Every finding on record at Jamaica Hospital Nursing Home Co Inc

Based on record review and interview during the Recertification and Complaint Survey (NY00352512) conducted from 02/18/2025 to 02/25/2025, the facility did not ensure a resident received adequate supervision and assistance devices consistent with resident's needs, goals, and care plan to prevent accidents. This was evident for one (1) (Resident #26) of 38 total sampled residents. Specifically, Resident #26 required total assistance of two (2) staff using mechanical lift for transfers as documented in the Comprehensive Care Plan. On 08/26/2024, Resident #26 was noted with ecchymosis (medical term for bruise) on the right leg. X-ray report revealed fractures of tibia (inner and larger of the two bones of the lower leg) and fibula (the outer and usually smaller of the two bones between the knee and the ankle). Investigation revealed Certified Nursing Assistant #1 transferred Resident #26 without assistance and pivoted the Resident from chair to bed. In addition, interview with Certified Nursing Assistants #3 and #4 revealed they had not used a mechanical lift during transfers prior to Resident #26 sustaining fractures. This resulted in actual harm to Resident #26 that was not Immediate Jeopardy. The findings include: The facility policy titled Prevention of Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property with a revised date of 01/2023 documented it was the policy of the facility to develop and implement written policies and procedures that prohibit and prevent mistreatment, neglect, and abuse of residents. Additionally, it was the policy of the facility to ensure appropriate investigation and follow-up of all allegations of mistreatment, neglect, abuse, exploitation, and misappropriation of resident's property. The facility policy titled Certified Nursing Assistant Accountability Record with a revised date of 01/2023 documented that the purpose of the policy was to ensure that Certified Nursing Assistants are instructed in all areas of Activities of Daily Living and to direct them to provide care and accurately document. Resident #26 had diagnoses that included Cerebrovascular Accident (medical term for stroke, interruption in the flow of blood to cells in the brain), Non-Alzheimer's Dementia (memory impairment in the elderly), Hemiplegia (one sided weakness of the face, arm, and leg). The Minimum Data Set assessment (a standardized, comprehensive assessment tool) dated 07/19/2024 documented that Resident #26 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for all activities of daily living. A Comprehensive Care Plan for Activities of Daily Living was initiated for Resident #26 on 07/17/2024. The care plan interventions included total assistance of two (2) for transfers with the use of a mechanical lift device. The Resident Certified Nursing Assistant Documentation History Detail (overview of tasks and assignments completed by the Certified Nursing Assistants) documented that Resident #26 was transferred by two (2) staff with no documentation that a mechanical lift was used on 08/20/2024 7:00 AM - 3:00 PM, 08/21/2024 7:00 AM - 3:00 PM, 08/22/2024 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM, 08/23/2024 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM, 08/24/2024 7:00 AM - 3:00 PM, and 08/25/2024 3:00 PM - 11:00 PM. Furthermore, Certified Nursing Assistant #1 documented in the Resident Certified Nursing Assistant Documentation History Detail that Resident #26 was transferred by pivot(a type of transfer that involves bearing weight on one or both legs and spinning to move their bottom from one surface to another) with 2-person assist on 08/19/2024 3:00 PM - 11:00 PM, 08/21/2024 3:00 PM - 11:00 PM and 08/24/2024 3:00 PM - 11:00 PM. A nurse's progress note dated 08/26/2024 at 2:19 PM by Registered Nurse #2 documented Resident #26 was observed with discoloration on the right shin and right foot. Resident #26 was contracted (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) due to right hemiparesis. An X-ray (a photographic or digital imaging of the body) was ordered by the physician, and pain medication was administered as ordered. A physician's progress note by the Medical Director dated 08/26/2024 at 9:51 PM documented Resident #26 was noted with right leg in contracture position with ecchymosis, swelling to leg and movement restriction due to pain and tenderness, unknown injury mechanism. An X-ray was noted with fracture of tibia, osteoporotic bones noted. Based on the findings, the resident was transferred to the emergency room for further evaluation and management. The facility Investigative Summary Report dated 08/28/2024 completed by Assistant Director of Nursing #2 documented on 08/26/2024 during the morning tour, Resident #26 was observed with right leg edema and bluish purplish discoloration of the right foot. Resident had severe cognitive impairment and cannot give account. An X-ray revealed non-displaced spiral tibial shaft, distal fibula fracture (broken leg), and disuse osteopenia (localized loss of bone due to decreased use). Resident #26 was transferred to the emergency room for further evaluation on 08/26/2024 and returned on 08/27/2024. Assigned Certified Nursing Assistants, who provided care for the past 72 hours prior to the incident were interviewed and they denied fall or trauma to the site of injury. Certified Nursing Assistant #1 stated they transferred Resident #26 to bed without assistance and without a lifting device. The Summary Report concluded that the investigation revealed during re-enactment that injury may have been sustained during the process of transfer. The hospital Discharge summary dated [DATE] documented Resident #26's primary diagnosis was closed fracture of right tibia and fibula. Resident was admitted under orthopedic surgery. Non-operative management was decided by the resident and the family. A cast was applied, and Resident was discharged back to the nursing home. On 02/25/2025 at 11:02 AM, Physical Therapist #1 was interviewed and stated Resident #26 required a mechanical lift for transfer since their assessment on 09/14/2022. They stated Resident #26 had no change in functional status and had always required two (2) staff assistance and mechanical lift during transfers. On 02/21/2025 at 10:13 AM, Certified Nursing Assistant #3, who was assigned to Resident #26 on 08/22/2024 and 08/23/2024 during the 7:00 AM - 3:00 PM shift was interviewed and stated they last transferred Resident #26 out of bed on 08/23/2024 and had not noticed any injury to the Resident. Certified Nursing Assistant #3 stated that prior to Resident #26 sustaining a fracture, they transferred Resident #26 with two (2) staff without using a mechanical lift. On 02/21/2025 at 11:00 AM, Certified Nursing Assistant #4 was interviewed and stated they had assisted Certified Nursing Assistant #3 in transferring Resident #26 on 08/23/2024 without using a mechanical lift. They stated they were not aware that Resident #26 required a mechanical lift for transfers. On 02/21/2025 at 4:08 PM, Certified Nursing Assistant #1, who was assigned to Resident #26 on 08/24/2024 during the 3:00 PM - 11:00 PM shift, was interviewed and stated they transferred Resident #26 alone on 08/24/2024. They stated they called for help that evening and one of the staff stated Resident #26 was small and could be transferred alone. Certified Nursing Assistant #1 declined to mention the name of the staff they contacted for help. Certified Nursing Assistant #1 stated Resident #26 had been in their assignment and is familiar with their transfer status. They stated they checked the instructions and was aware Resident #26 should be transferred by two (2) staff with mechanical lift. On 02/24/2025 at 3:33 PM, Licensed Practical Nurse #1 was interviewed and stated that instructions on how to transfer residents and other plan of care are in the Certified Nursing Assistant Accountability Record. Certified Nursing Assistants must check the accountability record before providing resident care every shift. They stated they give report at the start of shift to let the Certified Nursing Assistants know what is expected of them and remind them to check their accountability record and ask questions or if they need any assistance. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 did not report they needed assistance with Resident #26 and was not assisted by any staff during the shift. Licensed Practical Nurse #1 further stated that they sometimes make rounds if they are less busy with medication administration and documentation, to monitor how Certified Nursing Assistants are giving care to the residents and to provide assistance and directions as needed. On 02/21/2025 at 11:10 AM, Registered Nurse #2, was interviewed and stated that Resident #26 was assessed on 08/26/2024 with discoloration and swelling to the right leg and the x-ray report indicated fracture of right tibia and fibula. They stated they initiated the investigation and found out that Certified Nursing Assistant #1 did not follow the care plan when transferring Resident #26. On 02/24/2025 at 10:21 AM, Assistant Director of Nursing #2 was interviewed and stated they assessed Resident #26 on 08/26/2024 and the site of injury was consistent as if the injury was sustained during a transfer. They stated Resident #26 has a leg contracture and required mechanical lift for transfers. They stated based on the investigation, Certified Nursing Assistant #1 transferred Resident #26 without assistance from any of the staff, and that caused Resident #26's injury to the right leg. On 02/24/2025 at 10:58 AM, the Medical Director was interviewed and stated they evaluated Resident #26 on 08/26/2024 for leg fractures. They stated Resident #26 had no report of fall and is not able to move themselves in bed and needs help with repositioning. The Medical Director stated Resident #26 had osteoporosis and the leg fracture could have been caused by trying to move the Resident's contracted leg. On 02/25/2025 at 11:18 AM, the Director of Nursing was interviewed and stated Resident #26's injury might have occurred when Certified Nursing Assistant #1 transferred Resident #26 without help from another staff. The Director of Nursing stated, during the investigation, Certified Nursing Assistant #1 re-enacted the transfer. Certified Nursing Assistant demonstrated that Resident #26 was lifted from under both armpits and was pivoted from chair to bed which could have caused the leg fracture. 10 NYCRR 415.12(h)(2)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, sliced turkey lunchmeat stored in the refrigerator was not discarded in a timely manner and time/temperature control for safety foods (TCS) were not at acceptable temperatures (41 degrees Fahrenheit or less). This was evident during the Kitchen Observation task. The findings are: The facility policy Food Safety revised ,d+[DATE] documented the Food and Nutrition Department has a comprehensive food safety and self-inspection system that includes equipment monitoring to ensure the effectiveness and quality of the food safety program for all of our food service customers. Temperature records for Critical control points for all patient and cafeteria meals served are maintained and monitored. The temperatures are taken twice during meal service at breakfast lunch and dinner. The facility policy Sanitation and Infection Control- Meal Service Area (Pantry) effective ,d+[DATE] documented Food and Nutrition department in collaboration with Environmental Services will maintain a clean and safe meal service area (pantry) and follow food safety protocol to prevent the transmission of disease-carrying organisms. Pantry refrigerators must maintain Temperature Controlled for Safety (TCS) food at 41 degrees Fahrenheit or below. All TCS foods must meet the following temperature requirements cold foods are transported in a cold bin and held at 40 F or below. On [DATE] between 06:51AM and 07:24 AM, an initial tour of the kitchen and facility's emergency food supply was conducted. In was observed in the produce refrigerator there were two 5-pound (lb) containers of cranberry grain salad and one - 5-pound container of Asian noodle salad labeled with a use by date of [DATE]. In the meat refrigerator a pan containing 3 individually plastic wrapped slices of turkey labeled with preparation dates of [DATE], [DATE] and [DATE] were observed. On [DATE] between 12:14PM-12:24PM, the pantry refrigerator food temperature was taken on the 2nd floor dining room by FSM #1. The refrigerator temperature was 56 degrees Fahrenheit (F). The following items were observed not below 41F. FSM #1 took the temperatures with a thermometer of three containers of thickened milk in 4-ounce (oz) containers which had temperatures of 57.5F and 58.3F, two- 4 oz containers of cottage cheese had temps of 46.6F and 46.7F. Temperature was repearted with a second thermometer which showed 54F. Thickened milk temperature redone was 60.9F. The temperature log was last filled out on the ,d+[DATE] shift on [DATE]. On [DATE] between 12:36PM-12:42 PM, the dining room pantry refrigerator on the 3rd floor was at 46 degrees Fahrenheit. The temperatures taken by FSM #3 with a thermometer of two 4 oz containers of Coleslaw with use by date of ,d+[DATE] showed a temperature of 55.1F and 55.7F and a Roast beef sandwich at 57.4F. On [DATE] between 12:53 -12:59 PM, the dining room pantry refrigerator on the 4th floor was at 44 degrees Fahrenheit. There was an 8 oz carton of fat free milk with expiration date of ,d+[DATE]. The temperature was taken by FSM #3 with a thermometer of 2 eggsalad and one turkey sandwich. The turkey sandwich temperature was 53F and the egg salad sandwich temperatures were 53.3F and 53.4 F. The temperature log documented 40F on [DATE] (,d+[DATE] shift). On [DATE] at 07:46AM, an interview was conducted with the storeroom/porter person who stated they are familiar with First In First Out (FIFO). They do check with manager and check items if they are going to expire to make sure they are used up if they can and if they cannot, then throw them out. We can't serve expired food to patients. They got FIFO training every few months and training in 2023. Labeling items training also. Daily stock received on Monday, Tuesday and Thursdays, milk on Monday, Wednesday and Friday and bread delivered daily. On [DATE] at 4:43PM, an interview was conducted with the Dietary Aide/Porter who stated they sliced turkey meat recently and they sliced some this past Saturday. They only slice meat when they do meal preparation. Sliced turkey is held for 3 days. Held for 3 days because don't want people to get sick. They check pans before they slice the meat to see what is there. There was no sliced turkey that needed to be discarded and sandwich person used up the turkey and told them they needed some turkey sliced. The chef does in-service for them in relation to food contamination/food safety. On [DATE] at 07:54AM, an interview was conducted with the [NAME] helper who stated they sliced meat last week on Thursday. Slicing meat is a daily activity and slice for deli section of the cafeteria. Provide sliced meat for sandwiches for the nursing home. Meat is kept for 2 days once sliced. Food safety is followed, so meat is not kept too long, so it gets contaminated and make patients sick. On [DATE] at 10:28AM, an interview was conducted with the [NAME] helper/preparation person who stated they sliced meat yesterday and was not here on the weekend. Friday was the last time they cut meat. We cut meat for the nursing home and hospital. They would throw away meat if expired. Meat is held for 3 days. Food spoils and due to the growth of bacteria is why meat should be discarded. We had food safety in-service last week. We date food items and after the 3rd day they must be discarded. No one wants food that has bacteria. On [DATE] at 10:40AM, an interview was conducted with the Food Service Manager (FSM #2) who stated they do round's every morning and obviously they missed that. Three days is the time frame for holding the food to maintain food quality and to follow the facility policy. All food produced should be used within 3 days and should be discarded afterwards to maintain food safety. Sliced meat is used for nursing home residents. The facility cares for immune compromised and elderly /high risk residents which is why the policy documents to discard after three days. There was no log available that documented the meat slicing task. On [DATE] at 10:46AM, an interview was conducted with the Food Service Director (FSD) who stated they do rounds daily. On Mondays they go through food items and discard items that need to be discarded. We have a three-day policy to make sure we are giving the best food products. In relation to meat items, we may have to observe and smell the product. Deli meat is used for the nursing home. There were issues with listeriosis in the past and we had meat cooked in the oven and changed the policy to discard meat every 3 days. It should not have happened. The chef comes in and goes through boxes. Staff trained to look at everything. On [DATE] at 12:26PM, the Food Service Manager (FSM #1) for the 2nd floor kitchen pantry was interviewed and stated when the food items come up they are stocked in the refrigerator. The refrigerator should be 27- 40 degrees Fahrenheit. On [DATE] at 12:42PM, the Food Service Manager (FSM #3) for the 3rd floor kitchen pantry was interviewed and stated that the refrigerator temperature should be ,d+[DATE] Fahrenheit. Nurses take temperature of the refrigerator. Food items are stocked before we came up to serve lunch. Foods should be served at the correct temperature to decrease the potential of contamination, mold and foodborne illness. On [DATE] between 12:53PM -12:59P in the 4th floor pantry, the temperature on the thermometer in the refrigerator was observed to be 44 degrees F. There was one - 4 oz fat free milk carton in the refrigerator stamped with a sell by date of [DATE]:24 L2 PLT#,d+[DATE]. Also observed was 1 egg salad sandwich dated [DATE] and 1 turkey sandwich dated [DATE]. FSM #3 did the temperature of the turkey sandwich temperature was 53 F. Egg salad sandwich was 53.4F. On [DATE] at 01:01PM, the FSM#3 was interviewed and stated the date on the milk is [DATE] and it is expired. Nurses normally check refrigerator for food items. On [DATE] at 01:05PM, an interview was conducted with the 4th floor RN #5 who stated they took the temperatures this morning and they did not notice the expired milk. If anything is expired, they throw out in the morning and evening. We don't want any infection or food contamination or food poisoning. On [DATE] at 03:53PM, the 3rd floor LPN (LPN # 2) was interviewed and stated every shift they take temperatures. If the temperature is not within the proper range, then we tell the supervisor. Food for residents can freeze or spoil so the temperatures must be correct. On [DATE] between 02:43PM and 5:00PM, the 2nd floor Registered Nurse Supervisor (RNS #2) was interviewed and stated the nursing staff on the south side of the unit is assigned to take the pantry temperature but are not documented. In order to keep food safe and consumable and to prevent food poisoning or food borne illness food needs to be kept at adequate temperature, so the residents are safe. On [DATE] at 01:11PM, an interview was conducted with the Infection Preventionist (IP) who stated they play a role for infection control and food safety. The hold time for food is 2 days. When the refrigerator is checked, staff should look for expired food items. Food items should be labeled and dated. Any food items should be checked for an expiration/use by date for food safety to ensure the resident is not eating something that is contaminated, I was informed of the expired milk in the refrigerator. We need to make sure items are not outdated since it poses a risk. We constantly check the refrigerator for expired items. 415.14 (h)

Based on observations, interviews and record review conducted during the Recertification and Complaint Survey (NY00300942) from 05/22/23 to 05/26/23, the facility did not ensure all alleged violations involving abuse were reported immediately to the New [NAME] State Department of Health (NYSDOH), but not later than 2 hours after the alleged occurrence. This was evident for 1 resident (Resident #153) reviewed for Abuse out of 35 total sampled residents. Specifically, an allegation of abuse involving staff towards resident #153 was not reported to the NYSDOH within 2 hours. The findings are: The facility policy titled Prevention of abuse, mistreatment, neglect, exploitation and misappropriation of resident property, revised 1/2023, documented that any allegations of abuse, mistreatment, neglect, and exploitation are reported using the Nursing Home facility incident report form immediately but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. Resident #153 had diagnoses of dementia and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #153 had moderately impaired cognition and required limited assistance of 1 person for activities of daily living. The Facility Investigation Summary dated 8/23/22 documented that on 8/19/22 at approximately 9:30AM, Registered Nurse (RN) #2 was called by assigned morning Certified Nursing Assistant (CNA) to assess Resident #153 who had a yellow ecchymosis on the left forearm. Resident #153 stated it happened the day before, had been happening for 2 weeks, and they did not know the perpetrator's name. Resident #153 identified the regularly assigned night CNA, CNA #1, as the perpetrator by picture. After assessment by a physician, an x-ray revealed no left arm fracture. The yellowish coloring of the ecchymosis indicated a healing lesion. On subsequent interviews, Resident #153 changed their version of events two times. Resident #153's roommate and other residents who received care from CNA #1 were interviewed and did not report any issues. All present staff was interviewed and denied observing any abuse towards Resident #153 and CNA #1 had no history of abuse allegations. The investigation concluded there was no reasonable cause to believe Resident #153 was abused by staff. The Nursing Home incident form documented the incident was reported to the NYSDOH on 8/19/22 at 5:24 PM. There was no documented evidence the facility reported the allegation of abuse involving Resident #153 within 2 hours of occurrence on 8/19/22 at 9:30 AM. On 05/25/23 at 4:31 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated that they reported the incident involving Resident #153 to the NYSDOH on 8/19/22 at 5:24 PM, within 24 hours, because there was no serious bodily injury. Because there was no serious injury, they were not required to report within 2 hours. The ADNS stated the language of the regulation is confusing, and they understood that for injuries that are not serious, they could report within 24 hours. 415.4(b)(2)

Resident #146 Based on record review and interviews conducted during the Recertification survey of 5/22/23 - 5/26/23, the facility did not ensure that the comprehensive care plans were reviewed and/or revised after each assessment and as needed. Specifically, the Diabetes Mellitus care plan was not revised timely. This was evident for 1 of 4 residents reviewed for care planning (Resident #146). The findings are: The facility policy and procedure titled Care Planning effective date 8/2016, review date 10/22, states it is the policy to follow all the guidelines to develop resident-centered individualized care plans. The procedure includes to re-evaluate the resident's status at prescribed intervals (i.e.: quarterly, annually, or if significant change in status occurs), and then modifies the resident's care plan as appropriate and necessary. Resident #146 has diagnoses of Heart Failure, Hypertension, Renal Insufficiency, Depression and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact); the diagnoses included Heart failure, hypertension, renal insufficiency, Diabetes Mellitus, and Depression. The resident received Insulin injections 7 days. The Physician's orders included an order for insulin lispro 8 units three times/day for Type 2 Diabetes Mellitus. Start date 11/14/22, and Lantus Insulin once daily at bedtime, for Type 2 Diabetes Mellitus, start date 1/27/23, and an order to monitor Hemoglobin A1C every 3 months, start date 3/24/23. A Care Plan titled Diabetes Mellitus, Insulin Dependent Diabetes Mellitus (IDDM), effective 12/23/2022, reviewed 1/10/23; documented that the resident has elevated blood glucose level secondary to diagnosis of IDDM. The goals include that the resident will be free of observable signs and symptoms of hyper- and hypo-glycemia, and resident will minimize development of preventable side effects such as neuropathy, visual disturbances, and abnormal kidney function. The interventions include to administer medications as ordered; Monitor blood glucose level as ordered; Monitor for observable signs and symptoms of hyperglycemia or hypoglycemia. Notes: 1/10/23: Annual care plan meeting done on 1/10/22, care plan reviewed. No changes in current condition. Will monitor. There is no evidence that the care plan was reviewed and revised as per scheduled Quarterly MDS dated [DATE] or revised to reflect the order for monitor Hemoglobin A1C every 3 months. The care plan was reviewed and revised on 5/24/23 after interviews with the State Agency. On 5/24/23 at 9:31AM, an interview was conducted with Registered Nurse (RN) #1 who stated that the initiation of a Care Plan is done by the charge nurse or admitting nurse. They further stated that only an RN can initiate a Care Plan. A Licensed Practical Nurse (LPN) can do updating, but the RN needs to check it. RN #1 stated that updates are done quarterly and annually, with the MDS schedule, and as needed. The minimum time for an update is quarterly. RN #1 looked at the electronic medical record and stated that the Diabetes Mellitus care plan is not updated. They further stated that this was an oversight. On 5/24/23 at 9:43AM, an interview was conducted with Registered Nurse Supervisor (RNS) #1, who stated that the RNs are responsible for initiating care plans, the LPN can update the quarterly, but the RN does the annual and significant change updates. The RNS stated that updates are done according to the MDS schedule. The RNS stated they will add additional care plans as needed based on changes and orders. The RNS looked at the electronic medical record and noted that the Diabetes Mellitus care plan was not updated. An interview was conducted on 5/24/23 at 3:20 pm with the MDS / Case Manager, who stated that on admission, nursing starts care plans and then the MDS is done, and data is tied in with the care plans already done and those that are needed get done. At a quarterly MDS, the nurses will review and write a note. 415.11 (c)(2) (i-iii)

Based on observations, interviews and record review conducted during the Recertification Survey from 05/22/23 to 05/26/23, the facility did not ensure that a licensed pharmacist who conducted monthly medication regimen reviews (MRR) identified and reported irregularities of the resident's medical record to the attending physician, medical director, and the Director of Nursing (DON). This was evident for 1 of 6 residents (Resident #194) reviewed for Unnecessary Medications Review out of a total sample of 35 residents. Specifically, a medication regimen review did not identify that a resident was receiving an antipsychotic medication that was not approved for the resident's diagnosis. The findings are: The facility's policy and procedure titled Medication management/medication regimen review-monthly, revised 4/2021, documented that the consultant pharmacist would review the medical record of each resident and perform a drug regimen review at least once each month. The consultant pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician, where appropriate. Resident #194 had diagnoses of dementia, septicemia, and unspecified psychosis not due to a substance or known physiological condition. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance of 1 person with activities of daily living. Resident #194 presented no indicators of psychosis and exhibited physical and verbal behaviors towards others and rejection of care 1-3 days. The Physician's Orders dated 4/28/23, and renewed on 5/21/23, documented Resident #194 was to receive Quetiapine 50 mg orally daily in the evening and Quetiapine 25 mg orally daily in the morning. A review of the medication administration records since admission on 3/31/23 documented resident #194 had been receiving the nightly 50 mg dose of Quetiapine since admission, and the morning 25 mg dose was added on 4/15/23. A Psychiatry Consult dated 4/10/23 documented Resident #194 was evaluated for confusion and behavioral disturbances. Resident #194 had been agitated and more confused in the evenings. As per resident's wife, this had been happening since the pandemic started and had not been worsening. Resident #194 had a long history of alcohol abuse, and no other past psychiatric history. No depressive manic or psychotic episodes or symptoms. Resident continues to be confused, not oriented to place, or time. As per staff, Resident #194 has been increasingly combative and aggressive especially in the evenings. Family believes resident is getting confused at night because they are in an unfamiliar place. Family stated resident was on medication for sleep at night, but they do not know which medication. A 4/14/23 psychiatry follow-up note documented Resident #194 continued to have significant memory problems. Plan was to add Quetiapine 25mg in the morning for agitation and continue Quetiapine 50mg at 6 PM in the evening for agitation. A Medication Regimen Review dated 4/27/23 documented that no recommendations were made. The MRR was conducted by the Consultant Pharmacist. On 05/25/23 at 10:55AM the Medical Doctor (MD) was interviewed and stated that Resident #194 was agitated, confused, and aggressive with staff. The MD stated they were not sure of Resident #194's psychiatric history, and that they had a history of dementia. The MD stated that Resident #194 was being seen by psychiatry. The MD stated they were aware of the black box warning for the medication prescribed, but What can we do? We cannot restrain him, but he was agitated and aggressive. When asked why prescribing a medication that is not approved for elderly patients with dementia, the MD stated, You can talk to psychiatry. On 05/25/23 at 11:24 AM the Psychiatrist was interviewed and stated Resident #194 had been on Quetiapine before admission to the facility. Resident #194 had been a drinker for a long time and family noticed dementia during the pandemic. The Psychiatrist stated that at the facility, Resident #194 exhibited agitation and confusion especially at night, but Resident #194 did not exhibit psychotic behaviors. The diagnosis was neurocognitive disorder with a history of alcoholism. The Psychiatrist stated they evaluated the resident and had a full conversation with them through an interpreter. The Psychiatrist stated they were aware of the black box warning, but they were limited in what they can prescribe. Resident #194 had been on this medication, and it was working, so they would not stop it. On 05/26/23 at 10:46 AM the Consultant Pharmacist (CP) was interviewed and stated that once a month they review the charts for all residents in the nursing home and make recommendations for changes that need to be made. The facility will agree or disagree with recommendations. The CP stated they were aware of the black box warning for elderly residents with dementia on antipsychotic's. The CP was aware that Resident #194 did not have bipolar or schizophrenia diagnoses. The CP stated that at the time of the medication regimen review, Resident #194 had been seen by the Psychiatrist 3 times. The Psychiatrist was following the resident closely and the Psychiatrist believed the resident needed the medication. The CP stated the Psychiatrist was aware of the black box warning, so the CP didn't feel it was necessary to make a recommendation. On 05/26/23 at 10:59 AM the Assistant Director of Nursing (ADNS) was interviewed and stated that residents on psychotropic medications are followed regularly by Psychiatry. If they have behaviors, it is more often. The ADNS stated they have pharmacy medication reviews monthly, and the Pharmacists make recommendations. The ADNS stated they would expect the Pharmacist to make recommendations if needed. They would also expect the psychiatrist to adjust the medication as needed. 415.18 (c)(2)

Based on observations, interviews and record review conducted during the Recertification Survey from 05/22/23 to 05/26/23, the facility did not ensure that a resident's drug regimen was free from unnecessary psychotropic medications. This was evident for 2 of 6 residents (resident #194 and resident # 373) reviewed for Unnecessary Medications Review out of a total sample of 35 residents. Specifically, 1) Resident #194 received antipsychotic medication, Quetiapine (Seroquel), and antidepressant medication, Trazodone, without an appropriate diagnosis, and 2) Resident #373 received an antipsychotic medication without an appropriate diagnosis. The findings are: The facility's policy and procedure titled Psychotropic medication, revised 10/22, documented that psychotropic, medications may be used only for the treatment of specific medical and/or psychiatric conditions. 1) Resident #194 had diagnoses of Dementia, and unspecified psychosis not due to a substance or known physiological condition. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance of 1 person with activities of daily living. Resident #194 presented no indicators of psychosis and exhibited physical and verbal behaviors towards others and rejection of care 1-3 days. Resident #194 recieved antipscychotic medication for 5 days routinely and as needed, and no Gradual Dosage Reduction (GDR) was attempted. On 05/22/23 at 09:31 AM, 05/24/23 at 09:56 AM, and 05/25/23 at 10:32 AM Resident #194 was observed in their room, either lying in bed or sitting in their wheelchair. Each time the resident had a calm demeanor and, while confused, responded to surveyor's questions appropriately. On 05/24/23 at 11:14 AM Resident #194 was observed in their room with visitors. Resident's spouse stated that they visit often, but when they don't visit the resident misbehaves. Spouse stated, they don't know exactly what Resident #194 does, but Resident #194 can get mad, angry, and can be strong. Spouse stated that when Resident #194 misbehaves, they received medication to make him/her sleepy. Spouse stated that Resident #194 never had a mental health problem before, and only began losing their memory during the pandemic. A comprehensive care plan (CCP) for psychotropic drug use, effective 4/1/2023, documented Resident #194 was receiving Haldol / Quitiapine medication related to diagnosis of Agitation. Interventions included establish appropriate diagnosis for medication use and evaluate for reduction of medication dose. A CCP for behavior problems, effective 4/6/2023, documented Resident #194 exhibited physically aggressive behavior towards staff/others, made attempts to get out of bed and to stand up when sitting on the wheelchair. Haldol and Quetiapine are antipsychotic medications used to treat Schizophrenia. The FDA (Food and Drug Administration) black box warning documents elderly patients with dementia-related psychosis treated with antipsychotic drubs are at an increased risk of death. Quetiapine and Haldol are not approved for use in elderly patients with dementia-related psychosis. A social work admission note dated 4/1/23 documented resident had been admitted from hospital on 3/31/23. Resident noted very forgetful and reported feeling down related to missing their family, trouble staying asleep, decreased energy and poor appetite and trouble concentrating on doing things during mood assessment. Resident was able to make needs known in Spanish. A behavior note dated 4/6/23 at 6:35 AM documented a behavior note. At 1:30 AM, Resident #194 was sitting on a chiar in front of room [ROOM NUMBER]. The resident removed their diaper and was putting on their shoes. Staff assisted the resident back to bed. At 1:45 AM, the resident was at the nursing station. They were combative and trying to get out of the w/c. The Nurse and CNA attempted to calm the resident , and the resident hit the nurse, grabbed and twisted the CNA's arm, and punched the nurse in the left eyebrow. The resident was assisted for unmet needs and transferred to a quiet area. A nursing note dated 4/6/23 at 3:13 PM documented Resident remained restless attempting to get out of chair unassisted. Medical doctor present ordered one dose of Haldol 2.5 mg and Quetiapine 50 mg once daily at bedtime and Haldol 0.5mg IM every 6 hours as needed. A psychiatry consult dated 4/10/23 documented Resident #194 was evaluated for confusion and behavioral disturbance. The consult documented that Resident #194 had been agitated and more confused in the evenings. The report documented history from the resident's spouse. The spouse reported that this behavior had been happening since the pandemic started and had not been worsening. Resident had a long history of alcohol abuse, and no other past psychiatric history. No depressive manic or psychotic episodes or symptoms. The psychiatrist noted that the resident continued to be confused, not oriented to place, or time. The psychiatrist also documented that staff reported that Resident #194 has been increasingly combative and aggressive especially in the evenings. The family believed the resident was getting confused at night because they were in an unfamiliar place. Family stated resident was on medication for sleep at night, but they did not know which medication. The resident was diagnosed with Chronic Alcohol related Dementia with rule out mild neurocognitive disorder likely secondary to Alzheimer's Dementia and rule out Dementia with behavioral disturbane. the plan was to continue Quetiapinel 50 mg at 6 PM in the evening for agitation, continue Haldol 0.5 mg every 6 hours as needed for agitation, and stop Ambien due to paradoxical reaction. The physician's orders dated 4/28/23, renewed 5/21/23, documented Resident #194 was to receive quetiapine 50 mg orally daily in the evening and quetiapine 25 mg orally daily in the morning. Behavior notes dated 4/13/23 and 4/14/23 documented Resident #194 was very restless, making several attempts to get out from the wheelchair, and redirection was not helpful. A psychiatry follow-up note dated 4/14/23 documented Resident #194 continued to have significant memory problems. Nurses reported resident was also confused in the morning for AM care. The plan was to add quetiapine 25mg in the morning for agitation, continue quetiapine 50mg at 6 PM in the evening for agitation, and discontinue Ambien to avoid Ambien contributing to the confusion. A psychiatry follow-up note dated 4/18/23 documented Resident #194 was less agitated with fewer behavioral problems since Seroquel was increased to 25 mg in the morning, 50 mg at 6 PM. No excessive daytime sedation or other side effects were noted. Diagnosis was major neurocognitive disorder most likely secondary to Alzheimer's type dementia and/or alcohol abuse disorder and/or shunt, moderate. Recommendation was to continue Seroquel 25 mg in the morning, 50 mg at 6 PM to help reduce periods of agitation with disturbances. A Medication Regimen Review dated 4/27/23 documented no recommendations were made. The MRR was conducted by the consultant pharmacist. The Medication Administration Records (MAR) since admission on 3/31/23 to April 2023 documented Resident #194 received Seroquel 50 mg at bedtime (9:00 PM) from 4/6 to 4/9 and Seroquel 50 mg in the evening at 6:00 PM starting 4/10/23. A morning dose of Seroquel 25 mg OD was added and administered starting on 4/15/23. A Psychiatry follow-up note dated 5/18/23 documented Resident #194 was seen via video with staff assisting with interpreting. The resident stated he did not sleep well and denied anxious or depressed mood. Resident denied audio or visual hallucinations, suicidal ideation, and homicidal ideation. Per staff, the resident was doing well and not having behavioral problems. Per the assessment, the resident had Major neurocognitive disorder most likely secondary to Alzheimer's tupe dementia and/or alcohol abuse disorder and/or shunt, moderate. The targeted behaviors were confusion and aggression. The recommendations were to continue Seroquel 25 mg in the morning and 50 mg at 6 PM to reduce agitation and behavioral distrubances. Add Trazodone 50 mg at bedtime for sleep and follow-up in 1 month. Trazodone is an antidepressant medication indicated for treatment of Major Depressive Disorder. The MAR dated May 2023 documented Resident #194 was given Seroquel 25 mg at OD at 9:00 AM from 5/1/23 to 5/26/23, Seroquel 50 mg in the evening at 6:00 PM from 5/1/23 to 5/25/23, and Trazodone 50 mg HS from 5/19 to 5/25/23. There was no documented evidence that the resident exhibited psychotic behaviors. There was no documented evidence that a gradual dose reduction had been attempted for the antipsychotic medications. On 05/24/23 at 12:03 PM CNA #2 was interviewed and stated they have been taking care of resident #194 regularly for the past 2-3 weeks. CNA #2 stated resident #194 doesn't speak English but, they can understand each other. Resident #194 is very quiet and had never been combative or aggressive, no resistance to care. On 05/24/23 at 02:57 PM RN #2 was interviewed and stated Resident #194 is quiet and cooperative, and RN #2 was not aware of any behaviors. No aggression, no refusal of care. On 05/25/23 at 10:38 AM RN #3 was interviewed and stated Resident #194 was very abusive, combative, resistant to care on the first few days after admission. RN #3 stated Resident #194 speaks Spanish and would calm down when speaking with Spanish-speaking staff or with their spouse. Resident #194 would say they wanted to go home. Resident #194 continued periodically with resisting care, sometimes refused medications. Verbally aggressive, not physical. At night, sometimes they bring Resident #194 close to the nurse's station because Resident #194 would not sleep. When Seroquel was started Resident #194 became quiet, slept most of the time, and behavior started improving gradually. On 05/25/23 at 10:55 AM, the medical doctor (MD) was interviewed and stated that Resident #194 was agitated, confused, and aggressive with staff. The MD stated they were not sure of Resident #194's psychiatric history, and that they had a history of dementia. The MD stated that Resident #194 was being seen by psychiatry. The MD stated they were aware of the black box warning for the medication prescribed, but What can we do? We cannot restrain him, but he was agitated and aggressive. When asked why prescribing a medication that is not approved for elderly patients with dementia, the MD stated, You can talk to psychiatry. On 05/25/23 at 11:24 AM the psychiatrist was interviewed and stated Resident #194 had been on quetiapine before admission to the facility. Resident #194 had been a drinker for a long time and family noticed dementia during the pandemic. The psychiatrist stated that at the facility, Resident #194 exhibited agitation and confusion especially at night, but Resident #194 did not exhibit psychotic behaviors. The diagnosis was neurocognitive disorder with a history of alcoholism. The psychiatrist stated they evaluated the resident and had a full conversation with them through an interpreter. The psychiatrist stated they were aware of the black box warning, but they were limited in what they can prescribe. Resident #194 had been on this medication, and it was working, so they would not stop it. On 05/26/23 at 10:46 AM the consultant pharmacist was interviewed and stated that once a month they review the charts for all residents in the nursing home and make recommendations for changes that need to be made. The facility will agree or disagree with recommendations. The consultant pharmacist stated they were aware of the black box warning for elderly residents with dementia on antipsychotics. The consultant pharmacist was aware that Resident #194 did not have bipolar or schizophrenia diagnoses. The consultant pharmacist stated that at the time of the medication regimen review, Resident #194 had been seen by the psychiatrist three times, the psychiatrist was following the resident closely and the psychiatrist believed the resident needed the medication. The consultant pharmacist stated the psychiatrist was aware of the black box warning, so the consultant pharmacist didn't feel it was necessary to make a recommendation. On 05/26/23 at 10:59 AM the Assistant Director of Nursing (ADNS) was interviewed and stated that residents on psychotropic medications are followed regularly by psychiatry. If they have behaviors, it is more often. The ADNS stated they have pharmacy medication reviews monthly, and the pharmacists make recommendations. The ADNS stated they would expect the pharmacist to make recommendations if needed. Or they would expect the psychiatrist to adjust the medication as needed. 42101 Resident # 373 was admitted with diagnoses which include Encephalopathy, Urinary Tract Infection (UTI) and Vascular Dementia. The Pending Admission Minimum Data Set 3.0 (MDS) assessment assessed 06/04/2023 documented the resident was cognitively impaired. The assessment further documented the resident received anti-psychotropic medications daily and physician documented gradual drug reduction contraindicated on 05/16/2023. The Comprehensive Care Plan (CCP) for Psychotropic drug use 5/10/23 and interventions include evaluate action of medication and side effects, evaluate need for dose adjustment or reduction, monitor for changes in behavior and mood and observe for any signs of decline in function or cognitive status. The Physician's Order dated 05/10/2023 documented Quetiapine give 1 tablet 2 times a day for schizophrenia unspecified. The Physician's Order dated 05/11/2023 documented Quetiapine 25 mg in the evening at 6:00PM for Restlessness and Agitation. The Physician's Order dated 05/15/2023 documented an order for Quetiapine 25 mg twice daily on admission for Restlessness and agitation. The Physician's Order dated 05/16/2023 documented an order for Quetiapine 25 mg at bedtime at 9:00 PM for Restlessness and agitation. The Physician's order dated 05/17/2023 documented Seroquel 25 mg (give 1 tablet orally as one dose). Physician's order dated 05/19/2023 documented Seroquel 25 mg (once daily at bedtime). Physician's new order dated 05/19/2023 documented Seroquel 25 mg (1 tablet at bedtime for schizophrenia unspecified). Observation of Resident 373 between 05/23/2023 at 02:31 PM to 05/29/2023, the resident resting in their room in their room, visiting with family with a calm demeanor. The Medication Administration Record (MAR), starting 05/10/2023 documented the resident received Quetiapine (Seroquel) 25 mg BID daily, from 05/10/2023 -05/11/2023 for restlessness and agitation. Quetiapine (Seroquel) 25mg once daily at bedtime on 05/11/2023 - 05/12/2023. Quetiapine (Seroquel) 25mg once daily at bedtime for schizophrenia, from 05/19/2023-05/25/2023. There was no documentation in the resident's medical record that the resident had a history of schizophrenia prior to hospitalization and transfer to the nursing home. The PRI dated 05/08/2023 documented Resident #373 had no diagnosis of schizophrenia documented. Secondary diagnosis of dementia. The Level I screen dated 05/08/2023 documented Resident #373 had Alzheimer's dementia checked and no serious mental illness documented. Nursing Admission note dated 5/10/2023 documented cognition alert to person with periods of confusion and forgetfulness. Diagnosis that included encephalopathy, sepsis due to complicated UTI, E-coli- ESBL severe sepsis, CVA, Dementia, urinary retention. Medical note on 05/11/2023 documented resident had a previous medical history of CVA, Dementia, hypertension, urinary retention with foley and ESBL (Extended Spectrum Beta-Lactamase) UTI and history of acute encephalopathy at hospitalization . Documented resident was oriented to self. Active diagnosis includes major neurocognitive disorder with most likely vascular dementia. Documented medications Donepezil 10 mg once daily at bedtime, memantine 10 mg once daily and Quetiapine 25 mg once daily in the evening. Documented Seroquel was decreased to 25 mg at bedtime for agitation, psyche for further recommendation ad and fall precautions. Review of Nursing progress notes documented order received to change Seroquel 25 mg twice daily (BID) to only at hour of sleep (HS) and order carried out. Resident was also on intravenous (IV) antibiotics for UTI management also. Nursing Progress note on 5/14/2023 at 02:21AM documented resident did not sleep at night trying to get up from bed and calling stated I want to get up and go. Further documented every hour monitoring to continue to resident and resident incontinent of bowel with foley. At 4:03 PM resident was observed sitting on the floor mat next to their bed. MD and representative were both notified. Nursing Behavior not on 5/15/2023 documented resident alert responsive with confusion trying to get out from bed, repositioned, took off gown and sheet and threw on floor, tried to keep foot outside, reposition and asked resident where they were going. The note documented that the resident stated that they wanted to get up and got to doctor's office. Nursing progress note on 5/15/2023 at 09:43AM documented MD made aware of behavioral issues and MD ordered another consult with the psychiatrist. A Psychiatrist Consultation note was written by the psychiatry intern on 05/15/2023. It documented an assessment for ability to perform gradual drug dose reduction or discontinue psychoactive medication: documented consider restarting Seroquel which was discontinued. No individual or cumulative side effects documented. Targeted behaviors include agitation, combative behavior and not sleeping. Recommendation restart Seroquel Quetiapine 25 mg at bedtime for sleep and behavior problems. The Psychiatrist documented in a note on 05/16/2023 that the resident had been more agitated since Seroquel had been discontinued. They noted that they had been somewhat more combative and not sleeping at night. Continues to have significant memory problems and does not realize they are in a nursing facility or why they are here. They documented a diagnosis of major neurocognitive disorder most likely secondary to vascular dementia moderate. They did not document schizophrenia as a diagnosis. They documented that the resident was much less agitated on Seroquel and worse when off of this medication. They recommended to restart Seroquel at 25 mg nightly to help reduce agitation at night and insomnia. No side effects and good results noted when resident on this medication prior. Nursing progress note on 5/17/2023 at 04:33AM documented resident did not sleep all night, continuously trying to get out of bed, staff stayed with then to meet needs, provided snack, ate, incontinence care given, repositioned. The resident continued to come out of bed. Resident was assisted to chair and kept in front of nurse's station. Medical progress note on 05/17/2023 documented resident evaluated status post fall seen sitting on floor and no injuries noted and documented alert, episodes of confusion same as baseline. During an interview on 05/24/23 at 04:44 PM, an interview was conducted with CNA # 3 and stated that resident #373 behaviors include resident #373 climbing out of bed and having to be monitored throughout the evening shift. There are no other behaviors they are aware of. Nonpharmacological interventions include check if need ADL care, make sure resident not wet, ask resident is they are hungry and television. If you notice any change in behavior, they will notify nurse or supervisor. There is no CNA accountability task to monitor which behaviors are present for the resident. During an interview on 05/24/23 at 04:50 PM, RN # 2 stated Resident #373 is on Seroquel because they do not sleep at night. Resident had a history of getting out of bed at night and had a fall. Resident was placed on 25 mg of Seroquel at night. RN #2 stated that Resident #373 did well during the morning shift. When resident having issues sleeping's call medical provider. RN#2 stated that Resident #373 does get up when wet and agitated. Resident 373 was seen by psychiatrist. Resident 373 has Alzheimer's disease unspecified and schizophrenia unspecified and diagnosis is usually in the notes during admission. RN #2 reviewed the admission note and stated that diagnosis not written as schizophrenia, but secondary diagnosis was dementia. The pharmacist does the Medication Regimen Review (MRR) twice a week on rotating units and they communicate to them if any errors and communicate to pharmacy leader to contact DON if needed. During a follow up interview on 05/25/2023 at 04:36 PM and 5:02PM, Registered Nurse Supervisor (RNS # 2) was interviewed and stated the Resident #373 came in on Seroquel and resident was seen by psych for behaviors that included pulling out intravenous line and tried to pull out Foley catheter and peripherally inserted central catheter (PICC) line. Seroquel was discontinued from twice daily to only at night. Resident is sleeping better and the 1st week we had to manage 1:1 at times and they were combative during care. RN #2 stated that Resident #373 had behaviors at home, where they were also kicking and throwing things. Resident #373 behaviors included restlessness and agitation. The diagnosis was given by MD #2/Medical Director. RN #2 stated that on 5/19/2023 they took the order for Seroquel and entered the diagnosis of schizophrenia. RN#2 said in the eUHR there is a screen where the diagnosis for the medications. In a follow-up interview on 05/26/2023 at 11:24AM, RN #2 stated that they entered in the wrong diagnosis when they took the telephone order from MD#2. They stated that restless and agitation were the correct diagnosis. When an order is put in, it has to be signed by the medication nurse. The order is reviewed by another nurse then forwarded to the medical provider. Resident 373 does not have schizophrenia. They have restlessness and agitation and behavior of pulling intravenous (IV). During morning report, they are informed of the resident's primary and secondary diagnosis. As of 5/25/23 the resident still had incidents of restlessness at night. During an interview on 05/25/2023 at 11:40 AM, the Psychiatrist stated Resident #373 was on the psychotropic medication at the hospital. They were consulted to see the resident after behavior with staff due to possible encephalopathy complicated by UTI. The Seroquel is used for agitation when resident became combative. Resident 373 has vascular dementia and had sepsis in hospital which may affect their behavior. Any diagnosis is written in resident notes and the resident does not have any schizophrenia diagnosis. If we stop medication we come back in week and we were called in 3-4 days after staff stated resident was worse. Seroquel was initiated for resident. Resident 373 was not sleeping at night, had physical aggressiveness. History was obtained from the resident's representative. It is alright to use medication for the resident since it is for Alzheimer's disease. Symptoms to monitor includes sleepiness, increased appetite and metabolic syndrome. A low dose may not affect the resident. Residents have different tolerance levels to medications. The medication was discussed with resident's representative, and they agreed with the plan of care. Vascular dementia management medications include Aspirin 81 mg, Donepezil and Memantine. The Psychiatrist said that the resident is doing well on those medications. A Gradual Drug Reduction (GDR) for Seroquel was done and medication was stopped. The Resident is currently receiving Seroquel at night for sleep. During an interview on 05/25/2023 at 03:12 PM, the Pharmacist stated they were familiar with black box warning for Seroquel used in elderly residents. In the elderly it can cause cardiovascular and other issues. They were aware that a psychiatric evaluation was done for the resident approximately 6 days post admission. However, it is dangerous to just stop medication. There was no psych eval in hospital and it was hard to pinpoint why the resident was prescribed the medication while in the hospital. Seroquel can be used for schizophrenia and for neurocognitive bipolar. This medication should not be used to manage symptoms. The Medication Regimen Review (MRR) are done daily for residents. If there are any medication discrepancies, they reach out to provider and let them decide. During interviews conducted on 05/25/2023 at 12:13 PM and 12:28PM and again at3:42 PM, the Medical Doctor (MD #2) who is also the Medical Director stated that Resident #373 had a diagnosis of vascular dementia and dementia unspecified not schizophrenia. On 5/7/2023 or 5/8/2023 while Resident #373 was in the hospital they were placed on Seroquel with an indication of agitation. The resident had a foley and with their behaviors there was a risk to injury such as traumatic hematuria. It was beneficial to temporarily place on Seroquel at a lower dose and monitor to determine if they should discontinue completely. They tried to take wean off the medication. As a result, the resident had multiple falls and aggressive behavior. They are aware of the risks this is why psychiatry and medical were monitoring. MD#2 stated that the black box warning can apply to any resident based on their present situation. MD#2 stated that the Pharmacist did not indicate any medication irregularities during their review. They stated that nonpharmacological interventions were included for this resident. MD #2 stated that psychiatry communicates recommendations and they do try to avoid prescribing unnecessary antipsychotic medication. They attend the resident's interdisciplinary treatment team (IDTT) meetings. The resident has a foley catheter and was on antibiotics. There can be confusion and agitation with infection and foley use. This may decrease once foley is removed. During an interview on 05/26/2023 at 11:35AM, RN #4 stated that when a resident comes in with a diagnosis, they ask the doctor to clarify diagnosis for the order, this includes telephone orders. Resident #373 has dementia. Psychotropic medication include Seroquel and stated they are not sure what it is used to treat. RN #4 stated that the resident has exhibited agitation, but they are usually quiet when they provide care. They talk to resident calmly and answer calmly and explain medication when administered. RN #4 stated that the resident receives Memantine for dementia given in the morning. No refusals of meds for resident and explained to resident before administration. We don't want any misdiagnosis with the residents, make sure resident get correct medication for the correct diagnosis. No sleep disturbance aware of for resident when they come in the morning resident sleeping and resident 373 gets up when ready to eat breakfast. During an interview on 05/26/23 at 01:21 PM, the Assistant Director of Nursing (ADON) stated that the diagnosis in the medical record should be accurate. The nurse should read consultant recommendation and follow up with MD on all telephone orders. The nurse should look at diagnosis from the doctor. You cannot give medication for a diagnosis that a resident does not have. The diagnosis has to be in the resident's chart. When you see a schizophrenia diagnosis, we have to validate the diagnosis. The ADON stated that if the resident came from the hospital with a diagnosis of schizophrenia, then there would have been involvement from social services and the MDS coordinator along with psychiatrist. The interdisciplinary treatment team reviews the MDS and, social services reviews diagnosis in morning report. In order to provide the right care for the resident you cannot enter a diagnosis that is not part of the medical record, accuracy is very important. The ADON said that the diagnosis of schizophrenia may have been a typo and error. 415.18(c)(1)

Based on observation, record review and interviews, the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive and at a safe and appetizing temperature. Specifically, during the dining observation task, during the breakfast meal of 5/22/23, milk was not served at a safe and appetizing temperature. The findings are: A Policy and Procedure titled Taste & Temperature Control - remote dining, effective 5/15, revised 4/17, states that food is maintained at proper temperatures during meal service. It states the procedure that prior to the start of each meal period, there is an evaluation of the taste and temperature of food. This information is documented on a taste and temperature log. Cold foods should be held at temperature that will ensure HACCP standards are met at time of delivery. Cold foods, such as milk, butter, ice cream, and juices are refrigerated during service or properly iced. The dining server will transport sandwiches along with other cold items inside the cold bin. Once the dining room is reached, the items will be transferred into the pantry refrigerators waiting to be served on resident's trays. A Policy and Procedure titled Dining Room Meal Service Procedures, effective 11/18, no revision date, states the policy is to ensure residents receive meals in an accurate, safe, and timely manner. Cold foods should be held at temperature that will ensure HACCP standards are met at time of delivery. Temperature of cold foods will be recorded per taste and temperature log standards. Each tray will be pre-set in the kitchen with resident's meal ticket, utensils, napkins, and condiments. Food service employees will compile the rest of the tray up on the units by adding cold food items first (milk, juice, etc.) from the cold bin. Dietary server will pull one or two trays at a time, placing them on top of steam table, assembling the hot food plate, soup, and hot beverage. The HACCP Daily Taste Panel Chart, dated 5/22/23 3rd floor, had attached to it the HACCP Critical Control Points Daily Temperature Log, undated/floor not indicated, reflecting blank temperatures for the cold food items served at the breakfast meal. On 5/22/23 at 7:44AM, the breakfast trays for the 3rd floor were observed to be set up with juice, milk. cottage cheese, and yogurt. Also observed were 2 trays of supplements/nourishments, each tray with a quart of milk. On 5/22/23 at 8:09AM, the first resident's breakfast tray was set-up with hot food. No temperatures observed to be taken of hot or cold food prior to delivery. On 5/22/23 at 8:43AM, the State Agency took a 4-ounce container of milk off the last breakfast tray prepared prior to its service to the resident (a replacement milk was provided) in order to check its temperature. On 5/22/23 at 8:45AM, the Dietary Aide (DA) was interviewed and asked for the time that breakfast is scheduled to be served. The DA stated that breakfast service starts at 7:45AM. The trays are set up the night before with the condiments. The DA starts work at 7AM and gets the trucks, collect their supplies, and come to the unit. The DA further stated that their partner/co-worker, put the milk and juices on the trays around 7:25-7:30'ishAM. No temperatures were taken as they do not have a thermometer. The DA stated the manager or cook takes the temperature before it goes into the hot box in the kitchen. Today there was a hold up of service on the unit because of an issue with the coffee machine. On 5/22/23 at 8:52AM the Food Service Manager (FSM) came to the unit with a thermometer to check the temperature of the 4-ounce container of milk. The temperature was 50 degrees Fahrenheit. The DA was asked if this is an appropriate temperature and they stated it is not an appropriate temperature for milk. The FSM was asked about the temperature of milk. They stated milk should be between 35 to 37 degrees Fahrenheit, and that 50 degrees is not appropriate. The FSM stated that the cold items are put on the trays up on the unit. Breakfast service is started between 7:45 - 7:50AM. Staff usually put the items on 5 to 10 minutes before that. They stated usually the manager comes up and takes temperatures. The FSM stated that today they did not check the cold food temperatures. On 5/22/23 at 1:51PM, an interview was conducted with the Director of Food & Nutrition (DFN) who stated that the staff come in at 7AM. The trays are set up with the condiments the night before. The staff put their cold bin together (a container with cold items, ice it down and come to the unit). Once on the unit, the staff organize the trays, and at around 7:30AM they put the cold items onto the trays. The cold food item temperatures are done by the manager. The manager will verify hot food temperatures as well. The breakfast starts at 7:45AM. The manager takes hot food temperatures on the unit and will hit a few cold items here and there. The DFN stated that the nursing staff is responsible for putting the quart of milk (on the nourishment trays) into the refrigerator. 10NYCRR 415.14(d)(2)

Based on observations, record review, and interviews during the recertification survey (CM6T11), the facility did not ensure that infection control practices were maintained. This was evident for 1 of 6 units (Unit - 2 North) observed for Infection Control. Specifically, a Certified Nursing Assistant (CNA #3) was observed using a blood pressure cuff (BPC) on multiple residents without sanitizing the BPC between residents and having inconsistent hand hygiene. The findings are: The facility policy titled Infection Control last reviewed 05/2023, documented actions we take to eliminate reservoirs include they are everywhere! Everywhere you touch, there is an organism. Cleaning and disinfecting of community use items is critical in both compliance and prevention to include digital blood pressure machines. During an observation on 05/24/2023 from 3:59PM- 4:25PM, CNA #3 entered Resident #373's room without donning gloves and gown. CNA #3 took Resident #373's blood pressure (BP) on the right arm, pulse oximetry on right hand 2nd digit and used an oral thermometer to take the temperature. After completing the vital signs for Resident #373 they documented the resident's vital signs, removed the pulse oximetry, recorded additional readings and removed blood pressure cuff from resident's right upper arm. The items were placed into a caddy on the vital signs machine. The caddy was taken out of room. The blood pressure cuff fell on floor and the blood pressure cuff and pulse oximetry was wiped with a purple wipe with bare hands. CNA #3 proceeded to room [ROOM NUMBER] and took the vital signs of Resident #378 who was wearing a short sleeve shirt and documented their vital signs and proceeded to get linen for the resident in the cart close by the resident's room doorway. CNA #3 assisted Resident #378 to make the resident's bed. On 05/24/2023 at 04:11PM CNA #3 applied hand sanitizer to their hands. The BPC is not cleaned after use. CNA #3 proceeds to room [ROOM NUMBER] and the BPC was applied to Resident #374 who was wearing a short sleeve shirt and applied BPC to right upper arm and took their blood pressure, placed pulse oximetry on right hand 2nd digit, temperature done and documented. The pulse oximetry and BPC were placed in the caddy were not cleaned and no hand hygiene done. CNA #3 assisted Resident #377 to get to a sitting position for blood pressure by assisting them holding their left hand. BPC was applied to the right arm above long sleeve shirt, temperature done, CNA #3 removed resident's shirt, blood pressure done on bare skin with assistance of therapy staff present after curtain drawn for privacy from open doorway. The BPC was removed, and vital signs recorded, and hands sanitized. The BPC was not cleaned after use. CNA #3 does hand hygiene with soap and water in resident bathroom and walks to room [ROOM NUMBER] with the BPC and after plugs up the BPC in the wall outlet opposite room [ROOM NUMBER]. On 05/24/2023 at 4:44 PM, CNA #3 stated BPCs should be cleaned when finished taking vital signs. They forgot to clean the vital signs machine in between residents in rooms. For infection control don't want to pass anything to anyone. They have had in-service on infection control so far this year. Vital signs machine should be sanitized between each resident to prevent spreading infections between residents. On 05/25/2023 at 4:58PM, RNS #3 stated that the vital signs machine should be cleaned after each resident's use. We use purple wipes for the vital signs machine and handwashing and per policy. Staff are inserviced on this and upon hiring for infection control. Cleaning is for infection control. On 05/26/2023 at 01:00PM, the Infection Preventionist stated they do rounds daily and to make sure everything is in place by observing staff. In terms of infection control, if have an outbreak we failed and during COVID-19 could not help, control COVID-19. If there is a vital signs machine, [NAME] if you share it you clean it so staff can remember and we have enough of purple top wipes and cleaning of equipment. We don't want the spread of infection on residents' skin and we use standard precautions and make sure equipment is sanitized for all residents use and there is no spreading of anything in between use of equipment. On 05/26/2023 at 01:30 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated they do rounds daily. Staff have to clean equipment between usage. Disposable cuff for infectious disease has their own machine and after isolation is discarded. It should be cleaned between residents as part of infection control and can't use on another resident; any residue or dead tissue have skin infection and they may transmit it to another resident. On 05/26/2023 at 01:45PM, the Director of Nursing was interviewed and stated they do rounds in the morning and after morning meeting and on the 3-11 shift 3-4 times daily. Shared equipment should be cleaned before and after use. Cleaned at start of shift and if not used before. Make sure not transferring infections, microorganisms from previous patients to prevent contamination. 415.19 (a)(1),(b)(4)

Based on observations and staff interview, the facility did not ensure that sanitary conditions were maintained in the kitchen to prevent food borne illness and cross contamination. This was evident during observations conducted during the Kitchen Tour. This resulted in no actual harm with potential for more than minimal harm. On 1/28/15 at 11:40 am, a tray line observation in the kitchen was conducted. Food holding temperatures were taken by the Food Service Supervisor (FSS) in the steam table using a manual thermometer. During the observation, the FSS did not don gloves. He inserted the thermometer (with his bare hands) into the deep pan of rice and his hands came into direct contact with the cooked rice. After the surveyor pointed out that he was performing the task with his bare hands, he then donned on gloves. After checking the baked chicken temperature, he further attempted to put the same thermometer into the next food item (gravy) without wiping the thermometer. The Food Service Director (FSD)) and the Dietitian who were also observing the process, reminded the Supervisor to clean the thermometer with an alcohol swab, he stated that as long as all the foods are hot, there was no need to clean the thermometer. On the insistence of the Dietitian, the Supervisor took the alcohol swab and started cleaning the thermometer after checking each food item. In addition,during the temperature checks, an alcohol swab fell on to the floor. The Supervisor immediately picked it up with his gloved right hand, transferred the swab to his left hand and put it into his pant pocket. He then proceeded (with the same hand) to take the food temperatures. The surveyor then stepped in to remind him of the potential for food borne illness and cross contamination. After the surveyor pointed this out, the Supervisor then went and washed his hands, donned new gloves and took the temperatures for the remainder of the foods. On 1/28/15 at 11:55 AM the Food Service Supervisor was interviewed and stated that he needed to wear gloves while handling foods. He further stated that as soon as the surveyor stopped him (from taking further food temperatures) he realized his mistake, and went to wash hands and put new gloves on. He did not believe it was necessary to clean the thermometer between checking each food item, since all the items were hot foods. 415.14(h)

Based on record review and resident and staff interviews, the facility did not ensure that a resident's preference for bathing schedule was honored. This was evident for 1 out of 3 residents reviewed for choices out of sample of 40 residents. (Resident # 282) This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident #282 is a [AGE] years old male admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), quarterly assessment dated 10/4/11 documented that the resident has adequate hearing, speech, understanding, and vision, cognitively intact, no behavior issues, extensive assist of one for most activities of daily living (ADL), and requires extensive assistance of one person for transfer, dressing, personal hygiene and bathing. On 11/29/11 at 12:07 PM, the resident was interviewed and stated that he receives a shower 2 times per week, but he would prefer to have a shower 3 to 4 times a week. He stated that he asked the nursing staff to increase the frequency of his showers. He was told they could only give him a shower 2 times per week. The Comprehensive Care Plan (CCP) dated 10/15/11 documented that the resident requires extensive assist for most ADL (activities of daily living) including bathing. A review of Certified nursing assistant (CNA) accountability record for November 2011 documented that the resident received a total of 6 showers during the month. The resident received two showers during the 1st week of the month, one shower during the 2nd week of the month, two showers during the third week of the month and one shower during the 4th week of the month. On 11/30/11 at 2:30 PM, the day shift CNA was interviewed and stated that she is a floater, covering for the first time, and she gave the resident a bed bath today, since it is not the day he is to receive a shower. She further stated that resident wanted to get dressed, and be ready for breakfast, but he did not mention anything about not receiving a shower yesterday. On 12/1/11 at 10:30 AM the day shift CNA was interviewed and stated that she takes care of resident five (5) days a week. The CNA further stated that the resident likes to get up early, and gets a shower on Tuesday and Friday. The CNA further stated that resident has not expressed any preference for extra showers. On 11/29/11, the CNA stated she gave the resident a shower but documented she gave a bed bath; This is an error. On 11/30/11 at 2:35 PM, the Registered Charge nurse (RN) stated that resident made no request to be showered more frequently. She sees the resident daily and was not aware that the resident did not get shower 2 times per week this month. She further stated that she knows the resident likes his shower, sits and waits for it, but did not know he wanted more showers. The facility policy is to give a minimum of 2 showers per week. If a resident likes to have more showers, we try and accommodate, even if it is not on the same shift. On 12/1/11 at 10:27 AM, in a second interview, the Charge nurse (RN) stated that on admission nursing does basic assessment, and does not ask preferences for bathing. Have assignment for shower day, the charge nurse makes the decision of the days of shower, according to floor needs. If resident verbalizes preference, will reassign the days. The resident is on this floor for 3 months, we made the decision, but did not ask resident preference for bath days, time or how often to give. He only spoke with her yesterday and expressed that he would like to have 3 to 4 showers in a week. 415.5 (b)

Based on record review, resident and staff interviews, the facility did not ensure that residents' were notified prior to receiving a new roommate. This was evident for 2 of 40 residents reviewed for significant care concerns. (Residents #66 and #223) This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) Resident #66 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 10/12/2011 documented that the resident had intact memory and cognition. On 11/29/2011 at 12:03 PM, the resident was interviewed and stated she was not notified prior to the arrival of her new roommate. Review of the resident ' s medical record revealed no documentation about the advance notification of a new roommate's arrival on 11/11/2011 (Friday) at 2:15 PM. On 12/2/2011 at 1:50 PM, the unit Social Worker was interviewed and stated usually if she is in the building, when a new admission arrives on the rehabilitation unit, she tries to introduce the new resident to the resident already in the room. However, the Social Worker, continued, she is not always aware in advance of the arrival of a new resident, in addition many residents are being admitted on evenings or on the weekends at times when the Social Worker is not available. In these situations, she stated, the Social Worker follows up with any adjustment-related issues of the new roommates on the following work day. 2) Resident #223 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 12/22/2010 documented that the resident has intact cognition. On 11/28/2011 at 2:26 PM, the resident was interviewed and stated she received a new roommate a few months ago and "they did not tell me in advance about her (new roommate). I just came into my room and saw her in bed. " review of the resident's medical record revealed [REDACTED]. On 12/2/2011 at 12:22 PM, the unit Social Worker was interviewed and stated that most residents come to this unit as a transfer from the rehabilitation unit. Per the facility's protocol, both, the resident being transferred and the resident receiving a new roommate, are notified in advance about the change and this notification should be documented in the social services progress notes. The Social Worker confirmed that the notification notice could not be located in the resident's medical record. 415.5(e)(2)

Based on observation, record review and interview , the facility did not ensure that the care plans for pain, range of motion, and incontinence were developed. This was evident for 2 of 22 residents reviewed for significant care concerns. (Residents #68 and # 299). This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) Resident #68 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] documented the resident with intact cognition (BIMS - brief interview for mental status score 15/15). The assessment further documented that the resident required extensive to total assistance with all activities of daily living except for eating and had functional limitation in range of motion to upper and lower extremities on one side. In addition, the resident reported having occasional pain intensity 3/10. The Care area assessment (CAA) summary note dated 9/30/2011 documented " Chronic pain - Dx (diagnosis): [MEDICAL CONDITION]- [MEDICAL TREATMENT]- to proceed to care plan. " a) The Pain assessment tool dated 10/5/2011 documented " pain intensity 2-3 mild pain " with " disposition: mild, occasional and well controlled pain. Follow up and monitoring in CCP (comprehensive care plan). " The Physician ' s monthly assessment dated [DATE] documented " min (minimal) pain ...may take [MEDICATION NAME] PRN (as needed) for pain ... " The Phyisician's interim order dated 11/11/2011 documented " [MEDICATION NAME] 400mg (milligrams) PO (orally) BID (twice daily) (for) pain & (with) meals x 2 weeks," The Medication record for 11/1-11/30/2011 documents that the [MEDICATION NAME] was administered twice on 11/19/2011 and on 11/24/2011 for pain 3/10 and 2/10 and was effective. There is no documented evidence that the care plan for pain was developed. The Registered Nurse Supervisor was interviewed on 12/2/2011 at 2:50 PM and stated that according to the nursing assessment, annual MDS assessment and the use of pain medication, the care plan for pain should have been developed for this resident. b) The Physician ' s monthly assessment dated [DATE] documents " ROM decreased B/L bilateral wrist. " The Physician non medication order sheet dated 11/4/2011 documents " Bilateral wrist splints. Remove for care. " Clinical accountability & (and) assignment record for November and December 2011 document " Hand splint R (right) and L (left) " There is no documented evidence of the annual OT assessment or the OT care plan. The Director of Rehabilitation/Occupational Therapist was interviewed on12/2/2011 at 12:44 PM and stated she was not aware why the hand splints were indicated as she was not familiar with the resident. She continued stating that the resident should have been assessed by the OT during the annual MDS assessment period and the care plan should have been developed according to that assessment, but this was not done. The Director provided a blank copy of the OT assessment/care plan form and explained this form would be utilized to document recommended OT interventions including the type of devices the resident needs The Registered Nurse Supervisor was interviewed on 12/2/2011 at 2:50 PM and stated that the nursing completes entire Section G - Functional Status of the annual MDS assessment, but the OT should complete assessment of the resident, document it, and develop appropriate care plan 2) Resident # 299 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The preadmission review from the hospital dated 8/2/11 documented that the resident received bowel and bladder rehabilitation and was continent of bowel and bladder. The nursing incontinence assessment dated [DATE] documented that the resident was continent . A nursing admission note dated 8/3/11 documented: "incontinent, toilet after meals and at bedtime." The Nursing "day 2" notes documented on 8/5/11 "continent of bladder and bowel with extensive assistance of 1 for toileting". The initial minimum data set (MDS) 3.0 assessment dated [DATE] documented that the resident had frequent incontinence. The MDS Quarterly assessment dated [DATE] documented that the resident was always incontinent. The resident's comprehensive care plans (CCPs) were reviewed and did not include an incontinence care plan. The resident's assigned certified nursing assistant (CNA) was interviewed on 11/30/11 at 2:25 PM and stated that the resident is usually incontinent and receives a brief change every 3-4 hours. An interview was conducted with the registered nurse manager (RNM) on 11/30/11 at 2:30 PM who stated the resident is continent as she has personally provided the resident with a bedpan during rounds. She further stated that based on the documentation she should have initiated a CCP for incontinence. The resident was interviewed on 12/1/11 at 9:45 AM and stated: " I have never lost control of my bowels. My bladder is not able to hold if they take longer than 10 minutes to answer the bell so I would just go if I can't hold it anymore. When I first came from the hospital they had a diaper on me so I figured it was OK to just go because no one said anything to me about it. This morning the nurse and the aid told me to hold on to whatever control I have so not to do that any more." 415.11 (c)

Based on record review and resident and staff interviews, the facility did not ensure that a resident's rehabilitation care plan was revised after the resident was changed from acute to nursing rehabilitation. This was evident for 1 of 40 residents reviewed for significant care concerns (Resident #299). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident # 299 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The initial minimum data set (MDS) 3.0 assessment dated [DATE] documented that the resident received 255 minutes of occupational therapy (OT) and 265 minutes of physical therapy (PT) over the prior 5 days. The resident was observed participating in activities on 11/30/11 at 1:55 PM . She was also observed in bed, set up, and performing her own morning care on 12/1/11 at 9:45 AM. An interview was conducted with the resident on 12/2/11 at 10 :20 AM. The resident stated that the rehab CNA (Certified Nurse Aide) comes in once a day from Monday to Friday to "stretch me because my left side is very tight". The resident also stated that on the weekends she exercises her hands and feet to avoid "stiffening up". PT/OT notes were reviewed and documented that the resident received therapy for 5 weeks, reached maximum potential, and was discharged on [DATE]. The therapy recommendation was for "nursing rehabilitation ... all joints daily". The PT care plan initiated 8/4/11 was not revised to indicate if the PT/OT goals goals were met and did not document that the resident was discharged from restorative therapy and was to receive nursing rehabilitation. There was no documented evidence of a care plan for nursing rehabilitation and there no indication that nursing rehabilitation was being performed. The physician's orders [REDACTED]. physician's orders [REDACTED]. AROM RUE (right upper extremity) x 10 reps each joint x 3 sets BID". On 11/30/11 at 2:18 PM an interview was conducted with the rehab certified nursing assistant (CNA) who stated that she provides daily exercises to the resident but does not document that it was done. The unit registered nurse (RN) manager was also interviewed on 11/30/11 at 2:20 PM and stated that the facility instructed her not to document nursing rehab because they are not billing for it. She further stated that there was no place to document this therapy. 415. 11(c)(2)(i)

Based on record review and staff interview, the facility did not ensure that a physician's order for occupational therapy assessment after a fall was followed. This was evident for 1 of 40 residents reviewed for significant care concerns. (Resident # 68) This resulted in no actual harm with potential for more than minimal harm. The finding is: The resident # 68 is an [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident had intact cognition and required total assistance of two person for transfer, and total assistance of one person for locomotion on/off unit. The nursing progress notes dated 11/3/2011 document "At 3:25 PM ambulet driver called unit and informed the nurse that the resident is sliding from the chair and he needs help. Nurse along c (with) the supervisor went to the ambulet ...inside the vehicle the patient was seen lying on her back on the floor ...no injuries were visible and resident did not appear in any distress ... " The interim physician's order dated 11/7/2011 documented " OT (occupational therapy) eval (evaluate) pt's (patient's) wheelchair s/p (status [REDACTED]. The Interdepartmental request form dated 11/7/2011 documented " To: Occupational therapy (OT) consultation needed from OT Reason: Pls (please) eval. Positioning in W/C (wheelchair). Resident fell out of chair on 11/3/2011. " There is no documented evidence that the OT evaluation was completed. The Director of Occupational Therapy was interviewed on 12/2/2011 at 12:39 PM and stated she found the referral form in the rehabilitation office after she returned from vacation on 11/17/2011, but never got a chance to complete the assessment. The Director stated while she was on vacation an agency Occupational Therapist was covering and the assessment should have been done. In addition, the Director stated she just observed the resident sitting in a wheelchair without a cushion. However, she did not have a chance yet to complete the assessment of the resident's positioning in W/C. 415.11 (3) (c)(ii)

Based on observation, record review and resident and staff interviews, the facility did not provide care to a resident to maintain bladder function. This was evident for 1 of 3 residents reviewed for urinary incontinence out of a sample of 40 residents. (Resident #299) This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident # 299 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The preadmission review from the hospital dated 8/2/11 documented that the resident received bowel and bladder rehabilitation and was continent of bowel and bladder. The nursing incontinence assessment dated [DATE] documented that the resident was continent. A nursing admission note dated 8/3/11 documented: "incontinent, toilet after meals and at bedtime." The Nursing "day 2" notes documented on 8/5/11 "continent of bladder and bowel with extensive assistance of 1 for toileting". The initial minimum data set (MDS) 3.0 comprehensive assessment with an Assessment Reference date of 8/10/11 documented that the resident was frequently incontinent. There was no documented evidence of a written care plan addressing the resident's status of frequent incontinence following the comprehensive assessment. The MDS Quarterly with an assessment reference date of 11/2/11 documented that the resident was always incontinent. The resident's medical record did not document a written plan of care addressing the resident's status of incontinence. The resident's assigned certified nursing assistant (CNA) was interviewed on 11/30/11 at 2:25 PM and stated that the resident is usually incontinent and receives a brief change every 3-4 hours. The accountability record does not instruct her to toilet the resident. She is directed to change the resident's brief every 3 to 4 hours. An interview was conducted with the registered nurse manager (RNM) on 11/30/11 at 2:30 PM. She stated that the resident is continent as she has personally provided the resident with a bedpan during rounds. She further stated that based on the documentation she should have initiated a CCP for incontinence, and then the instructions for toileting would have been given to the CNA via the accountability sheet. The resident was observed on 12/1/11 at 9:45 AM sitting in bed and performing her own morning care, the resident was wearing an incontinence brief. The resident was interviewed on 12/1/11 at 9:45 AM and stated: " I have never lost control of my bowels. My bladder is not able to hold if they take longer than 10 minutes to answer the bell so I would just go if I can't hold it anymore. When I first came from the hospital they had a diaper on me so I figured it was OK to just go because no one said anything to me about it. This morning the nurse and the aid told me to hold on to whatever control I have so not to do that any more." There is no documented evidence that the facility provided the necessary care to maintain the resident's level of bladder function. 415.12 (d)(2)

Based on observation, record review, resident, and staff interviews, the facility did not ensure that residents with a limitation in range of motion were assessed and that interventions and devices were consistently implemented to prevent further decline. This was evident for 2 out of 22 residents reviewed for significant care areas. (Residents #223 and #68). This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) Resident # 223 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] documented the resident with intact cognition (BIMS - brief interview for mental status score 13/15). The assessment further documented that the resident required extensive to total assistance with all activities of daily living except for eating and had functional limitation in range of motion to upper and lower extremities on one side. During the individual interview on 11/28/2011 at 2:10 PM, the resident was observed sitting in a wheelchair (w/c) with her left arm positioned on a pillow. The left hand was observed contracted and the resident was not able to open it at will. The resident demonstrated she could not open her hand and stated she wears no splint. Per the resident she used to wear splint some time ago, but does not know what happened to it. In numerous subsequent observations including, but not limited to 11/29 at 10:53 AM, 1:15 PM, and 3 PM; on 12/1 at 10:35 PM and 2 PM; and on 12/2/2011 at 10:35 AM, the resident was observed in the W/C with her left hand contracted and without a splint. In some observations, the resident had a pillow underneath her hand and in others she had none. The last annual Comprehensive assessment and care plan for occupational therapy dated 1/8/2010 documents that the resident has range of motion and muscle strength impairment to left upper extremity. " Resident protective of left hand, no active range of motion, left extremity tightness in IPJt (interphalangeal joints) " , grasp and coordination impaired to left upper extremity. The care plan includes interventions as " L (left) hand splint to preserve joint integrity + (and) to reduce stiffness in L. hand + (and) fingers)." There is no documented evidence of an annual Occupational therapy assessment to accompany annual MDS 3.0 dated 12/22/2010. The quarterly assessment and care plan for Occupational therapy dated 3/22/2011 documented contracture/limitation to left upper extremity and left upper extremity spastic. The care plan also includes an intervention -left hand splint resting. The care plan was last reviewed on 8/22/2011. The Physician's monthly assessment dated [DATE] documented " contractures LUE (left upper extremity, ROM (range of motion) 0/L (none left). " The Physician non medication order sheets dated 10/31/2011 and 11/29/2011 document " left hand splint OOB (out of bed) daily. " The Certified Nursing Assistant (CNA) Clinical accountability & (and) assignment for November and December of 2011 document left hand splint OOB and were signed off as carried out per assignment. There is no documented evidence of the refusal to wear splints, no evidence of counseling, or behavioral care plan for refusal of splints. The Certified Nursing Assistant (CNA) assigned to the resident on day shift accompanied by the surveyor on 12/2/2011 at 12:30 PM located the left hand splint in the resident ' s closet. She stated that that the resident has a weak left hand and sometimes the resident uses a splint and sometimes she does not. Per the CNA the resident does not wear splint often and refuses it at least several times per week. The CNA stated she reported that to the nurse, who tried to encourage the resident to wear the splint. The Registered Nurse (RN) was interviewed on 12/2/2011 at 1:15PM and confirmed that the CNA reported to her that the resident was refusing to wear a left hand splint approximately 3 times per week. The RN stated that she tried to speak with the resident to encourage her to wear the splint. The RN further stated if the resident entirely refused the splint she would document that and report to the nursing supervisor, However, the RN stated she did not proceed in such a way as the resident refused sometimes, but not all the time. The Registered Nursing Supervisor was interviewed on 12/2/2011 at 2:50 PM and stated that the residents with contractures should be assessed by Occupational Therapy (OT) annually and on basis of that assessment, the OT would develop a care plan. Afterwards, if no significant changes were observed nursing would update the care plan with each quarterly assessment. If the resident is refusing to wear a splint, the resident should be counseled. The RNS continued stating that the refusal to wear the splint and counseling should be documented by nursing. If resident ' s refusals continue, the RNS stated, the physician should be notified and the resident would routinely be referred to OT for reassessment to determine if alternative interventions could be implemented. Also, the RNS stated, the appropriate care plan should be developed to address refusal and effectiveness of interventions. The Director of Rehabilitation/ Occupational Therapist was interviewed on 12/2/2011 at 12:39 PM and stated that the resident ' s care plan for contractures should have been updated with each quarterly assessment and the resident ' s refusal should have been reported to the OT department and care planned for. The Director stated that the left hand splint was recommended to prevent further deterioration in the resident ' s status and if the resident was refusing to wear it she should have been reassessed, but the OT was not aware of the resident ' s refusal. 2) Resident # 68 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] documented the resident with intact cognition (BIMS - brief interview for mental status score 15/15). The assessment further documented that the resident required extensive to total assistance with all activities of daily living except for eating and had functional limitation in range of motion to upper and lower extremities on one side. On 11/30/2011 at 2:45 PM, the resident was observed seated in a wheelchair without hand splints. On 12/2/2011 at 10:30 AM and at 11:15 AM the resident was observed in bed without hand splints, The resident responded to surveyor's questions by grimacing and body movement. She denied being in pain by head motion left to right and when questioned about the splints, resident shrugged her shoulders. The resident's wheelchair was observed in the room without a cushion. On 12/2/2011 at 11:30 AM the resident was observed in presence of the Registered Nurse in bed. without hand splints in place. The RN located both hand splints in the drawer and stated maybe resident did not want them on. The Physician ' s monthly assessment dated [DATE] documents " ROM decreased B/L bilateral wrist. " The Physician non medication order sheet dated 11/4/2011 documents " Bilateral wrist splints. Remove for care. " Clinical accountability & (and) assignment record (CAAR) for November and December 2011 document " W/C (wheelchair) cushion ...Hand wrist splint R (right) and L (left) ...Bil. (bilateral) wrist splint remove for care Goal: to mobilize for comfort 2 (due to) Arthritis " The records document daily administration of wrist splints on all three shifts. There is no documented evidence of the annual OT assessment or the OT care plan for decreased ROM. There is no documented evidence of the refusal to wear splints, no evidence of counseling, or behavioral care plan for refusal of splints. The Certified Nursing Assistant (CNA) regularly assigned to the resident on the day shift was interviewed on 12/2/2011 at 12 noon and stated that when she comes in the morning the resident is not wearing hand splints and she places them on after she provides care, although infrequently the resident refuses to use the hand splints, The CNA stated she usually renders morning care around 11 AM, except on the [MEDICAL TREATMENT] days, when care is provided earlier. The CNA continued stating she just assisted the resident and wanted to put on hand splints, but the resident refused them and she had no chance yet to report that to the nurse. The CNA also stated that the resident got her current wheelchair approximately 4-5 months ago and she was instructed to place in the resident ' s wheelchair a special pad on the [MEDICAL TREATMENT] days, while on the non-[MEDICAL TREATMENT] days the resident uses a W/C without a cushion or a pad. The CNA stated she did not report that to anyone as she did not know that the resident needs a cushion in her wheelchair. The Director of Rehabilitation/Occupational Therapist was interviewed on 12/2/2011 at 12:44 PM and stated she was not aware why the hand splints were indicated as she was not familiar with the resident. The Director stated that the physician's order [REDACTED]. She continued stating that the resident should have been assessed by the OT during the annual MDS assessment period and the care plan should have been developed according to that assessment, but this was not done. The Director further stated she just observed the resident seated in a W/C without a cushion and she was not aware that the resident had no cushion or that the resident was sporadically refusing to wear the splints. The OT states the resident should be using a gel or other appropriate cushion in her wheelchair. The Registered Nurse Supervisor was interviewed on 12/2/2011 at 2:50 PM and stated that the nursing completes entire Section G - Functional Status of the annual MDS assessment, but the OT should complete assessment of the resident, document it, and develop appropriate care plan. Also, The RNS stated when the CAAR is signed by the CNA it means that the assignment was carried out as directed and the CNA should have reported refusals to wear the splints and a missing W/C cushion. 415.12 (e)(2)

Based on observation, record review and interview , the facility did not ensure that a resident's medical record accurately documented the status of a pressure ulcer. This was evident for 1 out of 3 residents reviewed for prevalence of pressure ulcers out of a sample of 40 residents. (Resident # 32) This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident # 32 was most recently readmitted to the facility on [DATE] after hospitalization . The [DIAGNOSES REDACTED]. The admission record documents that the resident was originally admitted to the facility with a stage 4 decubitus sacral ulcer on 1/17/07. The Admission/Readmission Nursing Database dated 11/18/11 documented the resident with healing stage 4 sacral decubiti ulcer with measurements of 3.5 cm (centimeters) x 3 cm x 1 cm. The physician's orders [REDACTED]. telephone order for zinc oxide ointment QS (every shift) to sacral excoriation x 2 weeks. The order sheet documented a physician signature dated 11/21/11 and nurse signature dated 11/4/11. The physician's orders [REDACTED]. The RN charge nurse (registered nurse) was interviewed on 12/2/11 at 9:20 AM. She stated that the the RNS (nurse supervisor) reported the wound to the physician and obtained the treatment order. She made a mistake and documented an excoriation instead of the known healing stage 4. The RN charge nurse said that she reviewed the order sheet, the signature was hers and she incorrectly dated it 11/4/11. She signed the order on 11/21/11. On 12/2/11 at 9:30 AM an interview was conducted with the physician who stated that she reviewed and signed the order on 11/21/11. On 12/2/11 at 10 AM an interview was conducted with the RNS (Registered Nurse Supervisor. She stated that she looked at the wound and incorrectly documented and reported it to the physician as an as excoriation. The assistant director of nursing (ADNS) was interviewed on 12/2/11 at 11:15 AM. She stated that it is the responsibility of the nurse supervisor to accurately assess and document the resident's status prior to calling the physician. 415.22(a)(b)

Based on record review and staff interviews, the facility did not ensure that Standards of Practice were followed as evidenced by not transcribing physician orders [REDACTED]. This was evident for one of thirty sampled Residents. (Resident #16). This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident #16 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set 2.0 Quarterly assessment dated [DATE] documented that the resident is alert with moderately impaired cognitive skills who requires total care for all activities of daily living. A review of the Doctors' Medication Order Form dated 12/03/10 documented the following: Basic Metabolic Panel (BMP) now and monthly; D/C (discontinue) Multivitamin due to patient already on [MEDICATION NAME]. [MEDICATION NAME] 800 milligrams 20 ml(milliliter) Suspension PO (by mouth) daily times two weeks. A review of the Daily Laboratory Log dated 12/03/10 found no documented evidence that the blood work ordered on [DATE] were transcribed to the log and that a laboratory slip had been made out. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. On 12/07/10 at 11:15AM the Charge Registered Nurse (RN) who was on duty on 12/03/10 from 7am - 3pm was interviewed and she stated that she did not see the order and that it is also the responsibility for all three nursing shifts to check the MD order book for any new orders. She further stated that the MD orders are transcribed into the Daily Log, and a laboratory slip is made out. The orders for medications are then transcribed onto the MAR. On 12/08/10 at 10:00AM the RN supervisor was interviewed and she stated that all three nursing shifts are responsible for reviewing the MD ( Medical Doctor) order book and for the transcription of all orders. A laboratory slip is to be made out for the blood work ordered and transcribed to the Daily Laboratory Log for tracking. The RN Supervisor further stated that medications are to be transcribed onto the MARs. 415.11(c)(3)(i)

Based on record review and staff interviews, the facility did not ensure that the Physician's Orders were followed. This was evident for one of thirty sampled Residents. (Resident # 16). This resulted in no actual harm with the potential for more than minimal harm. The finding is: Resident #16 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set 2.0 Quarterly assessment dated [DATE] documented that the resident is alert with moderately impaired cognitive skills who requires total care for all activities of daily living. A review of the Doctors' Medication Order Form dated 12/03/10 timed at 9:30AM documented the following: Basic Metabolic Panel (BMP) now and monthly; D/C (discontinue) Multivitamin due to patient already on [MEDICATION NAME]. [MEDICATION NAME] 800 milligrams 20 ml(milliliter) Suspension PO (by mouth) daily, times two weeks. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of this same MAR found no documented evidence that the [MEDICATION NAME] was administered to the resident. A review of the Daily Laboratory Log dated 12/03/10 found no documented evidence that the blood work order on 12/3/10 were transcribed nor that a laboratory slip had been made out. On 12/07/10 at 11:15AM the Charge Registered Nurse (RN) on duty on 12/03/10 during the 7am - 3pm shift was interviewed and she stated that she was did not see the order and that it is also the responsibility for all three nursing shifts to check the MD order book for any new orders. She further stated that the MD orders are transcribed into the Daily Log, and a laboratory slip is made out. She further stated that the orders for medications are transcribed onto the MAR. On 12/08/10 at 10:00AM the RN supervisor was interviewed and she stated that all three nursing shifts are responsible for reviewing the MD order book and for the transcription of all orders. A laboratory slip is to be made out for the blood work ordered transcribed onto the Daily Laboratory Log for tracking. The RN Supervisor further stated that medications are to be transcribed onto the MARs. 415.11(c)(3)(ii)