognition, behavior, diagnosis, and antipsychotic medication use as the MDS assessment dated [DATE]. The resident no longer displayed disorganized thinking. On 12/03/19 at 11:03 AM, an initial interview was conducted with Resident #31. The resident answered questions appropriately and appeared calm, interactive, and stable. The admission Patient Review Instrument (PRI) dated 6/27/19 documented that the resident had no known history of verbal disruption, physical aggression, socially inappropriate behavior, or hallucinations. An addendum to the PRI documented that the resident had questionable cognitive impairment and was on [MEDICATION NAME], and antipsychotic medication, for an unclear reason. The resident had an odd affect and poor recall with an unclear etiology, possibly from Dementia related to a medical condition. The Comprehensive Care Plan (CCP) for Psychiatric Disorders dated 6/28/19 documented that the resident had a [DIAGNOSES REDACTED]. Interventions include monitoring the resident's behavior, setting limits, and referral to psych as needed. The CCP update on 9/22/19 documented that the resident was compliant with meds and stable. A CCP related to [MEDICAL CONDITION] Drug Use was initiated on 6/28/19 and documented that the resident is receiving [MEDICATION NAME] for [MEDICAL CONDITION]. Interventions include observing for changes in mood and behavior, follow up psych consults as ordered, and evaluating the effectiveness of [MEDICAL CONDITION] meds to evaluate for med reduction by decreasing dosage. The physician's orders [REDACTED]. This medication was originally ordered on [DATE]. A Medication Regimen Review (MRR) dated 6/30/19 documented that the resident was recently admitted on [MEDICATION NAME] ([MEDICATION NAME]) with no clear [DIAGNOSES REDACTED]. The MRR documented a recommendation to consider obtaining psychosocial workup along with performing a medical workup as soon as possible to assess for underlying causes of behaviors. Should the workups and nursing behavioral monitoring reveal no significant behaviors, please consider implementing a tapering schedule and/or discontinue. The physician documented that he disagreed, but he did not document the clinical rationale. The Admission Medical Doctor (MD) Note dated 7/1/19 documented that the resident was alert and oriented X 3 and scored a 25 out of 30 on the Mini-Mental Status Exam (MMSE). The resident had a possible mental illness. The Psychiatry Assessment done by the Psychiatric Nurse Practitioner (PNP) dated 7/4/19 documented that the resident was a poor historian, uncooperative, and would not answer questions during the assessment. The resident was confused with an odd affect. The resident did not present with any hallucinations or delusions and denied any psychiatric hospitalization s in the past. The PNP recommended to continue [MEDICATION NAME] 5mg once daily for Dementia- related to a medical condition and substance abuse disorder. The MRR dated 7/11/19 documented a recommendation for clarification in the resident's record related to the [DIAGNOSES REDACTED]. The MRR documented that the [MEDICATION NAME] has been ordered to treat [MEDICAL CONDITION]; however, the most recent psychiatry consult documented that the [DIAGNOSES REDACTED]. A MD Note dated 7/29/19 documented that the resident was evaluated by psychiatry on 7/4/19. The resident denied hearing voices and stated that he was ok. The MD assessment included that Unsubstantiated mental illness was likely. On 8/29/19, the MD note documented that the resident was alert and oriented x 3 and had possible resolving [MEDICAL CONDITION] causing dementia. The Pharmacist Signature Sheet documented the Pharmacist made recommendations in the MRR done on 9/7/19, but the facility was unable to provide the report. On 10/29/19 the MD note documented that the resident had questionable organic mental illness versus personality disorder, not yet established. None of the MD notes documented any reference to inappropriate behaviors displayed by the resident or that the resident was experiencing any hallucinations, delusion, or other psychotic symptoms. The MD Notes do not contain any documented evidence that the physician evaluated the continued use of [MEDICATION NAME] for Dementia. A Psychiatry Assessment completed by the PNP on 12/2/19 documented that the resident had an uneventful last period free from behavioral issues and free from [MEDICAL CONDITION]. The PNP documented that the resident sleeps well at night and keeps to himself most of the time. The recommendation was to continue [MEDICATION NAME] 5mg once daily for dementia related to a medical condition and substance abuse disorder. There were no Social Work (SW) notes, Nursing notes, or Certified Nursing Assistant (CNA) documentation that documented any inappropriate behaviors displayed by resident since admission to the facility on [DATE]. There was no documentation in the resident's record regarding any hallucinations, delusion, or decline in activities of daily living due to displayed behaviors. An interview with the Certified Nursing Assistant (CNA #1), the resident's assigned CNA, was conducted on 12/04/19 at 03:03 PM. CNA #1 stated that the resident has not exhibited any inappropriate behaviors, and he likes to keep to himself and stay in his room. The resident is very compliant with care and showers. He has never exhibited any agitation or aggression towards any other residents. CNA #1 stated that when she starts her shift, she checks in on Resident #31 during rounds and then observes him while he is ambulating on the unit. The resident does not require assistance with any other activities of daily living. Resident #31 leaves the unit to go to the smoke room and interacts with a few of other residents. He is peaceful and has never been observed hallucinating or having delusions. CNA #1 stated that Resident #31 is able to have very good conversations with her, and he is one resident that she can communicate with. He has never been disrespectful, keeps himself clean, has a good appetite, and does not wander at night or have difficulty sleeping. The CNA stated that she is not aware of any special precautions besides ensuring monitoring the resident for safety. On 12/04/19 at 02:33 PM, an interview was conducted with the Licensed Practical Nurse (LPN #2), the LPN assigned to the resident's unit. LPN #2 stated that the resident does not currently display any inappropriate behaviors, hallucinations, or delusions. The resident also does not have any history of displaying any inappropriate behaviors. LPN #2 stated that the resident has good conversations with him and self-reported to the nurse that he does not hear voices. Resident #31 keeps to himself, displays no agitation or aggression, and has not attempted to harm himself or others. LPN #2 stated that the resident may have a [DIAGNOSES REDACTED]. Resident #31 is very respectful, compliant, and responds to questions appropriately. LPN #2 was not aware of activities the resident attended, but he stated the resident is usually out of the room when he does rounds. The resident was recently approved to go Out on Pass independently, meaning that he could leave the facility without any escort or supervision from a responsible party. An interview was conducted with the PNP on 12/04/19 at 03:51 PM. The PNP stated that she has been working for the facility for approximately 3 years and was not affiliated with a psychiatric group or a psychiatrist. The PNP stated that she does not require a collaborating physician. The PNP stated that Resident #31 is prescribed [MEDICATION NAME] to treat dementia with behavioral disturbances. The resident was admitted from the hospital on this medication and the PNP stated she determined the resident should be kept on this medication after his admission to the facility. The resident displayed psychotic behavior by not being cooperative with interviews. During the initial assessment by the PNP, the resident responded only to his name, appeared to be internally preoccupied, and had an apathetic affect. The PNP stated that Resident #31 continued to have bouts of [MEDICAL CONDITION], is only oriented to himself, and does not know the time or date. The [MEDICATION NAME] is also used to help the resident sleep, and he sleeps well at night because of it. The PNP stated that the resident did not know where he was during her psychiatric assessment and that he had no expression on his face. The resident would look up in the air and he would answer as if he were talking to someone else. Sometimes he would look at the wall while the PNP was asking questions. The resident also has a history of substance abuse which more than likely contributed to the cognitive impairments. The PNP stated that according to her assessments, the resident had severe cognitive impairment and scored a 9-20 on the Montreal Cognitive Assessment (M[NAME]A). His mental status exam score was less than 20, indicating signs of dementia were present. The PNP stated that she was not aware of whether the facility staff documented that the resident displayed any delusions or hallucinations. When the PNP assessed the resident on 12/2/19, the resident did not display any behavioral issues; however, his cognitive status remained the same as when first assessed on 7/4/19. This was the reason she recommended that the resident continue to receive [MEDICATION NAME]. The PNP stated that [MEDICATION NAME] is an antipsychotic medication that is used to treat [MEDICAL CONDITION], a serotonin enhancer that helps with depression, and, at this low dose, can help with sleeping patterns. The PNP stated that she was unaware of Resident #31 having a history of depression; however, depression can usually be found in those diagnosed with [REDACTED]. The PNP stated that although she tries to taper a resident's antipsychotic medication every time, she evaluates them, Resident #31 has severe cognitive impairment and is ordered to receive such a low dose of [MEDICATION NAME], that she decided to continue prescribing the [MEDICATION NAME] to him. The PNP also stated that she evaluates Nursing Notes, talks with CNAs, assesses a resident's level of isolation, hygiene, sleep and appetite, reviews labs, and assess the resident's affect. The PNP stated that she did not ascertain whether the resident had any aggression, agitation, or decline in activities of daily living related to [MEDICAL CONDITION]. She does not recall the resident having any of these concerns. She determined that Resident #31 had an odd affect and that there was a strange oddity about him. This could have been caused by the [DIAGNOSES REDACTED]. Nonpharmacological interventions used to address the dementia symptoms displayed by Resident #31 included having the nursing staff reorient him and talk with him. Although the PNP stated that she does usually speak with the MD regarding residents, she has not specifically spoken to the MD about Resident #31. On 12/05/19 at 10:23 AM, an interview was conducted with the resident's assigned SW who has been working in the facility for [AGE] years. The SW stated that Resident #31 is a very pleasant resident and complies with his full plan of care. The SW stated that although there is no documented evidence in the resident's medical record, she believes that he has a [DIAGNOSES REDACTED]. No documented evidence was provided to support this [DIAGNOSES REDACTED]. Resident #31 does interact well with other and attend activity programs but prefers to be alone in his room. The resident has not displayed any aggressive or agitated behavior towards staff or other residents. He is always very respectful. When the resident was first admitted to the facility, his communication was tangential, and the resident would speak in a word salad with incomplete sentences. An interview was conducted with the MD on 12/05/19 at 11:01 AM. The MD has been assigned to oversee the resident's care since his admission to the facility. The MD stated that Resident #31 has an odd personality but does not exhibit any inappropriate or negative behaviors at all. The resident is not aggressive. The MD stated that he assessed the resident's cognition when he was first admitted to the facility and the resident scored a 25 out of 30 on the mini-mental exam. There was some discussion of whether he has [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder, but this has not been determined as of yet. The resident receives a low dose of [MEDICATION NAME] and consistently does well on mini-mental exams used to test his cognitive status. The facility determined that he was safe to go Out on Pass independently without supervision or an escort. The resident is compliant with his medication regimen and has never exhibited or reported any delusions or hallucinations. The MD stated that the resident is just odd. The resident answered appropriately when asked what state he was currently in, but he responded inappropriately when asked what country he resided in. The MD stated he got the impression that the resident was playing with me. The resident was admitted from the hospital on [MEDICATION NAME], and the MD believes that [MEDICAL CONDITION] disorder may be the diagnosis. It is difficult to obtain the psychiatric history for residents when they are admitted to the facility. Resident #31 does not have any involved family members, and the resident was unable to provide any history of his psychiatric treatment prior to admission. The resident has a current [DIAGNOSES REDACTED]. The MD stated that the resident might have a personality disorder or a mood disorder. The resident does not display any symptoms of mood issues. He stated it is more likely has a personality disorder because the resident is odd. Resident #31 has no problem conversing with the MD when approached. The MD stated that although the resident's record indicates that the resident has a [DIAGNOSES REDACTED]. The MD stated that if the resident had Dementia, he would expect to see some level of cognitive impairment. He does confer with the PNP, but he did not do so in this case. He would have communicated to the PNP that he does not believe that Resident #31 has a [DIAGNOSES REDACTED]. If the resident has not displayed any aggressive behavior or disordered thought process, then the [MEDICATION NAME] can be discontinued. According to the PNP, the [MEDICATION NAME] has been ordered for this resident to treat a [DIAGNOSES REDACTED]. The MD stated that he reviews the consults that the psychiatrist writes and determines if there should be any changes based on the recommendations made. The MD stated that [MEDICATION NAME] can be used to treat [MEDICAL CONDITION], thought disorders, and dementia with agitation and delusions. 415.12(l)(2)(ii)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that drugs and biological's were stored in accordance with Federal and State regulations. Specifically, 4 pre-filled syringes, containing expired Influenza Vaccine [MEDICATION NAME] Quadrivalent (YEAR)-2019, were in the medication refrigerator. This was evident for 1 of 9 areas observed for Medication Storage and Labeling (Nurse Staffing Coordinator's Office). The finding is: The facility policy titled, Expired Medications dated 4/22/19 documents: It is the policy of the Highbridge [NAME]ycrest Center to require the return of any expired medications to the pharmacy. Outdated (expired) drugs will be discarded and/or returned to the pharmacy per the manufacturers expiration date. All stock medications will be reviewed monthly to ensure that there are no expired drugs available for administration. The Charge Nurse will check the labels on the item each time prior to medication administration. The Nursing Supervisor will review stock items monthly to ensure there are no expired drugs available for use. On 12/3/19 at 3:35PM the facility medication storage task was performed in the Nurse Staffing Coordinator's Office. It was observed that one box of Influenza Vaccine [MEDICATION NAME] Quadrivalent (YEAR) - 2019 Season which contained 4 pre-filled syringes each containing a single 0.5 ml dose was stored in the medication refrigerator. The box was labeled with Lot number -YF and an expiration date of (MONTH) 30, 2019. On 12/3/19 at 3:42PM the Director of Nursing was interviewed and stated, This refrigerator contains active stock medications. In this refrigerator we store [MEDICATION NAME] Purified Protein Derivative (PPD), Influenza vaccine and [MEDICATION NAME] vaccine. You just showed me a box of Influenza vaccine that contains 4 pre-filled syringes which are expired. The expiration date says (MONTH) 30, 2019. Today's date is (MONTH) 3, 2019. So this Influenza vaccine is 156 days past its expiration date. It is the responsibility of the Nursing Supervisor on the day shift to check this refrigerator to make sure there are no expired medications in this refrigerator. This was probably overlooked as it is stored with the other in date Influenza vaccines. She will inservice the Nursing Supervisors and make sure, they check this refrigerator on a daily basis. The syringes will be discarded. No resident received the outdated Influenza vaccine this flu season. The dedicated Licensed Practical Nurse (LPN #1) that administers vaccines to the resident used the 2019-2020 vaccine. On 12/05/19 at 11:15 AM the LPN#1 was interviewed and stated, I usually administer the Influenza to all the residents in the facility. I go to the Nurse Staffing Coordinator's Office where the Influenza vaccine is given to me by the Nursing Supervisor on duty. I never go into the Nurse Staffing Coordinators Office to take any Influenza vaccine out of the refrigerator they keep there. I take the vaccine and I check the expiration date. I make sure the resident has a consent form. I will will do vital signs and administer the Influenza vaccine. I document the date administered and the site where it was injected. I take the extra sticker off the pre-filled syringe and paste it onto the vaccine administration record. The pre-filled syringe sticker shows you the Influenza vaccines lot number as well as the dates 2019-2020 documenting it is the new vaccine and not last year's expired vaccine. 415.18(d)

Based on record review and staff interview, during the recertification survey, the facility did not ensure that the infection prevention and control program included a water management plan that included a facility risk assessment, a water management program that considers ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standards, and water testing protocols to prevent the growth and spread of legionella and other waterborne pathogens. This was evident for the Facility which was reviewed for Infection Prevention, Control & Immunizations. The finding is: During the survey, the State Agency (SA) requested the water management plan developed to prevent Legionella and other waterborne pathogens. The facility did not have a water management plan that included the following requirements: A facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. A water management program that considers the ASHRAE industry standard and the CDC (Centers for Disease Control) toolkit. Specified testing protocols and acceptable ranges for control measures, and documentation of the results of testing and corrective actions taken when control limits are not maintained. On 10/17/18 at 2:00 PM, the Director of Administration (DOA) who oversees maintenance, housekeeping, and all contracts was interviewed. The DOA stated that the facility was taken over by new owners over a year ago. She further stated that the company that tests the water was going to come in to review the contract and what testing was done for the facility. On 10/18/18 at 11:00 AM and 10/22/18 at 11:15 AM, the DOA was re-interviewed. She stated that she was unaware that a facility risk assessment needed to be completed, but she is working on it. She further stated that she signed a contract last night with a company that will do water sampling. The DOA stated the previous owners were contacted and she was informed that no water testing was ever done at the facility. On 10/23/18 at 11:30 AM, the Lead Maintenance/Mechanic (LMM) was interviewed. He stated that the facility conducted monthly chlorine tests of the water. Last year, in (MONTH) (YEAR), the city came to the facility to confirm if the facility had a cooling tower that required Legionnaire's testing, but the facility does not have a cooling tower, so no testing was done. The LMM stated that now, the facility will begin testing for Legionnaire's quarterly, and ten water samples were taken on 10/17/18. He further stated that if any results were positive for Legionella, the contracted company would have to make recommendations regarding what actions should be taken. He stated the contracted company will provide the information to the DOA. 415.19(a)(1-3)

Based on observation, record reviews and interviews conducted during the Recertification survey, the facility did not ensure that a resident with Limited Range of Motion to upper extremity received the appropriate treatment and services to improve and/or to prevent a decrease in Range of Motion (ROM). Specifically, a resident was assessed to have limited range of motion to the right hand and no treatment and services were provided for the resident. This was evident for 1 resident that was reviewed for Range of Motion (ROM)Resident # 106. Findings are: Resident #106 is a [AGE] year-old, admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. On 08/30/2017 at 11:17 AM, the resident was observed in the room, alert and awake, was lying in bed, contracture noted to right hand in a form of a V shape, no splint device observed. The resident is non-verbal, unable to follow commands but the resident is able to open his eyes when the name is being called. On 08/30/17 during the Stage One Staff Interview, the Unit License Practical Nurse (LPN) stated that resident has a contracture to the right hand with no splint device and with no range of motion exercise provided. The Minimum Data Sets 3.0 (MDS) admission assessment dated [DATE] revealed that resident's cognitive status is severely impaired. The MDS also documented that resident required total assistance in performing Activity of Daily Livings (ADL'S). The MDS further documented that the resident had impairments to both upper and lower extremities. There is no documented evidence in the medical record that a care plan for contracture or range of motion was developed. The Physician order [REDACTED]. The Physical Therapy (PT) screening form dated 5/9/17 documented that the resident is non-verbal and unresponsive and the resident cannot follow commands. The PT further documented that the resident has a limited ROM to upper and lower extremities and dependent with all Activities of Daily Living (ADL's). The PT determined that the resident is total dependent in Activities of Daily Living (ADL's), nonverbal and cannot follow commands, therefore resident is not a candidate for PT services. The Occupational Therapy (OT) screening form dated 5/12/17 documented that the resident in non ambulatory and non-verbal. The OT evaluation further documented that the resident has a limited ROM to upper and lower extremities and dependent with all ADL's. The OT determined that the resident is total dependent in ADL's, nonverbal and cannot follow commands, therefore resident is not a candidate for PT/OT services. There was no documented evidence in the medical record that rehab made any recommendations to the nursing department for the resident's care. A review of the Certified Nursing Assistant (CNA) accountability records revealed no documented evidence that the resident received or was receiving passive range of motion exercises. On 8/30/17 at approximately 12:20 PM, an interview was conducted with the Certified Nursing Assistant (CNA) who stated that the resident is total care, cannot make needs known, and the resident is non-verbal. The CNA further stated that the resident never received range of motion exercises because it is not in the accountability form. The CNA also stated that the resident's right hand is contracted, and the resident can only move the left hand. On 08/31/2017 at 10:10AM, an interview was conducted with the Physical Therapist (PT), who explained the Rehab procedures as follow: every resident is screened and assessed for functional mobility. The Physical therapist assesses for balance, muscle strength. The PT stated that the resident is placed on restorative rehab program if the resident can follow commands. The PT further stated that resident # 106 was assessed to have limited mobility to upper and lower extremities, however not a candidate for both restorative and/or maintenance therapy. We only give therapy for residents who can follow simple commands. On 08/31/2017 at 10:33AM , an interview was conducted with Occupational Therapist (OT), who stated that all residents are screened during admission and they review the PRI , diagnosis, past medical history, cognitive assessment, the ADL's and of course the physical exams. The OT focuses on self-care assessment, that include feeding, grooming, dressing, toileting and hygiene. The OT further stated that this resident has poor cognition, unable to response to verbal commands, and the right hand is [DIAGNOSES REDACTED], no active movement, on the left hand there is a limited ROM. The OT determined that resident is not a candidate of OT because the resident has a poor cognition, unable to follow commands. On 08/31/2017 at 10:45AM, an interview conducted with the the Unit Licensed Practical Nurse (LPN) who stated that the resident was admitted with a contracture to right hand and had never received maintenance range of motion. The LPN further stated that resident can only receive ROM if recommended by the rehab staff. On 08/31/2017 at 11:05AM , an interview was conducted with the Assistant Director of Nursing (ADNS) who stated that the rehab staff will assess the resident as soon as the resident is admitted to the facility. Then the rehab would make recommendations. The rehab department develops a care plan based on the need of the residents. A restorative PT/OT is needed for resident who can achieve rehab goal. However, those residents who have impaired cognition can also benefit from maintainance rehab. There was no documented evident in the resident's medical record to indicate that the resident would not benefit from nursing rehabilitiation services. In addition there was nothing noted by the physician, or rehabilitiation department that indicated that a reduction in mobility was demonstrably unavoidable and as such rehabilitation services such as passive range of motion would not prevent further decline. 415.12(e)(2)

Based on observations and interviews the facility did not ensure that the kitchen stored food at the proper temperature to prevent contamination and food borne illness. This resulted in no actual harm with potential for more than minimal harm. The finding is: On 5/26/15 at approximately 10:00 am the initial tour of the kitchen was conducted. The walk in refrigerator temperature was observed at 60 degrees. The refrigerator contained uncooked meat, chicken, cold cuts and fresh produce. On 5/27/15 at 10:36 am a second observation of the walk in refrigerator revealed a temperature of 50 degrees. The Refrigerator Temperature Log For 24-Hour Operation Form revealed that on 5/26/15 and 5/27/15 at 6:00am the temperature was 36 degrees. On 5/27/15 at approximately 11:00am the General Manager of Nutrition Services was interviewed and stated that the refrigerator was serviced and that a part needed to be replaced. The Service Contractor work order dated 5/26/15 at 10:56 am documented that the refrigerator temperature was 55 degrees and the defrost clock needed to be replaced. On 5/28/15 at 10:30 am the FSD (Food Service Director) was interviewed and stated that on 5/26/15 the staff had been loading the refrigerator from a morning delivery, and by keeping the door open it caused the refrigerator temperature to increase. She stated that the refrigerator temperature is monitored 3 times a day at 6 am, 9-9:30am and 6:00pm and is logged on the log form. She added that the refrigerator temperature should be between 36-40 degrees . 415.14(h)

Based on observations , record reviews and interviews the facility did not ensure that expired medications were discarded from the medication refrigerator. This was evident on unit 2 of 4 units observed for medication storage (units 1 and 4). This resulted in no actual harm with potential for more than minimal harm. The findings are: On 5/26/15 at 9: 57am the medication refrigerator was observed on the 4th floor. The refrigerator contained 1 vial of Humulog Insulin, Lispro, for resident #94. The label on the Lispro vial documented an opening date of 4/22/15. The Licensed Practical Nurse ( LPN ) was interviewed immediately and stated that she had checked for expired medications this morning but did not discard the Lispro. She stated that she was holding on to it in case she needed it. She added that she was aware that the Lispro, once opened the vial should be discarded after 28 days. On 5/26/15 at 10:15am the medication refrigerator was observed on the 1st floor. The refrigerator contained the following expired medications. One vial of Tuberculin, Purified Protein Derivative (PPD) one quarter full , documented an opening date of 3/28/15. A second vial PPD one quarter full, documented an opening date of 4/10/15. The RN ( Registered Nurse ) Supervisor was interviewed immediately and stated that she had checked the refrigerator 2 days ago and she did not see the PPD's. The LPN stated that she did not see them on the day before and did not check the refrigerator on 5/26/15. It is the responsibility of the Nurse to check the refrigerator every morning. The PPD once opened should be discarded after 30 days. The Policy and Procedure revision dated 10/2008 Storage of Medication documented: Multi dose vials whether or not requiring refrigeration, upon opening must be labeled with the residents name , date medication vial is opened and date of discard. Multi-dose vial medications are good for 28 days. 415.18 (d)

Based on record review and interview the facility did not ensure a surety bond was obtained to ensure the security of all personal funds of residents deposited with the facility. This resulted in no actual harm with potential for no more than minimal harm. The findings are: The ledger dated 6/12/14 documented the total balance of resident funds deposited was $24,738.97. An interview was conducted with the finance manager on 6/12/14 at 10:00am. She stated that she was not aware of a surety bond or any other insurance to ensure the security of residents' personal funds. An interview was conducted with the Administrator on 6/13/14 at approximatly 9:30am. The Administrator stated that they do not have a surety bond because it is not cost effective. He further stated that it cost $3,000 to obtain a surety bond and usually the resident population usually has less then $10,000. He further stated that the facility is affiliated with a hospital, and the finaincial aspect of the facility is managed by the hospital's business office. He further stated that they would cover the costs in the event of a loss. 415.26(h)(5)(v)

Based on observation and staff interview during the annual survey, it was determined that the facility did not ensure that the resident call bell system was installed and functioned as required. This was evidenced by: (1) The lack of call bell lights outside the resident rooms and inside the soiled utility rooms and (2) The ability of staff to deactivate the call bell system from the nurse ' s station on the floors without having to go to the location where the call was generated. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings are: On 6/4/13 during environmental rounds it was noted that the resident call bell system did not provide an audible and a visible signal outside the residents ' rooms, and in the soiled utility rooms on 4 of 4 resident floors. It was also noted that after the call bell system had been activated at the residents ' rooms and the bathrooms that the system could be deactivated at the nurse ' s station by the staff communicating over the speaker to the resident. Call bell system should not be installed to be turned off at the nurse ' s station. In an interview with the Director of Environmental Services on 6/4/13 at approximately 11:30 AM he stated that the system had always been that way and he also indicated that there were talks about upgrading the system but nothing had been done. NYCRR 713-1.19(a) (2) (g)

Based on record reviews, resident and staff interviews, the facility failed to conduct an investigation of how illicit drugs were obtained by residents known to have a history of substance abuse and recurrent history of drug relapses. The facility failed to report to the proper authorities the use of illicit drugs by residents. This was evident for three (3) of seventeen (17) sampled residents. (Resident # 3, # 11, and # 14). This resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This also resulted in the potential for serious harm to the health and safety of 45 additional residents in the facility with a history of substance abuse. The findings are: A review of facility policy and procedure for Resident Neglect and Abuse and Misappropriation of Resident Property dated March 2010, documented the following: All alleged violations involving mistreatment, neglect or abuse including injuries of unknown origin and misappropriation of resident property shall be immediately reported to the Administrator or designee. When required by law or regulation, the case will be reported to the New York State Department of Health (NYSDOH) in accordance with section 2803 -D of the Public Health Law and immediate corrective actions will be initiated. All alleged violations shall be thoroughly investigated and documented. The Investigation section E portion documents the following: All complaints must be investigated immediately and be concluded in no longer than five (5) days and in a manner that protects a complainant's anonymity and privacy and keeps the resident free from physical, mental, and sexual, verbal and psychological abuse at all times (particularly when either a staff member or another resident is alleged to have committed the abuse). Investigations will be conducted with respect of due process rights of individuals under investigation. Oral and written evidence will be collected. Sources of information will include residents, their families, visitors and staff. 1) Resident #3 is a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] Dose Distributed (MDD) 20 mg per 24 hours. [DIAGNOSES REDACTED]. There is no documented evidence that the medication benzodiazepine was prescribed for the resident.The counselor note dated 5/31/11 (unspecified time) documented "counselor received phone message from substance abuse counselor (SAC) regarding concerns relative to res abusing medications ([MEDICATION NAME]). SAC recommendation for res to be seen by psychiatrist for evaluation. Counselor informed medical doctor of her concerns. Counselor met with client to assess for drug abuse. Resident was counseled in preventing further use of illicit drugs." There is no documented evidence that an investigation was conducted regarding the use and/or source of illicit drugs. The Medical Assessment form dated 6/8/11 documented that the resident has history of benzodiazapine abuse and was counseled. The nursing note dated 6/9/11 at 11:10 pm documented that the resident was found in room unresponsive. Following the resident's return from the hospital on [DATE] with [DIAGNOSES REDACTED]. There is no documented evidence that an investigation was done regarding the resident obtaining illicit drugs that resulted in resident being admitted to hospital with a [DIAGNOSES REDACTED]." The nursing note dated 7/1/11 documented "late entry...resident found in parking lot very lethargic..." The Security Incident Report dated 7/01/11 documented, ..." body search on .. (name of resident ) and found one (1) bottle of 25 - 30 [MEDICATION NAME] pills, 8 [MEDICATION NAME], money (100.00 dollars). While conducting the search (name of resident) appeared to be under the influence of something." This report documents "New York Police Department (NYPD) CALLED?: and was checked "NO." A note from the (SAC) dated 7/5/11 documented "late entry counselor met with resident to address non compliance of rules and regulations regarding illicit drug use/possession. Resident was found to have in his possession 25-30 [MEDICATION NAME] pills/ [MEDICATION NAME] (8) in addition to 100 dollars in his person upon entering the facility. Resident counseled on preventing further illegal activity additionally he was placed on 45 day therapeutic restriction, SAC also placed a call to his SAC at the [MEDICATION NAME] clinic to establish weekly pick up by our representative....Counselor met with resident to offer Detox services for Benzodiazapine abuse...resident refused services ..." There is no documented evidence that an investigation was conducted was conducted and/or the police were notified after the resident was known to have illicit drugs in his possession in the nursing home. The urine toxicology reports dated 7/8/11 and 7/29/11 documented that the results were positive for Benzodiazapine screen. There is no documented evidence that an investigation was done regarding the positive results for benzodiazapine screen. 2) Resident # 11 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident is cognitively intact and independent with activities of daily living. The physician's orders [REDACTED]. 40 mg(s) by mouth one time a day provided by MMTP ([MEDICATION NAME] Maintenance Treatment Program), (MDD=40mgs per 24 hours) ([MEDICATION NAME] Dose Distributed), Dx. (Diagnosis) Opioid Dependence. On 8/15/11 at 12:20 pm the resident was interviewed and stated that "some of the residents in the facility are selling drugs that they get at their [MEDICATION NAME] Program..."It is too easy to get the drugs here and no one is watching." He further stated that he has "become more depressed following his repeated relapses and that a lack of group sessions and programs here make it harder to remain drug free." The resident added that he has had a total of 6 relapses since his admission. He was required to sign a non-compliance contract after each relapse..."I am feeling more depressed." The resident further stated that on 7/15/11 he bought five sticks of [MEDICATION NAME] from another resident he took all five sticks and was sitting near the nurses station. He was "nodding out" and the nurse came over to check on him and he was sent out to the hospital. On 8/16/11 at 3:10 pm the ADON ( Assistant Director of Nursing) was interviewed and she stated that she did not initiate an investigation because the resident was sent out due to a change in his mental status. She further stated that she was aware that some of the residents obtained drugs while at the [MEDICATION NAME] Clinic. Physician's Note dated 7/27/11 for resident readmission following overdose documented that Patient was admitted to the hospital for opiate overdose, intubated initially for [MEDICAL CONDITION] and later extubated. There is no documented evidence that an investigation was done and/or the police notified regarding the resident's illegal use of drugs and his possession of drugs in the nursing home. There is no documented evidence that an investigation was done regarding the resident's admission to the hospital with a drug overdose. The Hospital Discharge summary dated 7/26/11 documented that "the resident was brought from the Nursing home (NH) due to altered mental status and [MEDICAL CONDITION] ( low oxygen saturation) with oxygen saturation of 89 % (percent). Initially improved on venting mask and had pinpoint pupils. Initial [DIAGNOSES REDACTED]. [MEDICATION NAME] drip was given after which, mental status improved." 3) Resident #14 was admitted to facility on 7/3/09 with [DIAGNOSES REDACTED]. The Multidisciplinary Progress Notes (MPN) were reviewed and they revealed several inconsistencies in their documentation. The note written by the SAC staff dated 2/17/11 documented that the "...Counselor met with resident to address concerns of purchasing pills from client at the [MEDICATION NAME] treatment program ...resident was counseled and redirected to speak to social worker for further instructions..." The Urine Toxicology test collected on 2/24/11 documented a positive result for Benzo/opiate screen. There is no documented evidence that an investigation was conducted regarding the resident obtaining and injecting illicit drugs and the results of the positive Urine Toxicology Screen. The nursing note dated 6/2/11 at 10:30 am documented " Late entry for 6/1/11 - 2:30 pm - Resident observed at nurses station asleep in chair, when aroused resident fell right back to sleep. Resident was heavily sedated and found it hard to keep his head up or eyes open. Unable to hold conversation without drifting off. MD (Medical Doctor) called to nurses station to evaluate resident who at this time was asking for pain medications ([MEDICATION NAME] sulfate)..." The Incident /Accident Report dated 06/07/11 documented "...witnessed..." ..."noted resident give a white pill to another resident..." The Multidisciplinary Progress Note (MPN) dated 6/8/11 written by the Social Worker documented, "General meeting with resident to follow up with incident report. Resident was found giving another resident a white pill. Resident denies report. Resident Services Director and Social Worker informed resident if he is caught with any transactions, he will be placed on restriction. If resident continues with problem behaviors, facility will proceed with discharge to appropriate placement. Resident understood and agreed. Continue with careplan goals and interventions " . There is no documented evidence that an investigation was done regarding the resident obtaining a white pill that was given to another resident. The note written by the resident service director dated 6/24/11 documented " Special CCP meeting held with resident to address his involvement with the distribution of pills to other residents. Initially resident denied above allegations, however shortly after admitted his involvement in the above matter..." . The Routine Resident Checks policy and procedure dated 7/09 documented that the "Routine resident checks shall be made every shift at designated hours ...to ensure that the resident's safety and well being is maintained ...the nursing personnel will ensure the safety and well being of the residents and make a resident check at least once every shift throughout each 24 hour shift. It further documented that the nursing supervisor will review rounds sheets, and ensure that rounds/checks are documented and sent to the ADNS/nursing office on a daily basis. However, this policy does not address the facility investigation into how residents obtain illicit drugs. The Facility documented that there are 45 residents in the facility with a history of substance abuse. 4) On 08/12/11 at 10:00 am eleven (11) Residents attended the Resident Group Session. Eleven (11) of eleven (11) Residents complained that their recovery here at the facility was being compromised because of the ongoing use and sale of illicit drugs here at the facility. On 08/16/11 at 3:10 pm the Registered Nurse (RN) was interviewed and stated that she was aware that residents bought drugs from the clinic and nothing is done. She further stated that she was not aware of anything being done to deal with the issue of illicit drugs being brought into the facility by the residents. .On 8/18/11 at 4:45 pm the charge nurse was interviewed and stated that she was aware of illicit drug uses within the facility and from residents having positive urine tests....She further stated she has heard from other residents about illicit drug uses and had reported to the Substance Abuse Counselor to investigate. On 08/19/11 at 2:30 pm the Administrator was interviewed and he stated that he did not notify the police and that there were no investigations conducted regarding the residents' use of illicit drugs. He further stated that it his responsibility is to provide residents with a safe environment, free of illicit drugs, relapse and to ensure the prevention of residents relapsing. 415.4(b)(1)(ii)

Based on record reviews, resident and staff interviews the facility failed to implement their policies and procedures to investigate, protect, prevent and notify the appropriate authorities when the residents were found with illicit drugs and or hospitalized for [REDACTED]. This was evident for three (3) of 17 sampled Residents. (Resident # 3, # 11, and # 14.). This resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This also resulted in the potential for serious harm to the health and safety of 45 additional residents in the facility with a history of substance abuse. The findings are: A review of facility policy and procedure for Resident Neglect and Abuse and Misappropriation of Resident Property dated march 2010 documented the following: All alleged violations involving mistreatment, neglect or abuse including injuries of unknown origin and misappropriation of resident property shall be immediately reported to the Administrator or designee. When required by law or regulation, the case will be reported to the New York State Department of Health (NYSDOH) in accordance with section 2803 -D of the Public Health Law and immediate corrective action will be initiated. All alleged violations shall be thoroughly investigated and documented. The Investigation section E portion documents the following: All complaints must be investigated immediately and be concluded in no longer than five (5) days and in a manner that protects a complainant's anonymity and privacy and keeps the resident free from physical, mental, and sexual, verbal and psychological abuse at all times (particularly when either a staff member or another resident is alleged to have committed the abuse). Investigations will be conducted with respect of due process rights of individuals under investigation. Oral and written evidence will be collected. Sources of information will include residents, their families, visitors and staff. 1) Resident #3 is a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] Dose Distributed (MDD) 20 mg per 24 hours. [DIAGNOSES REDACTED]. There is no documented evidence that the medication benzodiazepine was prescribed for the resident.The counselor note dated 5/31/11 (unspecified time) documented "counselor received phone message from substance abuse counselor (SAC) regarding concerns relative to res abusing medications ([MEDICATION NAME]). SAC recommendation for res to be seen by psychiatrist for evaluation. Counselor informed medical doctor of her concerns. Counselor met with client to assess for drug abuse. Resident was counseled in preventing further use of illicit drugs." There is no documented evidence that an investigation was conducted regarding the use and/or source of illicit drugs. The Medical Assessment form dated 6/8/11 documented that the resident has history of benzodiazapine abuse and was counseled. The nursing note dated 6/9/11 at 11:10 pm documented that the resident was found in room unresponsive. Following the resident's return from the hospital on [DATE] with [DIAGNOSES REDACTED]. There is no documented evidence that an investigation was done regarding the resident obtaining illicit drugs that resulted in resident being admitted to hospital with a [DIAGNOSES REDACTED]." The nursing note dated 7/1/11 documented "late entry...resident found in parking lot very lethargic..." The Security Incident Report dated 07/01/11 documented, ..." body search on .. (name of resident ) and found one (1) bottle of 25 - 30 [MEDICATION NAME] pills, 8 [MEDICATION NAME], money (100.00 dollars). While conducting the search (name of resident) appeared to be under the influence of something." This report documents "New York Police Department (NYPD) CALLED?: and was checked "NO." A note from the (SAC) dated 7/5/11 documented "late entry counselor met with resident to address non compliance of rules and regulations regarding illicit drug use/possession. Resident was found to have in his possession 25-30 [MEDICATION NAME] pills/ [MEDICATION NAME] (8) in addition to 100 dollars in his person upon entering the facility. Resident counseled on preventing further illegal activity additionally he was placed on 45 day therapeutic restriction, SAC also placed a call to his SAC at the [MEDICATION NAME] clinic to establish weekly pick up by our representative....Counselor met with resident to offer Detox services for Benzodiazapine abuse...resident refused services ..." There is no documented evidence that an investigation was conducted and/or the police notified after the resident was known to have illicit drugs in his possession in the nursing home. The urine toxicology reports dated 7/8/11 and 7/29/11 documented that the results were positive for Benzodiazapine screen. There is no documented evidence that an investigation was done regarding the positive results for benzodiazapine screen. 2) Resident # 11 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident is cognitively intact and independent with activities of daily living. The physician's orders [REDACTED]. 40 mg(s) by mouth one time a day provided by MMTP ([MEDICATION NAME] Maintenance Treatment Program), (MDD=40mgs per 24 hours) ([MEDICATION NAME] Dose Distributed), Dx. (Diagnosis) Opioid Dependence. On 8/15/11 at 12:20 PM the resident was interviewed and stated that "some of the residents in the facility are selling drugs that they get at their [MEDICATION NAME] Program..."It is too easy to get the drugs here and no one is watching." He further stated that he has "become more depressed following his repeated relapses and that a lack of group sessions and programs here make it harder to remain drug free." The resident added that he has had a total of 6 relapses since his admission. He was required to sign a non-compliance contract after each relapse..."I am feeling more depressed." The resident further stated that on 7/15/11 he bought five sticks of [MEDICATION NAME] from another resident he took all five sticks and was sitting near the nurses station. He was "nodding out" and the nurse came over to check on him and he was sent out to the hospital. On 8/16/11 at 3:10 P.M. the ADON ( Assistant Director of Nursing) was interviewed and she stated that she did not initiate an investigation because the resident was sent out due to a change in his mental status. She further stated that she was aware that some of the residents obtained drugs while at the [MEDICATION NAME] Clinic. Physician's Note dated 7/27/11 for resident readmission following overdose: Pt. was admitted to the hospital for opiate overdose, intubated initially for [MEDICAL CONDITION] and later extubated. There is no documented evidence that an investigation was done and/or the police notified regarding the resident's illegal drug use and his possession of drugs in the nursing home. There is no documented evidence that an investigation was done regarding the resident's admission to the hospital with a drug overdose. The Hospital Discharge summary dated 7/26/11 documented that "the resident was brought from the Nursing home (NH) due to altered mental status and [MEDICAL CONDITION] ( low oxygen saturation) with oxygen saturation of 89 % (percent). Initially improved on venting mask and had pinpoint pupils. Initial [DIAGNOSES REDACTED]. [MEDICATION NAME] drip was given after which, mental status improved." A review of facility policy and procedure for Resident Neglect and Abuse and Misappropriation of Resident Property dated march 2010 documents that all incidents will be fully investigated irrespective of the source. The investigations will include assessment of signs of physical injury and or changes in mental status mood or behavior. Steps of the investigation include strategies to prevent occurrences. Including reassessment of facility strategies on a regular basis to prevent occurrences. Supervision and Monitoring of the individual for any change that would trigger identified behaviors. 3) Resident #14 was admitted to facility on 7/3/09 with [DIAGNOSES REDACTED]. The note written by the SAC staff dated 2/17/11 (unspecified time) documented that the " Counselor met with resident to address concerns of purchasing pills from client at the [MEDICATION NAME] treatment program ...resident was counseled and redirected to speak to social worker for further instructions..." The Urine Toxicology test collected on 2/24/11 documented a positive result for Benzo/opiate screen. There is no documented evidence that an investigation was conducted regarding the resident obtaining and injecting illicit drugs and the results of the positive Urine Toxicology Screen. The Resident Council Minutes dated 03/16/11 documented that the residents asked "...can there be more drug test, because people are acting strange. They give urine today and then get high tomorrow..." The Resident Council Minutes dated 4/20/11 documented, "...groups on how to deal with street issues, drugs..." The nursing note dated 6/2/11 at 10:30 am documented " Late entry for 6/1/11 - 2:3 - Resident observed at nurses station asleep in chair, when aroused resident fell right back to sleep. Resident was heavily sedated and found it hard to keep his head up or eyes open. Unable to hold conversation without drifting off. MD (Medical Doctor) called to nurses station to evaluate resident who at this time was asking for pain medications ([MEDICATION NAME] sulfate)..." The Incident /Accident Report dated 06/07/11 documented "...witnessed..." ..."noted resident give a white pill to another resident..." The Multidisciplinary Progress Note (MPN) dated 6/8/11 written by the Social Worker documented, "General meeting with resident to follow up with incident report. Resident was found giving another resident a white pill. Resident denies report. Resident Services Director and Social Worker informed resident if he is caught with any transactions, he will be placed on restriction. If resident continues with problem behaviors, facility will proceed with discharge to appropriate placement. Resident understood and agreed. Continue with careplan goals and interventions " . .There is no documented evidence that an investigation was done regarding the resident obtaining a white pill that was given to another resident. The note written by the resident service director dated 6/24/11 documented " Special CCP meeting held with resident to address his involvement with the distribution of pills to other residents. Initially resident denied to above allegations, however shortly after admitted his involvement in the above matter..." . The Routine Resident Checks policy and procedure dated 7/09 documented that the "Routine resident checks shall be made every shift at designated hours ...to ensure that the resident's safety and well being is maintained ...the nursing personnel will ensure the safety and well being of the residents and make a resident check at least once every shift throughout each 24 hour shift. It further documented that the nursing supervisor will review rounds sheets, and ensure that rounds/checks are documented and sent to the ADNS/nursing office on a daily basis. However, this policy does not address the facility investigation into how residents obtain illicit drugs. The Facility documented that there are 45 residents in the facility with a history of substance abuse. 4) On 08/12/11 at 10:00 AM eleven (11) Residents attended the Resident Group Session. Eleven (11) of eleven (11) Residents complained that their recovery here at the facility was being compromised because of the ongoing use and sale of illicit drugs here at the facility. On 08/16/11 at 3:10 PM the Registered Nurse (RN) was interviewed and stated that she was aware that residents bought drugs from the clinic and nothing is done. She further stated that she not aware of anything being done to deal with the issue of illicit drugs being brought into the facility by the residents. .On 8/18/11 at 4:45 PM the charge nurse was interviewed and stated that she was aware of illicit drug uses within the facility and from residents having positive urine tests....She further stated she has heard from other residents about illicit drug uses and had reported to the Substance Abuse Counselor to investigate. On 08/19/11 at 2:30 pm the Administrator was interviewed and he stated that he did not notify the police and that there were no investigations conducted regarding the residents' use of illicit drugs. He further stated that it his responsibility is to provide residents with a safe environment, free of illicit drugs, relapse and to ensure the prevention of residents relapsing. 415.4(b)(1)(ii)

Based on record review and resident and staff interview the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and in accordance with their care plan as evidenced by specifically: Failure to take corrective actions for residents known to be a substance abuser which resulted in incidences of relapse/overdose and failed to implement non compliance contracts given to residents that mandated group attendance. Failure to investigate and properly discharge residents who were found in possession of illicit drugs. Failure to provide in-service training to all pertinent staff other than the Substance Abuse Counselor on the management of residents with history of substance abuse. Failure to provide the mandates groups. This was evident for three (3) of 17 sampled Residents. (Resident # 3, # 11, and # 14.). This resulted in actual harm for (Residents#3 and #11) and Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This also resulted in the potential for serious harm to the health and safety of 45 additional residents in the facility with a history of substance abuse. The findings are: 1) Resident #3 is a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Methadone Dose Distributed (MDD) 20 mg per 24 hours. [DIAGNOSES REDACTED]. There is no documented evidence that the medication benzodiazepine was prescribed for the resident.The counselor note dated 5/31/11 (unspecified time) documented "counselor received phone message from substance abuse counselor (SAC) regarding concerns relative to res abusing medications (xanax). SAC recommendation for res to be seen by psychiatrist for evaluation. Counselor informed medical doctor of her concerns. Counselor met with client to assess for drug abuse. Resident was counseled in preventing further use of illicit drugs." There is no documented evidence of arranging for the continuous provision of needed counseling and obtaining services from outside entities for the resident regarding the use of illicit drugs. The physician Medical Assessment form dated 6/8/11 documented that the resident has history of benzodiazapine abuse and was counseled. The nursing note dated 6/9/11 at 11:10 pm documented that the resident was found in room unresponsive. Following the resident's return from the hospital on [DATE] with [DIAGNOSES REDACTED]. The nursing note dated 7/1/11 documented "late entry...resident found in parking lot very lethargic..." The Security Incident Report dated 07/01/11 documented, ..." body search on .. (name of resident ) and found one (1) bottle of 25 - 30 Methadone pills, 8 Xanax, money (100.00 dollars). While conducting the search (name of resident) appeared to be under the influence of something." This report documents "New York Police Department (NYPD) CALLED?: and was checked "NO." A note from the (SAC) dated 7/5/11 documented "late entry counselor met with resident to address non compliance of rules and regulations regarding illicit drug use/possession. Resident was found to have in his possession 25-30 methadone pills/ xanax (8) in addition to 100 dollars in his person upon entering the facility. Resident counseled on preventing further illegal activity additionally he was placed on 45 day therapeutic restriction, SAC also placed a call to his SAC at the Methadone clinic to establish weekly pick up by our representative....Counselor met with resident to offer Detox services for Benzodiazapine abuse...resident refused services ..." There is no documented evidence that social service intervened regarding the administrative discharge of resident who is non-compliant to facility rules and regulations regarding illicit drug use, possession, and overdose of illicit drugs. there is no documented evidence that social service/SAC conducted an investigation regarding resident being found with illicit drugs. The urine toxicology reports dated 7/8/11 and 7/29/11 documented that the results were positive for Benzodiazapine screen. There is no documented evidence that SAC continuously met and counseled with resident regarding positive results for Benzodiazapine screen. 2) Resident # 11 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident is cognitively intact and independent with ADL's. The Non Compliance contract dated 8/2/10 documented that the resident admitted to manipulating urine provided on 8/2/10. There are a total of 8 groups that the resident was mandated to attend as part of this contract. These include: Journey to Recovery, Positive Living, Focusing on Self, Tools to Recovery, Relapse Prevention, Anger, Behavior and Compliance. In addition, the contract reads: "1) I shall remain on Non Compliance contract from 8/2/10 until 9/15/10. This means that I may not leave the facility for any reason other than an approved medical appointment and other necessary appointments. I may go onto the patio but not down the back stairs into the parking lot. Any infraction of this restriction will result in final warning or discharge. 2) I shall remain drug/alcohol free for the duration of my residency at this facility. 3) I shall attend all groups. 5) I shall attend all my medical appointments. 6) I shall take my medication as indicated by the treatment plan. 7) I shall submit toxicology profiles whenever requested by members of the Medical, Resident Services or nursing staff. THERE WILL BE NO EXCEPTIONS. FAILURE TO SUBMIT A TOXICOLOGY PROFILE WILL RESULT IN A FINAL WARNING OR DISCHARGE. 8) I shall meet with my Social Worker (SW) and Substance Abuse counselor (SAC) for scheduled counseling and relapse prevention sessions. 9) I understand that any deviation from this contract shall result in a final warning or discharge. 10) I understand that criminal or other antisocial behavior is prohibited. The following are grounds for immediate discharge: a) Drug dealing b) Any unsafe behavior. 'I have read and understand the terms of this contract and agree to abide by all components'." Contract #2 from 9/15/10 until 10/29/10 " Resident admits to consuming Xanax. ( over medication/ purchasing on the street)" this contract includes all of the above with the exception of the mandated groups: All Mainstream Groups as well as the ABC Groups, (Anger, Behavior and Compliance). Contract #3 from 11/30/11 until 1/15/11 "Resident in possession of 3 Xanax not prescribed by Physician" this contract includes all of the above with the exception of the mandated groups: All mainstream Groups in addition to the ABC Groups, Anger, Behavior and Compliance. Contract #4 "Toxicology results indicate positive for unauthorized benzodiazapine/ In addition to manipulation of urine." Contract for urine manipulation from 3/1/11 until 4/15/11 and Benzodiazapine contract from 3/1/11 until 3/31/11. Same groups as above. Contract #5 "Positive toxicology results indicate Benzodiazapine on 4/15/11 and 4/26/11" this contract includes: Mainstream Groups, Positive Living, Community Meeting and Resident Council. Contract #6 from 7/15/11 until 8/14/11 " Toxicology report on 7/8/11 indicates positive results for Amphetamine and Benzodiazapine" this contract includes: Community Group, Resident Council, Smoking Group and NA Group (Narcotics Anonymous). The physician's orders [REDACTED]. 40 mg(s) by mouth one time a day provided by MMTP (Methadone Maintenance Treatment Program), (MDD=40mgs per 24 hours) (Methadone Dose Distributed), Dx. (Diagnosis) Opioid Dependence. The Hospital Discharge summary dated 7/26/11 documented that "the resident was brought from the Nursing home (NH) due to altered mental status and hypoxia ( low oxygen saturation) with oxygen saturation of 89 % (percent). Initially improved on venting mask and had pinpoint pupils. Initial [DIAGNOSES REDACTED]. Narcan drip was given after which, mental status improved." Physician's Note dated 7/27/11 for resident readmission following overdose: Pt. was admitted to the hospital for opiate overdose, intubated initially for hypoxia and later extubated. Psychiatry consult dated 8/1/11 documented that the resident "has a long history of Schizoaffective Disorder and Substance Abuse vs. Dependence. Pt. was recently hospitalized 2nd unintentional overdose with Xanax." " I took 5 sticks I thought I could handle them " "in May pt. had an episode of over sedation for similar situation." Psych Meds: Methadone 40 mg. QD; Seroquel 100mg HS, Zoloft 100 mgr QD (from 200) mg daily. Diagnosis: [REDACTED]. A review of the Monthly Inter-Disciplinary CCP Meeting Note dated 8/11/11 under Concerns/Issues: "Ambulates with cane, compliant with care and treatment regimen, no behavior issues". On 8/15/11 at 12:20 PM the resident was interviewed and stated that "some of the residents in the facility are selling drugs that they get at their Methadone Program..."It is too easy to get the drugs here and no one is watching." He further stated that he has "become more depressed following his repeated relapses and that a lack of group sessions and programs here make it harder to remain drug free." The resident added that he has had a total of 6 relapses since his admission. He was required to sign a non-compliance contract after each relapse..."I am feeling more depressed." The resident further stated that on 7/15/11 he bought five sticks of Xanax from another resident he took all five sticks and was sitting near the nurses station. He was "nodding out" and the nurse came over to check on him and he was sent out to the hospital. On 8/16/11 at 3:10 P.M. the ADON ( Assistant Director of Nursing) was interviewed and she stated that she did not initiate an investigation because the resident was sent out due to a change in his mental status. She further stated that she was aware that some of the residents obtained drugs while at the Methadone Clinic. A review of facility policy and procedure for Resident Neglect and Abuse and Misappropriation of Resident Property dated march 2010 documents that all incidents will be fully investigated irrespective of the source. The investigations will include assessment of signs of physical injury and or changes in mental status mood or behavior. Steps of the investigation include strategies to prevent occurrences. Including reassessment of facility strategies on a regular basis to prevent occurrences. Supervision and Monitoring of the individual for any change that would trigger identified behaviors. 3) Resident #14 was admitted to facility on 7/3/09 with [DIAGNOSES REDACTED]. The note written by the SAC staff dated 2/17/11 (unspecified time) documented that the " Counselor met with resident to address concerns of purchasing pills from client at the Methadone treatment program ...resident was counseled and redirected to speak to social worker for further instructions..." The Urine Toxicology test collected on 2/24/11 documented a positive result for Benzo/opiate screen. There is no documented evidence that an investigation was conducted regarding the resident obtaining illicit drugs and the results of the positive Urine Toxicology Screen. The nursing note dated 6/2/11 at 10:30 am documented " Late entry for 6/1/11 - 2:3 - Resident observed at nurses station asleep in chair, when aroused resident fell right back to sleep. Resident was heavily sedated and found it hard to keep his head up or eyes open. Unable to hold conversation without drifting off. MD (Medical Doctor) called to nurses station to evaluate resident who at this time was asking for pain medications (morphine sulfate)..." The Incident /Accident Report dated 06/07/11 documented "...witnessed..." ..."noted resident give a white pill to another resident..." The Multidisciplinary Progress Note (MPN) dated 6/8/11 written by the Social Worker documented, "General meeting with resident to follow up with incident report. Resident was found giving another resident a white pill. Resident denies report. Resident Services Director and Social Worker informed resident if he is caught with any transactions, he will be placed on restriction. If resident continues with problem behaviors, facility will proceed with discharge to appropriate placement. Resident understood and agreed. Continue with careplan goals and interventions " . There were 3 group meetings held from 6/27/11 thru 7/25/11 as documented and the resident attended none of the meetings held. The note written by the resident service director dated 6/24/11 documented " Special CCP meeting held with resident to address his involvement with the distribution of pills to other residents. Initially resident denied to above allegations, however shortly after admitted his involvement in the above matter..." . The Job Description and Appraisal for the Substance Abuse Counselor documented that she "Reports to: Director of Resident Services"...and Responsibilities include..."Liaison with AA/NA...Provide in-house substance abuse related in-services/workshops for (facility name) Staff". . 4) The Resident Council Minutes dated 03/16/11 documented that the residents asked "...can there be more drug test, because people are acting strange. They give urine today and then get high tomorrow..." The Resident Council Minutes dated 4/20/11 documented, "...groups on how to deal with street issues, drugs..." 08/12/11 at 10:00 AM eleven (11) Residents attended the Resident Group Session. Eleven (11) of eleven (11) Residents complained that their recovery here at the facility was being compromised because of the ongoing use and sale of illicit drugs here at the facility. On 8/19/11 at 1:15 PM the Substance Abuse Counselor was interviewed and stated that according to groups scheduled between 4/1/11 thru 7/30/11 one hundred and forty four groups should have occurred and only 17 groups were held as planned due to being the only SAC on staff. On 08/19/11 at 1:45 PM the Director of Social Services (DSS) was interviewed and was asked to explain her role and responsibilities here at the facility. She stated that she is responsible for the Advocacy of the Residents and is responsible for overseeing the Substance Abuse Program. " I am responsible for ensuring that the Residents attend their mandatory meetings and assist in the referral to outside agencies and programs." The Substance Abuse Counselor (SAC) reports to me and she is the person who heads the three (3) Mandated Groups. These groups are the ABC acronym for "Anger Management", "Behavior Management", and "Compliance". The DSS stated that when a resident is assessed as having infringed on facility policy involving any illicit and unauthorized drug use or misuse then the facility imposes what is known as a "Non Compliant Therapeutic Contract" with the Resident and that Restrictions are imposed for 30 days. Restrictions include "Intense Therapy". When asked about the 'Intense Therapy" she disclosed that this included the Groups, that were not consistently being offered as required by the residents' contract "we were short of staff." She stated that the "Relapse Prevention" group was not offered. The Relapse Prevention Group she stated was to be included as part of the Intense Therapeutic Sessions. Included in the Intense Therapy Groups were: "Staying Out" which the DSS stated, "was not offered." "Tools for Recovery" which was "not held." The Anger Management sessions were, "not held." The Compliance Group was, "not held." The Behavior Group was, "not held." The "Positive Living was offered once a week on Tuesday by the DSS. The Orientation Groups were offered for "newly admitted Residents once a week." The DSS stated that the Chaplain offered a group once a week called "Search through Group." The DSS stated that staffing was an issue and that Administration was aware. The DSS stated that her role to advocate was compromised and that because the programs that were to be provided were not offered this would certainly compromise the well being and the psychosocial aspect of the Resident. The DSS stated that she would offer outside detoxification programs to those Residents with issues of relapse and would sometimes council them on staying clean but that she had limited time and resources. 415.5(g)

Based on record reviews, resident and staff interviews the facility failed to ensure that each resident receive the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being in accordance with their plan of care as evidenced by: Failure to have an effective process of monitoring and take corrective actions of residents(res) with history of substance abuse and multiple incidences of relapse thereby compromising other residents with history of substance abuse in their recovery. Failure to investigate how the residents obtained illicit drugs. Failure to protect res from psychological and physical harm. Failure to provide an effective comprehensive substance abuse program to facilitate recovery. Failure to inservice staff for substance abuse management. Failure to follow up on non compliance contracts given to residents that mandated group attendance for non prescribed illicit drug usage. Failure to properly discharge res who were found in possession of illicit drugs and to notify the proper authorithy. This was evident for three (3) of 17 sampled residents. (Residents #3, #11, and #14). This resulted in actual harm for (Residents#3 and #11) and Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This also resulted in the potential for serious harm to the health and safety of 45 additional residents in the facility with a history of substance abuse. The findings are: 1) Resident #3 is a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission monthly Inter-Disciplinary Comprehensive Care Plan (CCP) meeting dated 5/26/11, documented that the resident(res) "... continues to abuse Bensos-Drowsy most of the time...". The physician's orders [REDACTED]. [MEDICATION NAME] Dose Distributed (MDD) 20mg per 24 hours. [DIAGNOSES REDACTED]. There is no documented evidence that the benzodiazepine medication was prescribed for the resident.The Multidisciplinary progress notes documented that on 5/29/11 (unspecified time) the res reported a fall with no injuries on assessment. The notes further documented that on 5/31/11 at 11 pm, status [REDACTED]. At 11:50 pm the nursing note documented that the res showed up at nursing home with no discharge papers and stated that he walked out of the hospital. The revised Incident/Accident Policy dated 3/08 documents that "...the resident must be monitored over a 72 hour period with documentation in progress notes in residents medical record and the nursing care plan to be updated..." There is no documented evidence that the res was monitored consistently on all shifts by nursing staff for 72 hours s/p resident's allegation of a fall with complaint of a headache, and for signs and symptoms (s/s)of illicit drug use from 05/27/11 - 05/31/11. The counselor note dated 5/31/11 (unspecified time) documented that the"counselor received phone message from substance abuse counselor regarding concerns relative to res abusing medications ([MEDICATION NAME]). SAC recommendation for res to be seen by psychiatrist for evaluation. Counselor informed medical doctor of her concerns. Counselor met with client to assess for drug abuse. Resident was counseled in preventing further use of illicit drugs". There is no documented evidence that the res was monitored by staff for s/s of illicit drug use from 6/1/11 thru 6/6/11. The physician's Medical Assessment form dated 6/8/11 documented that the resident has history of benzodiazapine abuse and was counseled. There is no documented evidence that the Comprehensive Care Plan dated 5/26/11 for "substance abuse" was not revised to address the incidences of drowsiness (5/26/11), abuse of medication [MEDICATION NAME] (5/31/11), and regarding the hospitalization incident of overdose on 6/9/11. The expected outcome is documented as "will remain drug free for 60 days with interventions of "...ensure resident attends all groups delineated in his treatment plan". There was no therapeutic treatment plan to address the resident's drug seeking behavior. The physician note dated 6/17/11 further documented that resident was status [REDACTED]. The nursing note dated 6/9/11 at 11:10 pm documented that the "resident was found in room unresponsive". The vital signs were documented as being Pulse 104, blood pressure 74/48 and oxygen saturation is 40 percent. "MD on call notified and res was transferred to Hospital". The res was readmitted back to the facility on [DATE] at 11:00 pm with [DIAGNOSES REDACTED]. The nursing note dated 06/10/11 at 7:00 AM documented that the res was admitted to the Hospital's Intensive Care Unit. The Psychiatry consult report documented that on 6/17/11"...pt asked for [MEDICATION NAME] or [MEDICATION NAME] or klonopin or [MEDICATION NAME] or [MEDICATION NAME]." The Dietary note dated 06/17/11 at 9:00 AM documented that res readmitted s/p hospital for changes in mental status likely secondary to overdose. The [DIAGNOSES REDACTED]. There is no documented evidence that the resident was monitored by nursing for s/s of illicit drug use on the evening and night shift from 6/17/11 thru 06/21/11. There is no documented evidence that the res was being monitored by nursing from 6/22/11 thru 6/23/11 and 6/25/11 thru 6/29/11. The physician's note dated 6/29/11 documented that the neurologic exam done found resident appeared drowsy but arousable and the treatment plan was documented to check urine toxicology. The interim physician order [REDACTED]. there is no documented evidence that this test was done. The nursing note dated 7/1/11 (unspecified time) documented "late entry...resident found in parking lot very lethargic complained of fall in parking lot secondary loss of balance while walking to the transportation to take him to the [MEDICATION NAME] clinic." The nursing notes dated 7/1/11 and 7/2/11 (unspecified time) documented, "...closely monitored during the tour". There is no documented evidence that the resident was being closely monitored for every shift for s/s of illicit drug use from 07/01/11 - 07/05/11. The security incident report dated 7/1/11 at 10:35 am documented that security was called to bring resident to first floor to be searched as per SAC staff. A body search on resident was done and found one bottle of 25-30 [MEDICATION NAME] pills, eight [MEDICATION NAME], one hundred dollars. "while conducting the search resident appeared to be under the influence of something". A note from the Substance Abuse Counselor (SAC) dated 7/5/11 documented "late entry counselor met with resident to address non compliance of rules and regulations regarding illicit drug use/possession. Resident was found to have in his possession 25-30 [MEDICATION NAME] pills/ [MEDICATION NAME] (8) in addition to 100 dollars in his person upon entering the facility. Resident counseled on preventing further illegal activity additionally he was placed on 45 day therapeutic restriction, SAC also paced a call to his SAC at the [MEDICATION NAME] clinic to establish weekly pick up by our representative....Counselor met with resident to offer Detox services for Benzodiazapine abuse...resident refused services ..." The consult report dated 7/8/11 documented resident with history of (h/o) [MEDICAL CONDITION] with recent overdose with Benzodiazapine and [MEDICATION NAME] during the last admission he admitted to taking Benzos for eight years stating he use to get a prescription and pulled out an old medication receipt for [MEDICATION NAME] and requested to be placed on [MEDICATION NAME]. The res left the office once he was told that the doctor had no intention of giving him any type of Benzodiazapines. "mood elated". The plan/recommendation documented patient (pt) seems to be under the influence of Benzodiazapine obtain utox (urine toxicology) substance abuse counseling and treatment, monitor for behavioral disturbances. The non-compliant contract dated 7/1/11 documented that the res was found to have [MEDICATION NAME] pills in addition to [MEDICATION NAME] pills in his possession. It further documented that the res shall remain on the contract from 7/1/11 until 8/14/11, and that the res may not leave the facility for any reason other than approved medical appointments. Remain drug free for the duration of residency, and any infraction of this restriction will result in final warning or discharge. The agreement documented that the res shall attend the following groups: Positive Living, Community Group, Resident Council and shall meet with Social Work and Substance Abuse counselor for scheduled counseling and relapse prevention sessions. The quarterly Interdisciplinary CCP meeting progress note dated 7/14/11 documented Discharge Plan not in progress. On restriction 30 days therapeutic. A review of the groups schedule revealed that from 7/5/11 thru 8/12/11 fifteen groups were held and the res attended only one group which was "Positive Living," on 07/12/11. On 8/16/11 at 11:15 am the Assistant Director Of Nursing was interviewed and stated that the the team including social worker, nursing, and medical doctor met with the res regarding the use of illicit drugs after each incident when he came back from the hospital. She further stated that security checked his possessions and no drugs were found. She stated that the res should have been monitored for 3 days on every shift after returning from the hospital for drug overdose. She further stated that no investigation was done for the incidences of drug use on 05/11/11 and drug overdose on 06/09/11. She further stated the CCP should have been revised for these incidences. On 08/17/11 at 10:30AM the Security staff was interviewed and he stated that the Administrator and the SAC told him to discard the [MEDICATION NAME] and the [MEDICATION NAME] pills. 2) Resident # 11 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident is cognitively intact and independent with ADL's. The Non Compliance contract dated 8/2/10 documented that the resident admitted to manipulating urine provided on 8/2/10. There are a total of 8 groups that the resident was mandated to attend as part of this contract. These include: Journey to Recovery, Positive Living, Focusing on Self, Tools to Recovery, Relapse Prevention, Anger, Behavior and Compliance. In addition, the contract reads: "1) I shall remain on Non Compliance contract from 8/2/10 until 9/15/10. This means that I may not leave the facility for any reason other than an approved medical appointment and other necessary appointments. I may go onto the patio but not down the back stairs into the parking lot. Any infraction of this restriction will result in final warning or discharge. 2) I shall remain drug/alcohol free for the duration of my residency at this facility. 3) I shall attend all groups. 5) I shall attend all my medical appointments. 6) I shall take my medication as indicated by the treatment plan. 7) I shall submit toxicology profiles whenever requested by members of the Medical, Resident Services or nursing staff. THERE WILL BE NO EXCEPTIONS. FAILURE TO SUBMIT A TOXICOLOGY PROFILE WILL RESULT IN A FINAL WARNING OR DISCHARGE. 8) I shall meet with my Social Worker (SW) and Substance Abuse counselor (SAC) for scheduled counseling and relapse prevention sessions. 9) I understand that any deviation from this contract shall result in a final warning or discharge. 10) I understand that criminal or other antisocial behavior is prohibited. The following are grounds for immediate discharge: a) Drug dealing b) Any unsafe behavior. 'I have read and understand the terms of this contract and agree to abide by all components'." Contract #2 from 9/15/10 until 10/29/10 " Resident admits to consuming [MEDICATION NAME]. ( over medication/ purchasing on the street)" this contract includes all of the above with the exception of the mandated groups: All Mainstream Groups as well as the ABC Groups, (Anger, Behavior and Compliance). Contract #3 from 11/30/11 until 1/15/11 "Resident in possession of 3 [MEDICATION NAME] not prescribed by Physician" this contract includes all of the above with the exception of the mandated groups: All mainstream Groups in addition to the ABC Groups, Anger, Behavior and Compliance. Contract #4 "Toxicology results indicate positive for unauthorized benzodiazapine/ In addition to manipulation of urine." Contract for urine manipulation from 3/1/11 until 4/15/11 and Benzodiazapine contract from 3/1/11 until 3/31/11. Same groups as above. Contract #5 "Positive toxicology results indicate Benzodiazapine on 4/15/11 and 4/26/11" this contract includes: Mainstream Groups, Positive Living, Community Meeting and Resident Council. Contract #6 from 7/15/11 until 8/14/11 " Toxicology report on 7/8/11 indicates positive results for [MEDICATION NAME] and Benzodiazapine" this contract includes: Community Group, Resident Council, Smoking Group and NA Group (Narcotics Antonymous). The physician's orders [REDACTED]. 40 mg(s) by mouth one time a day provided by MMTP ([MEDICATION NAME] Maintenance Treatment Program), (MDD=40mgs per 24 hours) ([MEDICATION NAME] Dose Distributed), Dx. (Diagnosis) Opioid Dependence. The Hospital Discharge summary dated 7/26/11 documented that "the resident was brought from the Nursing home (NH) due to altered mental status and [MEDICAL CONDITION] ( low oxygen saturation) with oxygen saturation of 89 % (percent). Initially improved on venting mask and had pinpoint pupils. Initial [DIAGNOSES REDACTED]. [MEDICATION NAME] drip was given after which, mental status improved." There is no documented evidence that resident's medical and psychosocial needs were being met. Physician's Note dated 7/27/11 for resident readmission following overdose: Pt. was admitted to the hospital for opiate overdose, intubated initially for [MEDICAL CONDITION] and later extubated. There is no documented evidence that an investigation was done for a resident who was admitted to the hospital for illicit drug use and overdose. Psychiatry consult dated 8/1/11 documented that the resident "has a long history of [MEDICAL CONDITION] Disorder and Substance Abuse vs. Dependence. Pt. was recently hospitalized 2nd unintentional overdose with [MEDICATION NAME]." " I took 5 sticks I thought I could handle them " "in May pt. had an episode of over sedation for similar situation." Psych Meds: [MEDICATION NAME] 40 mg. QD; [MEDICATION NAME] 100mg HS, [MEDICATION NAME] 100 mgr QD (from 200) mg daily. Diagnosis: [REDACTED]. A review of the Monthly Inter-Disciplinary CCP Meeting Note dated 8/11/11 under Concerns/Issues: "Ambulates with cane, compliant with care and treatment regimen, no behavior issues". There were no documented intervention to address the resident's continue drug seeking behavior. On 8/15/11 at 12:20 pm the resident was interviewed and stated that "some of the residents in the facility are selling drugs that they get at their [MEDICATION NAME] program. I was told that I would be attending groups to assist in my recovery. There is only a one day a week group and there is no Narcotics Anonymous (NA) meeting here either. It is too easy to get the drugs here and no one is watching." He further stated that he has "become more depressed following his repeated relapses and that a lack of group sessions and programs here make it harder to remain drug free." The resident added that" he has had a total of 6 relapses since his admission. He was required to sign a non-compliance contract after each relapse. The contract requires that I must attend certain groups, which never took place. I stay in my room most of the day with no groups to keep my mind busy. I am feeling more depressed." The resident further stated that on 7/15/11 he bought five sticks of [MEDICATION NAME] from another resident. he took all five sticks and was sitting near the nurses station. He was "nodding out" and the nurse came over to check on him and he was sent out to the hospital. On 8/16/11 at 3:10 pm the ADON ( Assistant Director of Nursing) was interviewed and she stated that she was aware that some of the residents obtained drugs while at the [MEDICATION NAME] Clinic. The Substance Abuse Counselor (SAC) was interviewed on 08/12/11 at 11:20 am, and stated that she had been the only SAC counselor at the facility for the last 14 months. The facility hired another SAC counselor 2 weeks ago. She further stated that she has been unable to facilitate groups because she is the only SAC counselor in the building. In addition she stated that she also has to go the the [MEDICATION NAME] Clinic every Friday and pick up the residents [MEDICATION NAME] for Friday, Saturday and Sunday. This takes her out of the building for some time. The only staff certified to pick up the [MEDICATION NAME] is herself or an RN (Registered Nurse). 3) Resident #14 admitted to facility on 7/3/09 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan # 45 (CCP) for "Substance Abuse" initially dated 8/1/09 with interim revision dates of 2/1/11, 3/4/11 and 4/11 thru 8/2/11 documented interventions as being "...random toxicology profiles, ensure resident attends all groups delineated in his treatment plan ...ensure resident will adhere to 45 day in house therapeutic protocol ...on 90 mg [MEDICATION NAME] at (Hospital) ...intensive individual counseling secondary to relapse " by SAC from 6/24/11 thru 7/23/11. There is no documented evidence of a revision of CCP for the incidents documented on 2/17/11 and 6/8/11. An additional problem area is listed as CCP #38 Problem Behavior initiated on 5/26/11 which documents interventions ...provide group counseling ...redirect negative behaviors ...document inappropriate behavior according to facility protocol. There is no documented evidence of group counseling done and how negative behaviors are being redirected by staff. The note written by the SAC staff dated 2/17/11 (unspecified time) documented that the " Counselor met with resident to address concerns of purchasing pills from client at the [MEDICATION NAME] treatment program ...resident was counseled and redirected to speak to social worker for further instructions " . There is no documented evidence that toxicology test was done timely, no evidence of authorities being notified, no evidence of a thorough investigation done, no evidence of monitoring of resident and no evidence that the resident was given a non-compliant contract. The urine toxicology test collected on 2/24/11 documented a positive result for Benzo/opiate screen which is 7 days delay after the documented 2/17/11 incident. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. It further documented that although in the early afternoon the resident was observed to be heavily sedated he was given [MEDICATION NAME] sulfate ER 30 mg two tablets orally at 9:00 pm as scheduled. The MPN dated 6/2/11 10:30 am documented " Late entry for 6/1/11 - 2:30 pm - Resident observed at nurses station asleep in chair, when aroused resident fell right back to sleep. Resident was heavily sedated and found it hard to keep his head up or eyes open. Unable to hold conversation without drifting off. MD called to nurses station to evaluate resident who at this time was asking for pain medications ([MEDICATION NAME] sulfate). There is no documented evidence that resident was further monitored for incidence of heavy sedation from 6/2/11 thru 6/7/11. The Incident /Accident report dated 6/7/11 documented that the resident was noted to give a white pill to another resident with actions to prevent reoccurrence as " instructed resident not to share medication with other residents. MD made aware " . There is no documented evidence that the facility thoroughly investigated where the resident obtained the white pill, no evidence of search done of his room, and no evidence of toxicology done at that time. There is no documented evidence that the resident self medicates. The Multidisciplinary Progress Note (MPN) dated 6/8/11 written by the social worker documented " General meeting with resident to follow up with incident report. Resident was found giving another resident a white pill. Resident denies report. Resident services director and social worker informed resident if he is caught with any transactions, he will be placed on restriction. If resident continues with problem behaviors, facility will proceed with discharge to appropriate placement. Resident understood and agreed. Continue with careplan goals and interventions " . The NON-COMPLIANCE CONTRACT documented that the resident was found to possess illicit drugs during room search([MEDICATION NAME]) and was signed by the resident on 6/9/11 that he must abide by the contract, not leave the facility for any reasons or be subjected to immediate discharge. The same contract documented signatures from the team (Director of resident services, case manager, and SAC) with a signed date of 6/24/11. The team did not sign the contract until 15 days after the resident was informed of the groups that he was mandated to attend including Positive Living, Community group, All mainstream groups. It further documented that the resident shall submit toxicology whenever requested and that drug dealing and any unsafe behaviors are grounds for immediate discharge. There are no documented evidence of any (MPN) notes written from 6/9/11 thru 6/23/11 that resident is being monitored by staff for any further problem behavior episode. The note written by the resident service director dated 6/24/11 documented " Special CCP meeting held with resident to address his involvement with the distribution of pills to other residents. Initially resident denied to above allegations, however shortly after admitted his involvement in the above matter. Discharge options presented such as : transfer to another NH and or supportive living. Resident opted for another NH. Will proceed to complete necessary paper work and transfer to resident to another NH " . There is no documented evidence of further notes from 6/25/11 thru 6/28/11 regarding monitoring of resident as well as there is no further documentation regarding the resident ' s pending discharge. The social worker note dated 7/5/11 (unspecified time) documented " Due to several infractions , resident was placed on restriction from 6/24/11 until 7/23/11. Care plan #38 was updated. Social will follow up with care plan goals and interventions as needed " ....careplan #57 was initiated and filed due noted behaviors. " resident is a potential risk to others (residents). This note is written approximately one month after the incident of 6/7/11. On 8/12/11 at 11:20 am the Substance Abuse Counselor was interviewed and stated she has been the only SAC on staff For The past 14 months (6/9/10 to 8/1/11) and have not conducted the group counseling sessions for this reason and due to the fact that she was also responsible for escorting the residents to the MMTP programs from Monday to Thursday. Additionally on Friday she was responsible for picking up the residents [MEDICATION NAME] doses for Friday thru Sunday. The [MEDICATION NAME] Treatment Services policy and procedures with a revised date of 3/11 documented " the SAC will facilitate the [MEDICATION NAME] group every other week. She will address all issues pertinent to [MEDICATION NAME] treatment including adherence to policy and procedure on [MEDICATION NAME] treatment " ... The URINE COLLECTION PROTOCOL policy and procedures with a revision date of 3/11 documented that the purpose for urine toxicology is a valuable instrument in measuring compliance and will be monitored according to a number of individual resident factors including clean time, risk or relapse and outside agency ' s mandates. It further documents a paragraph documented as " Relapse Intensive Intervention Counseling that refers to residents who relapse will be provided with individual counseling and have documentation at least one time per week. The Orientation/Therapeutic Protocol List policy and procedure documented that the residents with positive urine toxicology for illicit drug or behavior issues will be placed on the therapeutic protocol list, to ensure monitoring of problematic residents with drug relapses and behavioral problems. The Administrative Discharge Policy documented that the purpose for administrative discharge applies for a resident that the facility initiates discharge if a resident...."safety of individuals in the facility is endangered" and the facility must have sufficient inter-disciplinary documentation supporting the reasons for the discharge. The Certified Nurse Aide (CNA) was interviewed on 08/19/11 at 8:30 am and stated that there were rumors of Res. # 3, # 11 and # 14 being seen "nodding" and "sleepy." She stated that she has not been inserviced on res illicit drug use, but would notify the SAC and that a urine is collected by the SAC. She further stated that she is aware of groups for the res and that she would be told on report who would need close monitoring. The Licensed Practical Nurse (LPN) was interviewed on 08/19/11 at 8:45 am and stated that there have been rumors of illicit drugs use in the facility. She stated that Res # 11 and # 14 have been rumored to use illicit drugs and as being "high". The LPN further stated that she has not witnessed any drug interaction and would notify the SAC if she suspects incident of illicit drug use. The R.N. was interviewed on 08/19/11 at 9:30 am and stated that Res. # 3, # 11, and # 14 had been observed several months ago with "lethargy, and drowsy" and was sent out to Hospital. The RN stated that groups are offered and the residents are sent out when they exhibit s/s of illicit drug use. He stated that the SAC is involved and groups are offered. 415.12

Based on record reviews, resident and staff interviews the facility failed to ensure that the residents environment was free of accident hazards as evident by: 1) Residents with known history of Polysubstance abuse were not being supervised to prevent the availability of non prescribed illicit drug usage within the facility which subsequently led to the incidence of relapses/overdose of the drugs Benzodiazapine and Methadone while at the facility (Residents #3 and #11). 2) During a group session conducted with the residents 11 of 11 residents reported that other residents are selling non prescribed illicit drugs in the facility which is impairing their sobriety and recovery. 3) Residents with known histories of relapse continued to be sent to the Methadone Program unescorted although during random room searches illicit non prescribed drugs were found, and residents continued to test positive for non prescribed illicit drug use. This was evident for three of seventeen sampled residents (Residents #3, #11, and #14). This resulted in actual harm for (Residents#3 and #11) and Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This also resulted in the potential for serious harm to the health and safety of 45 additional residents in the facility with a history of substance abuse. The findings are: 1) Resident #3 is a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Methadone Dose Distributed (MDD) 20 mg per 24 hours. [DIAGNOSES REDACTED]. There is no documented evidence that the benzodiazepine medication was prescribed for the resident.The Multidisciplinary progress notes documented that on 5/29/11 (unspecified time) the res reported a fall with no injuries on assessment. The notes further documented that on 5/31/11 at 11 pm, status [REDACTED]. At 11:50 pm the nursing note documented that the res showed up at nursing home with no discharge papers and stated that he walked out of the hospital. The revised Incident/Accident Policy dated 3/08 documents that "...the resident must be monitored over a 72 hour period with documentation in progress notes in residents medical record and the nursing care plan to be updated..." There is no documented evidence that the res was being supervised consistently on all shifts by nursing staff for 72 hours for signs and symptoms (s/s)of illicit drug use from 05/27/11 - 05/31/11. The counselor note dated 5/31/11 (unspecified time) documented that the"counselor received phone message from substance abuse counselor regarding concerns relative to res abusing medications (xanax). SAC recommendation for res to be seen by psychiatrist for evaluation. Counselor informed medical doctor of her concerns. Counselor met with client to assess for drug abuse. Resident was counseled in preventing further use of illicit drugs". There is no documented evidence that the res was supervised by staff for s/s of illicit drug use from 6/1/11 thru 6/6/11. The physician Medical Assessment form dated 6/8/11 documented that the resident has history of benzodiazapine abuse and was counseled. There is no documented evidence that the Comprehensive Care Plan dated 5/26/11 for "substance abuse" was revised to address the incidences of drowsiness (5/26/11), abuse of medication xanax (5/31/11), and regarding the hospitalization incident of overdose on 6/9/11. The expected outcome is documented as "will remain drug free for 60 days with interventions of "...ensure resident attends all groups delineated in his treatment plan". There is no documented evidence of plan in the interventions for supervision of the resident. The physician note dated 6/17/11 further documented that resident was status [REDACTED]. The Psychiatry consult report documented that on 6/17/11"...pt asked for diazepam or valium or klonopin or xanax or ativan.". The nursing note dated 6/9/11 at 11:10 pm documented that the "resident was found in room unresponsive". The vital signs were documented as being Pulse 104, blood pressure 74/48 and oxygen saturation is 40 percent. "MD on call notified and res was transferred to Hospital". The res was readmitted back to the facility on [DATE] at 11:00 pm with [DIAGNOSES REDACTED]. The nursing note dated 06/10/11 at 7:00 AM documented that the res was admitted to the Hospital's Intensive Care Unit. The Dietary note dated 06/17/11 at 9:00 AM documented that res readmitted s/p hospital for changes in mental status likely secondary to overdose. The [DIAGNOSES REDACTED]. There is no documented evidence that the resident was supervised by staff for s/s of illicit drug use on the evening and night shift from 6/17/11 thru 06/21/11. There is no documented evidence that the res was being supervised by nursing from 6/22/11 thru 6/23/11 and 6/25/11 thru 6/29/11. The physician's note dated 6/29/11 documented that the neurologic exam done found resident appeared drowsy but arousable and the treatment plan was documented to check urine toxicology. The interim physician order [REDACTED]. there is no documented evidence that this test was done. The nursing note dated 7/1/11 (unspecified time) documented "late entry...resident found in parking lot very lethargic complained of fall in parking lot secondary loss of balance while walking to the transportation to take him to the Methadone clinic." The nursing notes dated 7/1/11 and 7/2/11 (unspecified time) documented, "...closely monitored during the tour". There is no documented evidence that the resident was being closely monitored and or supervised on every shift for s/s of illicit drug use from 07/01/11 - 07/05/11. The security incident report dated 7/1/11 at 10:35 am documented that security was called to bring resident to first floor to be searched as per SAC staff. A body search on resident was done and found one bottle of 25-30 methadone pills, eight xanax, one hundred dollars. "while conducting the search resident appeared to be under the influence of something". A note from the Substance Abuse Counselor (SAC) dated 7/5/11 documented "late entry counselor met with resident to address non compliance of rules and regulations regarding illicit drug use/possession. Resident was found to have in his possession 25-30 methadone pills/ xanax (8) in addition to 100 dollars in his person upon entering the facility. Resident counseled on preventing further illegal activity additionally he was placed on 45 day therapeutic restriction, SAC also paced a call to his SAC at the Methadone clinic to establish weekly pick up by our representative....Counselor met with resident to offer Detox services for Benzodiazapine abuse...resident refused services ..." The consult report dated 7/8/11 documented resident with history of (h/o) Schizophrenia with recent overdose with Benzodiazapine and Methadone during the last admission he admitted to taking Benzos for eight years stating he use to get a prescription and pulled out an old medication receipt for Xanax and requested to be placed on Xanax. The res left the office once he was told that the doctor had no intention of giving him any type of Benzodiazapines. "mood elated". The plan/recommendation documented patient (pt) seems to be under the influence of Benzodiazapine obtain utox (urine toxicology) substance abuse counseling and treatment, monitor for behavioral disturbances. The non-compliant contract dated 7/1/11 documented that the res was found to have Methadone pills in addition to xanax pills in his possession. It further documented that the res shall remain on the contract from 7/1/11 until 8/14/11, and that the res may not leave the facility for any reason other than approved medical appointments. Remain drug free for the duration of residency, and any infraction of this restriction will result in final warning or discharge. The agreement documented that the res shall attend the following groups: Positive Living, Community Group, Resident Council and shall meet with Social Work and Substance Abuse counselor for scheduled counseling and relapse prevention sessions. The quarterly Interdisciplinary CCP meeting progress note dated 7/14/11 documented Discharge Plan not in progress. On restriction 30 days therapeutic. A review of the groups schedule revealed that from 7/5/11 thru 8/12/11 fifteen groups were held and the res attended only one group which was "Positive Living," on 07/12/11. On 8/16/11 at 11:15 am the Assistant Director Of Nursing was interviewed and stated that the the team including social worker, nursing, and medical doctor met with the res regarding the use of illicit drugs after each incident when he came back from the hospital. She further stated that security checked his possessions and no drugs were found. She stated that the res should have been monitored for 3 days on every shift after returning from the hospital for drug overdose. She further stated that no investigation was done for the incidences of drug use on 05/11/11 and drug overdose on 06/09/11. She further stated the CCP should have been revised for these incidences. On 08/17/11 at 10:30AM the Security staff was interviewed and he stated that the Administrator and the SAC told him to discard the Xanax and the Methadone pills. 2) Resident # 11 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident is cognitively intact and independent with ADL's. The Non Compliance contract dated 8/2/10 documented that the resident admitted to manipulating urine provided on 8/2/10. There are a total of 8 groups that the resident was mandated to attend as part of this contract. These include: Journey to Recovery, Positive Living, Focusing on Self, Tools to Recovery, Relapse Prevention, Anger, Behavior and Compliance. In addition, the contract reads: "1) I shall remain on Non Compliance contract from 8/2/10 until 9/15/10. This means that I may not leave the facility for any reason other than an approved medical appointment and other necessary appointments. I may go onto the patio but not down the back stairs into the parking lot. Any infraction of this restriction will result in final warning or discharge. 2) I shall remain drug/alcohol free for the duration of my residency at this facility. 3) I shall attend all groups. 5) I shall attend all my medical appointments. 6) I shall take my medication as indicated by the treatment plan. 7) I shall submit toxicology profiles whenever requested by members of the Medical, Resident Services or nursing staff. THERE WILL BE NO EXCEPTIONS. FAILURE TO SUBMIT A TOXICOLOGY PROFILE WILL RESULT IN A FINAL WARNING OR DISCHARGE. 8) I shall meet with my Social Worker (SW) and Substance Abuse counselor (SAC) for scheduled counseling and relapse prevention sessions. 9) I understand that any deviation from this contract shall result in a final warning or discharge. 10) I understand that criminal or other antisocial behavior is prohibited. The following are grounds for immediate discharge: a) Drug dealing b) Any unsafe behavior. 'I have read and understand the terms of this contract and agree to abide by all components'." Contract #2 from 9/15/10 until 10/29/10 " Resident admits to consuming Xanax. ( over medication/ purchasing on the street)" this contract includes all of the above with the exception of the mandated groups: All Mainstream Groups as well as the ABC Groups, (Anger, Behavior and Compliance). Contract #3 from 11/30/11 until 1/15/11 "Resident in possession of 3 Xanax not prescribed by Physician" this contract includes all of the above with the exception of the mandated groups: All mainstream Groups in addition to the ABC Groups, Anger, Behavior and Compliance. Contract #4 "Toxicology results indicate positive for unauthorized benzodiazapine/ In addition to manipulation of urine." Contract for urine manipulation from 3/1/11 until 4/15/11 and Benzodiazapine contract from 3/1/11 until 3/31/11. Same groups as above. Contract #5 "Positive toxicology results indicate Benzodiazapine on 4/15/11 and 4/26/11" this contract includes: Mainstream Groups, Positive Living, Community Meeting and Resident Council. Contract #6 from 7/15/11 until 8/14/11 " Toxicology report on 7/8/11 indicates positive results for Amphetamine and Benzodiazapine" this contract includes: Community Group, Resident Council, Smoking Group and NA Group (Narcotics Antonymous). The physician's orders [REDACTED]. 40 mg(s) by mouth one time a day provided by MMTP (Methadone Maintenance Treatment Program), (MDD=40mgs per 24 hours) (Methadone Dose Distributed), Dx. (Diagnosis) Opioid Dependence. The Hospital Discharge summary dated 7/26/11 documented that "the resident was brought from the Nursing home (NH) due to altered mental status and hypoxia ( low oxygen saturation) with oxygen saturation of 89 % (percent). Initially improved on venting mask and had pinpoint pupils. Initial [DIAGNOSES REDACTED]. Narcan drip was given after which, mental status improved." There is no documented evidence that an investigation was done regarding the resident's admission to the hospital with a drug overdose. Physician's Note dated 7/27/11 for resident readmission following overdose: Pt. was admitted to the hospital for opiate overdose, intubated initially for hypoxia and later extubated. There is no documented evidence that an investigation was done for a resident who was admitted to the hospital for illicit drug use and overdose. Psychiatry consult dated 8/1/11 documented that the resident "has a long history of Schizoaffective Disorder and Substance Abuse vs. Dependence. Pt. was recently hospitalized 2nd unintentional overdose with Xanax." " I took 5 sticks I thought I could handle them " "in May pt. had an episode of over sedation for similar situation." Psych Meds: Methadone 40 mg. QD; Seroquel 100mg HS, Zoloft 100 mgr QD (from 200) mg daily. Diagnosis: [REDACTED]. A review of the Monthly Inter-Disciplinary CCP Meeting Note dated 8/11/11 under Concerns/Issues: "Ambulates with cane, compliant with care and treatment regimen, no behavior issues". There were no documented interventions to address supervising the resident's drug seeking behavior. On 8/15/11 at 12:20 PM the resident was interviewed and stated that "some of the residents in the facility are selling drugs that they get at their methadone program. I was told that I would be attending groups to assist in my recovery. There is only a one day a week group and there is no Narcotics Anonymous (NA) meeting here either. It is too easy to get the drugs here and no one is watching." He further stated that he has "become more depressed following his repeated relapses and that a lack of group sessions and programs here make it harder to remain drug free." The resident added that" he has had a total of 6 relapses since his admission. He was required to sign a non-compliance contract after each relapse. The contract requires that I must attend certain groups, which never took place. I stay in my room most of the day with no groups to keep my mind busy. I am feeling more depressed." The resident further stated that on 7/15/11 he bought five sticks of Xanax from another resident. he took all five sticks and was sitting near the nurses station. He was "nodding out" and the nurse came over to check on him and he was sent out to the hospital. On 8/16/11 at 3:10 P.M. the ADON ( Assistant Director of Nursing) was interviewed and she stated that she was aware that some of the residents obtained drugs while at the Methadone Clinic. The Substance Abuse Counselor (SAC) was interviewed on 08/12/11 at 11:20 AM, and stated that she had been the only SAC counselor at the facility for the last 14 months. The facility hired another SAC counselor 2 weeks ago. She further stated that she has been unable to facilitate groups because she is the only SAC counselor in the building. In addition she stated that she also has to go the the Methadone Clinic every Friday and pick up the residents Methadone for Friday, Saturday and Sunday. This takes her out of the building for some time. The only staff certified to pick up the methadone is herself or an RN (Registered Nurse). 3) Resident #14 admitted to facility on 7/3/09 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan # 45 (CCP) for "Substance Abuse" initially dated 8/1/09 with interim revision dates of 2/1/11, 3/4/11 and 4/11 thru 8/2/11 documented interventions as being "...random toxicology profiles, ensure resident attends all groups delineated in his treatment plan ...ensure resident will adhere to 45 day in house therapeutic protocol ...on 90 mg Methadone at (Hospital) ...intensive individual counseling secondary to relapse " by SAC from 6/24/11 thru 7/23/11. There is no documented evidence of a revision of CCP for the incidents documented on 2/17/11 and 6/8/11. An additional problem area is listed as CCP #38 Problem Behavior initiated on 5/26/11 which documents interventions ...provide group counseling ...redirect negative behaviors ...document inappropriate behavior according to facility protocol. There is no documented evidence of group counseling done and how negative behaviors are being redirected by staff and or supervision of the resident. The note written by the SAC staff dated 2/17/11 (unspecified time) documented that the " Counselor met with resident to address concerns of purchasing pills from client at the Methadone treatment program ...resident was counseled and redirected to speak to social worker for further instructions " . There is no documented evidence that toxicology test was done timely, no evidence of authorities being notified, no evidence of a thorough investigation done, no evidence of supervision of resident and no evidence that the resident was given a non-compliant contract. The urine toxicology test collected on 2/24/11 documented a positive result for Benzo/opiate screen which is 7 days delay after the documented 2/17/11 incident. There is no documented evidence of supervision of the resident for the 7 days. The Medication Administration record (MAR) with the columns dated 6/1/11 documented that at 6:45 am the resident received morphine sulfate 15 mg 2 tablets as per his request and 6/2/11 at 5:45 am. It further documented that although in the early afternoon the resident was observed to be heavily sedated he was given Morphine sulfate ER 30 mg two tablets orally at 9:00 pm as scheduled. The MPN dated 6/2/11 10:30 am documented " Late entry for 6/1/11 - 2:30 pm - Resident observed at nurses station asleep in chair, when aroused resident fell right back to sleep. Resident was heavily sedated and found it hard to keep his head up or eyes open. Unable to hold conversation without drifting off. MD called to nurses station to evaluate resident who at this time was asking for pain medications (morphine sulfate). There is no documented evidence that resident was further supervised for incidence of heavy sedation from 6/2/11 thru 6/7/11. The Incident /Accident report dated 6/7/11 documented that the resident was noted to give a white pill to another resident with actions to prevent reoccurrence as " instructed resident not to share medication with other residents. MD made aware " . There is no documented evidence that the facility thoroughly investigated where the resident obtained the white pill, no evidence of search done of his room, and no evidence of toxicology done at that time and no evidence of supervision after the resident was noted with the pill. There is no documented evidence that the resident self medicates. The Multidisciplinary Progress Note (MPN) dated 6/8/11 written by the social worker documented " General meeting with resident to follow up with incident report. Resident was found giving another resident a white pill. Resident denies report. Resident services director and social worker informed resident if he is caught with any transactions, he will be placed on restriction. If resident continues with problem behaviors, facility will proceed with discharge to appropriate placement. Resident understood and agreed. Continue with careplan goals and interventions " . The Non-COMPLIANCE CONTRACT documented that the resident was found to possess illicit drugs during room search(xanax) and was signed by the resident on 6/9/11 that he must abide by the contract, not leave the facility for any reasons or be subjected to immediate discharge. The same contract documented signatures from the team (Director of resident services, case manager, and SAC) with a signed date of 6/24/11. The team did not sign the contract until 15 days after the resident was informed of the groups that he was mandated to attend including Positive Living, Community group, All mainstream groups. It further documented that the resident shall submit toxicology whenever requested and that drug dealing and any unsafe behaviors are grounds for immediate discharge. There are no documented evidence of any (MPN) notes written from 6/9/11 thru 6/23/11 that the resident is being supervised by staff for any further problem behavior episode. The note written by the resident service director dated 6/24/11 documented " Special CCP meeting held with resident to address his involvement with the distribution of pills to other residents. Initially resident denied to above allegations, however shortly after admitted his involvement in the above matter. Discharge options presented such as : transfer to another NH and or supportive living. Resident opted for another NH. Will proceed to complete necessary paper work and transfer to resident to another NH " . There is no documented evidence of further notes from 6/25/11 thru 6/28/11 regarding supervision of resident as well as there is no further documentation regarding the resident ' s pending discharge. The social worker note dated 7/5/11 (unspecified time) documented " Due to several infractions , resident was placed on restriction from 6/24/11 until 7/23/11. Care plan #38 was updated. Social will follow up with care plan goals and interventions as needed " ....careplan #57 was initiated and filed due noted behaviors. " resident is a potential risk to others (residents). Resident This note is written approximately one month after the incident of 6/7/11. On 8/12/11 at 11:20 am the Substance Abuse Counselor was interviewed and stated she has been the only SAC on staff For The past 14 months (6/9/10 to 8/1/11) and have not conducted the group counseling sessions for this reason and due to the fact that she was also responsible for escorting the residents to the MMTP programs from Monday to Thursday. Additionally on Friday she was responsible for picking up the residents methadone doses for Friday thru Sunday. The Methadone Treatment Services policy and procedures with a revised date of 3/11 documented " the SAC will facilitate the methadone group every other week. She will address all issues pertinent to methadone treatment including adherence to policy and procedure on methadone treatment " ... The Routine Resident Checks policy and procedure dated 7/09 documented that the routine resident checks shall be made every shift at designated hours ...to ensure that the resident ' s safety and well being is maintained ...the nursing personnel will ensure the safety and well being of the residents and make a resident check at least once every shift throughout each 24 hour shift. It further documented that the nursing supervisor will review rounds sheets, and ensure that rounds/checks are documented and sent to the ADNS/nursing office on a daily basis. There is no documented evidence that round checks were being done daily and sent to nursing office as specified. The URINE COLLECTION PROTOCOL policy and procedures with a revision date of 3/11 documented that the purpose for urine toxicology is a valuable instrument in measuring compliance and will be monitored according to a number of individual resident factors including clean time, risk or relapse and outside agency ' s mandates. It further documents a paragraph documented as " Relapse Intensive Intervention Counseling that refers to residents who relapse will be provided with individual counseling and have documentation at least one time per week. The Orientation/Therapeutic Protocol List policy and procedure documented that the residents with positive urine toxicology for illicit drug or behavior issues will be placed on the therapeutic protocol list, to ensure monitoring of problematic residents with drug relapses and behavioral problems. The Administrative Discharge Policy documented that the purpose for administrative discharge applies for a resident that the facility initiates discharge if a resident...."safety of individuals in the facility is endangered" and the facility must have sufficient inter-disciplinary documentation supporting the reasons for the discharge. The Certified Nurse Aide (CNA) was interviewed on 08/19/11 at 8:30 AM and stated that there were rumors of Res. # 3, # 11 and # 14 being seen "nodding" and "sleepy." She stated that she has not been inserviced on res illicit drug use, but would notify the SAC and that a urine is collected by the SAC. She further stated that she is aware of groups for the res and that she would be told on report who would need close monitoring. The Licensed Practical Nurse (LPN) was interviewed on 08/19/11 at 8:45 AM and stated that there have been rumors of illicit drugs use in the facility. She stated that Res # 11 and # 14 have been rumored to use illicit drugs and as being "high". The LPN further stated that she has not witnessed any drug interaction and would notify the SAC if she suspects incident of illicit drug use. The R.N. was interviewed on 08/19/11 at 9:30 AM and stated that Res. # 3, # 11, and # 14 had been observed several months ago with "lethargy, and drowsy" and was sent out to Hospital. The RN stated that groups are offered and the residents are sent out when they exhibit s/s of illicit drug use. He stated that the SAC is involved and groups are offered. 415.12

Based on record reviews, resident and staff interviews the Administrator: 1.) Failed to ensure that systems were in place to adequately supervise and monitor residents with a history of and /or known substance abuse 2.) Failed to ensure implementation of facility policy and procedures for the monitoring and response to known illicit drug use, solicitation, and internal and external distribution of controlled substances 3.) Failed to consistently implement effective group counseling sessions for residents' treatment and recovery for substance abuse as defined by the residents' plan of care 4.) Failed to investigate the source of illicit drugs found during room/resident searches 5.) Failed to report to the proper authorities the use of illicit drug by the residents. Specifically: two (2) residents were hospitalized for [REDACTED].# 11) and one (1) additional resident tested positive for an illicit drug (Resident # 14) . Upon return to the facility after hospitalization following a drug overdose, one of the two residents was in possession of 25 to 30 [MEDICATION NAME] pills and 8 [MEDICATION NAME] pills that are both controlled substances (Resident #3). During the Group Interview 11 of 11 residents expressed that the constant drug activity at the facility has caused them to have great difficulty in maintaining sobriety which impairs their recovery. This was evident for three of seventeen sampled residents. (Residents #3, #11, and #14). These deficient practices have the potential of affecting all 45 of 90 residents in the facility with a known history of substance abuse. This resulted in serious physical harm to two residents (Resident #3 and #11), psychological harm to the 11 residents who attended the Group Interview, and the potential for serious harm to the health and safety of the 45 of 90 residents in the facility with known history of substance abuse, that is Immediate Jeopardy. The findings are: On 08/18/11 at 3:00 PM the Administrator was interviewed and he stated that his role is to enforce facility policies and procedures and to ensure and maintain the Resident safety and well-being. He stated that he did not report to the Police Department nor did he consider notifying the State Department about the frequent and illegal occurrences of illicit drugs found at his facility. He stated that he should have notified the appropriate agencies. He further stated that he was aware that the mandated group sessions and meetings were not being held consistently and cited the shortage of a substance abuse counselor (SAC). He stated that a new SAC was just hired in August. He stated that the Residents who were placed on "Restriction" were allowed to leave the facility unescorted to pick up their [MEDICATION NAME] and for clinic appointments. He stated that he does not no how the illicit drugs were obtained. He stated that he could have implemented an Administrative Discharge for those Residents with recurrent illicit drug use and recurrent relapses and did not. The Administrator stated that the issue of illicit drugs in the facility was not looked into as an immediate topic of concern. However, he stated "I can see how this looks now." I did not do my job to the fullest in providing a safe environment and a sense of well being to the all the Residents. See F225 K, F226 K, F250 K, F309 K, F323 K, F 501 K. 415.26

Based on record reviews, resident and staff interviews the Medical Director: 1.) Failed to implement policies and procedures and coordinate the Medical care for residents with a history of and /or known substance abuse. 2.) Failed to ensure implementation of facility policy and procedures for the monitoring and response to known illicit drug use and positive results of toxicology screens. 3.) Failed to consistently follow up treatment and recovery for residents with history of substance abuse and relapse/overdose. 4.) Failed to report to the proper authorities the use of illicit drug by the residents. Specifically, two(2) residents were hospitalized for [REDACTED].# 11) and one (1) additional resident tested positive for an illicit drug (Resident # 14). Upon return to the facility after hospitalization following a drug overdose, one (1) of the two (2) residents was in possession of 25 to 30 [MEDICATION NAME] pills and 8 [MEDICATION NAME] pills that are both controlled substances (Resident #3). During the Group Interview 11 of 11 residents expressed that the constant drug activity at the facility has caused them to have great difficulty in maintaining sobriety which impairs their recovery. This was evident for three of seventeen sampled residents. (Residents #3, #11, and #14). These deficient practices have the potential of affecting all 45 of 90 residents in the facility with a known history of substance abuse. This resulted in serious physical harm to two residents (Resident #3 and #11), psychological harm to the 11 residents who attended the Group Interview, and the potential for serious harm to the health and safety of the 45 of 90 residents in the facility with known history of substance abuse, that is Immediate Jeopardy and Substandard Quality of Care. The findings are: On 08/22/11 at 2:25 PM the Medical Director (Med. Dir.) was interviewed and he stated that he is responsible for the oversight of his physicians which includes the Assessment, Treatment and [DIAGNOSES REDACTED]. Issues concerning the Residents and the [MEDICATION NAME] Program or problems of recurrent drug relapses were not seen as a major concern. When a Resident is suspected of being under the influence of unprescribed drugs, then a urine for toxicology is collected. We either send the Resident out to the emergency room , we council the Resident, and we require the Resident to be placed on a Non Compliance Therapeutic Restriction contract for 30 days. We also have psychiatry involved. However, the issue of illicit drug use had not been brought up as a facility concern. The random collection of urine for toxicology is what we have in place to determine a positive finding. I am not aware that the mandated groups and programs were not being provided. See F 225 K, F 226 K, F 250 K, F 309 K, F 323 K, F 501 K. 415.15(a)