Every finding on record at Jefferson's Ferry

Based on observation, record review and interviews during the abbreviated survey (NY00374255) the facility did not ensure the resident's right to be free from abuse and neglect for one (Resident #1) of three residents reviewed. Specifically, During Activities of Daily living care Resident #1 fell from their chair to the floor and sustained an injury of a skin tear to the right lower extremity. Additionally, the resident struck their head on the floor and sustained a hematoma with an abrasion to their left forehead. Resident #1 was transported to the hospital for an evaluation. The finding is: The facility's policy titled, Resident Abuse and Reporting of Abuse dated 10/24/2022 documented, it will be the policy of the facility to ensure that each resident's rights will be free and protected from abuse, neglect, and mistreatment. Neglect is defined as the refusal or failure to fulfill any part of a person's obligations or duties to a resident. Neglect typically means the refusal or the failure to provide a resident with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed upon responsibility to a resident. The facility's policy titled, Assist for Ambulation and Transfers dated 11/30/2009 documented staff will use the proper level of assistance indicated in the plan of care. Resident #1's diagnoses included Dementia with Mood Disturbance, Heart Failure, and anxiety disorder. The Minimum Data Set assessment dated [DATE] documented Resident #1 had severe cognitive impairment. The Minimum Data Set Assessment also documented Resident #1 had no upper or lower extremity impairment, used a wheelchair for mobility, and was dependent for transfer. A Comprehensive Care Plan titled activities of daily living dated 4/7/2021 documented Resident #1 required the use of a mechanical lift with two people from bed to chair transfer. Resident #1's Certified Nursing Assistant Resident Nursing Instructions dated 4/11/2024 documented Resident #1's mode of transfer as, lifted mechanically with two people. An Accident and Incident Report dated 3/7/2025 documented Certified Nursing Assistant #4 provided a written statement dated 3/6/2025 stated Certified Nursing Assistant #4 used a mechanical lift to assist Resident #1 into their recliner chair then straitened the resident in the recliner. Certified Nursing Assistant #4 then proceeded to put the resident in an upright position, and Resident #1 fell forward and to the right. The Accident and Incident Report's facility summary documented, Resident #1 was seated in their recliner chair, Certified Nursing Assistant #4 attempted to raise the reclining seat to an upright position, as Certified Nursing Assistant #4 adjusted the pitch of the seat Resident #1 unexpectedly fell forward out of the recliner chair to the floor. Resident #1 was transferred to the hospital for evaluation. A Nursing Progress Note dated 3/6/2025 documented Resident #1 was assessed after a fall from their chair to the floor. Resident #1 complained of bilateral shoulder pain (both shoulders) and a skin tear was noted to right lower extremity. Resident #1 struck their head and a hematoma with an abrasion was noted to their left forehead. The Medical Doctor was notified and ordered Resident #1 to be transferred to the hospital. Resident #1's hospital discharge date d 3/7/2025 documented that Resident #1 was evaluated by the trauma team after a fall and striking her head on the floor. Resident #1 was admitted to the hospital for a urinary tract infection. The hospital Medication Administration Record documented to apply Aquaphor to the right lower extremity skin tear. During an interview on 4/17/2025 at 4:46 PM, the Director of Nursing Services stated Certified Nursing Assistant #4 improperly transferred Resident #1 into the reclining chair from their bed with a mechanical lift without assistance from another staff member. The Director of Nursing Services stated Certified Nursing Assistant # 4 did not follow the Comprehensive Care Plan for Resident #1, they should have had a coworker assist them with the transfer. During an interview on 4/25/2025 at 10:31 AM, Certified Nursing Assistant #4 stated they transferred Resident #1 from their bed to their reclining chair using a mechanical lift. Certified Nursing Assistant #4 stated once they placed Resident #1 in their reclining chair, they (Certified Nursing Assistant #4) stood behind the reclining chair to straighten the chairback. Certified Nursing Assistant #4 stated while they were behind the reclining chair they used the chair lever to straighten the chairback and Resident #1 suddenly fell forward onto the floor. During an interview on 6/13/2025 at 2:28 PM with Registered Nurse #2, Registered Nurse #2 stated that on 3/6/2025 they heard screaming from Resident #1's room. Registered Nurse #2 stated they entered Resident #1's room and observed Resident #1 on the floor. Registered Nurse #2 stated they observed Resident #2 laying on the floor in front of their reclining chair receiving care from another Registered Nurse. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00344039) the facility did not ensure that all residents were free from physical restraints imposed for the purpose of discipline or convenience and are not required to treat the resident's medical symptoms. This was identified for 17 (Resident #1 through, Resident #17) of 17 residents observed with alarms and reviewed for restraints. Specifically, 1) Resident #1 was observed to have a chair and bed alarm. 2) Resident #2 was observed sitting on an alarm pad that was connected to their shirt by a cord. 3) Resident #3 was observed with a clip attached to the back of the collar and connected by a wire to an alarm box hooked to the back of Resident #3's wheelchair. There was no documented evidence that an assessment for medical necessity was completed for the use of the alarm restraints for 17 of 17 residents. The findings are: The facility's policy titled, Physical Restraint Use last revised 6/2023 documented in accordance with federal and state regulations, the use of physical restraints will be imposed only to assure the physical safety of the resident or other residents. The policy further documented, a physical restraint is any physical means used to control or restrict freedom of movement. It includes any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, and which restricts freedom of movement or normal access to the body. The facility's policy titled, Alarms for Fall Prevention with an effective date of 9/28/2017 documented, staff will be aware of the different types of alarms utilized to prevent falls if warranted using The Morse Scale (a tool used to assess a resident's risk of falling). The policy further documented; a new resident will be evaluated using The Morse Scale to determine if an alarming device is warranted. A mean score of 55 or above will determine 5-day usage and the Charge Nurse will assess the continued need for an alarm for any new admission and will assess need for any other resident who displays a lack of safety awareness and the need for the alarm. 1) Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Acute Respiratory Failure with Hypoxia (when the lungs are unable to provide enough oxygen to the body's tissues), and Gout (a form of arthritis caused by too much uric acid that crystallizes and is deposited in joints). Resident 1#'s Minimum Data Set, dated dated dated [DATE] documented Resident #1 had a Brief Interview for Mental Status of 10 indicating a moderately impaired cognition. The Minimum Data Set Documented Resident #1 used a chair and bed alarm daily. The Minimum Data Set Documented Resident #1 used a walker and a wheelchair for mobility, had upper and lower extremity impairment on both sides and required substantial/maximum assistance for transfer. Resident #1's Morse Fall Scale dated 6/8/2024, 6/17/2024, and 8/21/2024 documented Resident #1 was a high fall risk and to implement fall prevention interventions. Resident #1's Comprehensive Care Plan for falls effective 10/26/2021 documented Resident #1 was at risk for falls for reasons that included but were not limited to, not using their call bell, not asking for assistance, right foot drop, use of bilateral ankle (both ankles) foot orthotics, and gout. Interventions included but were not limited to a low bed, bed alarm, chair alarm (physical or electronic device that monitors resident movement and alerts the staff when movement is detected) in place, and education related to call bell usage. A note in the Comprehensive Care Plan Documented Resident #1 was found on the floor on 6/2/2024 and was sent to the hospital. Resident #1's Certified Nursing Assistant Accountability for June 2024, July 2024, August 2024, September 2024, and October 2024 documented Resident #1's chair and bed alarms were check for functionality each shift. There was no documented evidence that Resident #1 was assessed for the use of alarms or had a physician's order in place for the chair and bed alarms. Resident #1 was discharged from the facility and was not available for observation or interview. During an interview on 11/7/2024 at 11:20 AM with Licensed Practical Nurse #1they stated the alarms were used for resident safety. During an interview on 11/7/2024 at 11:29 AM Certified Nursing Assistant #1 stated they were responsible for checking that the alarms were functioning, and they documented that they check the alarms in the Certified Nursing Assistant Accountability for each resident. Certified Nursing Assistant #1 stated they needed to check the alarms for resident safety when they are a high fall risk. During an interview on 11/7/2024 at 11:37 AM with Certified Nursing Assistant # 2 they stated they were assigned to Resident #1 on 6/2/2024 when Resident #1 fell in their room. Certified Nursing Assistant #2 stated the chair alarm was not sounding when they found Resident #1 on the floor. Certified Nursing Assistant # 2 stated alarms are used for resident safety. During an interview on 11/7/2024 at 1:15 PM the Assistant Director of Nursing stated residents do not need a physician's order for chair and bed alarms because they are not considered restraints. During an interview on 11/8/2024 at 2:48 PM with Licensed Practical Nurse #3 they stated an alarm would be put in place if a resident was observed ambulating unsafely or a fall concern. Licensed Practical Nurse #3 stated alarms would be used for resident safety, as an alert to staff if a resident was getting up. During an interview on 11/8/2024 at 3:00 PM with Registered Nurse #2 they stated if a resident is a high fall risk an alarm is used as a nursing intervention for resident safety and is not a restraint. The alarms do not require physician's order. During an interview on 11/8/2024 at 3:16 PM with the Assistant Director of Nursing they stated alarms are put in place if a resident is deemed a fall risk and if there are other factors such as a resident that does not ask for assistance. The Assistant Director of Nursing stated alarms are a nursing intervention and do not need a physician's order. The Assistant Director of Nursing stated they do not consider an alarm a restraint. During an interview on 11/8/2024 at 3:58 PM the Administrator they stated alarms are used if a resident is considered a high fall risk and are based on their fall assessment, which is a nursing intervention, and does not require a physician's order. The Administrator stated they did not consider an alarm a restraint. During an interview on 11/18/2024 at 2:14 PM the Medical Director stated they were aware that alarms were in use for some residents. The Medical Director stated alarms were used for resident safety if a resident was a high fall risk. The Medical Director stated alarms did not require a physician's order, but the attending physician should be aware that an alarm was in use. The Medical Director did not consider an alarm a restraint. 2) Resident #2's diagnoses included a fracture of the pubis (both pair of bones that form the two sides of the pelvis), Osteoarthritis (degenerative joint disease that causes the cartilage in the joints to break down over time), and Hypertensive Heart Disease (a disease of the heart caused by chronic high blood pressure). Resident #2's Minimum Data Set, dated dated dated [DATE] documented Resident #2 had a Brief Interview for Mental Status of 12 indicating a moderately impaired cognition. The Minimum Data Set Documented Resident #2 used walker and wheelchair for ambulation, did not have upper or lower extremity impairment, and required partial/moderate assistance with transfer. The Minimum Data set documented Resident #2 did not use any alarms. Resident #2's Morse Fall Scale dated 8/30/2024 documented Resident #2 was not at risk for falls. Resident #2's Morse Fall Scale dated 9/15/2024 documented Resident #2 was a high fall risk and to implement fall prevention interventions. Resident #2's Comprehensive Care Plan for Falls effective 8/30/2024 documented Resident #2 was at risk for falls related to not using the call bell and not asking for assistance. Interventions included but were not limited to a low bed, a bed alarm, and a clip alarm. A Nursing Progress Note dated 10/24/2024 written by Registered Nurse #3 documented they were walking past Resident #2's room and Resident #2 was ambulating in their room without their assistive device, their gait was unsteady, and they were holding on to their bed while attempting to go to the bathroom. Resident #1 was very confused, unsure of where they were and asked to go to the bathroom. Registered Nurse #3 assisted Resident #2 to the bathroom, Resident #2 remained confused, and Resident #2 was assisted back to their recliner chair. A clip alarm and bed alarm were issued, and the Comprehensive Care Plan was updated. There was no documented evidence that Resident #2 had physician's orders in place for the chair and bed alarms. There was no documented evidence that Resident #2 was assessed for use of the chair and bed alarms. On 11/7/2024 at 11:42 AM Resident #2 was observed in their room. Resident #2 was seated in their recliner chair. Resident #2 had their eyes closed and they did not response to a greeting. Resident #2 was sitting on an alarm pad and there was a clip attached to back of their shirt at the collar. There was a wire attached to the clip and the wire ran down the back of Resident #2's shirt to the alarm pad. A second observation of Resident #2 was made on 11/7/2024 at 2:24 PM. Resident #2 was seated in their recliner in their room. Resident #2 was sitting on an alarm pad and there was a clip attached to back of their shirt at the collar. There was a wire attached to the clip and the wire was attached to the alarm pad. Resident #2 stated they were not aware of the alarm pad or the clip on the back of their shirt at the collar. Licensed Practical Nurse #1 entered the room and assisted Resident #2 to rise from their recliner chair. When Resident #2 stood the wire detached from the alarm pad and an alarm sounded. During an interview with Licensed Practical Nurse #1 on 11/7/2024 at 2:27 PM they stated when a chair alarm in a resident's room sounds it can be heard from the hallway and alerts staff to a safety concern. Licensed Practical Nurse #1 stated the alarm is one measure used to ensure resident safety. During an interview on 11/8/2024 at 3:16 PM with the Assistant Director of Nursing they stated alarms are put in place if a resident is deemed a fall risk and if there are other factors such as a resident that does not ask for assistance. The Assistant Director of Nursing stated alarms are a nursing intervention and do not need a physician's order. The Assistant Director of Nursing stated they do not consider an alarm a restraint. During an interview with Registered Nurse #3 on 11/8/2024 at 3:42 PM they stated they put Resident #2's chair and bed alarms in place when they observed Resident #2 ambulating unsafely in their room. Registered Nurse #3 stated Resident #2 was very confused, not aware of their surroundings and they were not using their walker. Registered Nurse #3 stated they were concerned for Resident #2's safety and spoke to the care team at the morning meaning about putting the alarms in place as a nursing intervention, they do not require a physician's order and are used for safety. During an interview on 11/8/2024 at 3:58 PM the Administrator stated alarms are used if a resident is considered a high fall risk and are based on their fall assessment, they are a nursing intervention, and does not require a physician's order. The Administrator stated they did not consider an alarm a restraint. During an interview on 11/18/2024 at 2:14 PM the Medical Director stated they were aware that alarms were in use for some residents. The Medical Director stated alarms were used for resident safety if a resident was a high fall risk. The Medical Director stated alarms did not require a physician's order, but the attending physician should be aware that an alarm was in use. The Medical Director did not consider an alarm a restraint. 3) Resident #3 had diagnoses that included Alzheimer's Disease, Cerebral Ischemic Attack (a temporary interruption of blood flow to the brain), and Cerebral Infarction (ischemic stroke, when blood flow to the brain is blocked, causing an area of dead brain tissue). Resident #3's Minimum Data Set, dated dated dated [DATE] documented Resident #3 had a Brief Interview for Mental Status of 12 indicating a moderately impaired cognition. The Minimum Data Set Documented Resident #3 used a chair and bed alarm. The Minimum Data Set Documented Resident #3 used walker and wheelchair for ambulation, did not have upper or lower extremity impairment, and required partial/moderate assistance with transfer. Resident #3's Morse Fall Scale dated 10/28/2024 and 11/5/2024 documented Resident #3 was a high fall risk and to implement fall prevention interventions. Resident #3's Comprehensive Care Plan for Falls effective 12/20/2023 documented Resident #3 was at risk for falls related to restlessness, anxiety, poor safety awareness, medication use, frequent falls, not using the call bell and not asking for assistance. Interventions included but were not limited to a low bed, a bed alarm, a clip alarm, and visual checks. Notes in the Comprehensive Care Plan dated 9/1/2024, 9/27/2024, and 10/25/2024 documented Resident #3 fell after standing up from wheelchair and attempting to ambulate. On 9/1/2024 Resident #3 was in a high visibility area, stood up from their wheelchair, hit a staff person and fell backwards. On 9/27/2024 Resident #3, while in the company of a Certified Nursing Assistant assigned as their one-to-one supervision, rose from their wheelchair, and turned around and placed themselves kneeling on the floor. On 10/25/2024 Resident #3 was in a high visibility area when a loud noise was heard, and Resident #3 was observed on the floor. There was no documented evidence that Resident #3 had physician's orders in place for the chair and bed alarms. There was no documented evidence that Resident #3 was assessed for use of the chair and bed alarms. During an observation of Resident #3 on 11/7/2024 at 11:40 AM they were observed in their wheelchair in the common area in front of the nurse's station. Resident #3's eyes were closed, and they did not respond to a greeting. Resident #3 was observed with a clip on the back of their shirt at the collar. A wire extended from the clip to an alarm box hooked to the back of Resident #3's wheelchair. During an observation of Resident #3 on 11/8/2024 at 2:26 PM they were observed in their wheelchair in the common area in front of the nurse's station. Resident #3's eyes were closed, and they did not respond to a greeting. The clip and alarm box were not in place. During an interview on 11/8/2024 at 2:48 PM with Licensed Practical Nurse #3 they stated an alarm would be put in place if a resident was observed ambulating unsafely or note another fall concern. Licensed Practical Nurse #3 stated alarms would be used for resident safety, as an alert to staff if a resident is getting up. During an interview on 11/8/2024 at 3:00 PM with Registered Nurse #2 they stated if a resident is a high fall risk alarms are nursing intervention used for resident safety, not a restraint and do not require physician's order. Registered Nurse #2 stated when they put an alarm in place, they documented the intervention in a progress note and updated the Comprehensive Care Plan. During an interview on 11/8/2024 at 3:16 PM with the Assistant Director of Nursing they stated alarms are put in place if a resident is deemed a fall risk and if there are other factors such as a resident that does not ask for assistance. The Assistant Director of Nursing stated alarms are a nursing intervention and do not need a physician's order. The Assistant Director of Nursing stated they do not consider an alarm a restraint. During an interview on 11/8/2024 at 3:58 PM the Administrator stated alarms are used if a resident is considered a high fall risk and are based on their fall assessment, is a nursing intervention, and does not require a physician's order. The Administrator stated they did not consider an alarm a restraint. During an interview on 11/15/2024 at 2:14 PM the Medical Director stated they were aware that alarms were in use for some residents. The Medical Director stated alarms were used for resident safety if a resident was a high fall risk. The Medical Director stated alarms did not require a physician's order, but the attending physician should be aware that an alarm was in use. The Medical Director did not consider an alarm a restraint. 10NYCRR 483.10(e)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/28/2024, and completed on 5/31/2024, the facility did not ensure that food was served at a safe and appetizing temperature in accordance with professional standards for food service safety. This was identified for one (Unit 2 West) of two residents during the Dining Task. Specifically, the facility did not monitor the food temperatures of cold foods served to the residents. During a lunch meal observation on Unit 2 West, a tray of key lime pie with whipped cream measured a temperature of 66.5 degrees Fahrenheit. The finding is: An undated facility policy and procedure titled Log Recording and Thermometer Possession Culinary Management documented all food temperatures to be taken and logged immediately when food arrived at the designated unit. If food is in the Danger Zone (40-140 degrees Fahrenheit), the Executive Chef is to be contacted immediately to ensure the concern is corrected. The Unit 2 [NAME] temperature logs were reviewed. Only the hot food temperatures were recorded on the log sheet. The cold food temperatures were not noted for the first two weeks of May 2024. During the lunch meal observation on 5/28/2024 at 12:30 PM a tray containing multiple individual plates of key lime pie with whipped cream for the Unit 2 [NAME] residents was observed. The Assistant Director of Culinary Services was interviewed on 5/28/2024 at the time of the observation and they stated that the Dietary Supervisors are responsible for taking the food temperatures in the dining room on the units. The Assistant Director of Culinary Services acknowledged that the food temperature logs for Unit 2 [NAME] only included hot food temperatures; cold food temperatures were not noted for the first two weeks of May 2024. The Assistant Director of Culinary Services stated that cold foods include milk, juice, pie, pudding, and sandwiches stated that they do not take the temperature of the cold foods. On 5/28/2024 at 12:40 PM, at the request of the Surveyor, the Culinary Manager took the temperature of the key lime pie. The temperature registered 66.5 degrees Fahrenheit. The Culinary Manager stated that 66.5 degrees Fahrenheit temperature was too hot for any cold food item and the facility was not in compliance with temperature controls. The Director of Culinary Operations was interviewed on 5/31/2024 at 10:36 AM and stated that the facility's policy for food temperatures included taking temperatures of hot food at multiple points in time; including at final production, before being placed in the transport box, and then when transferred to the unit's steam table. The Director of Culinary Operations acknowledged that no cold food temperatures were being recorded on the temperature logs. The Director of Culinary Operations further stated that they use ice blankets under the cold food items, and it appeared to be insufficient. The [NAME] President of Culinary Operations was interviewed on 5/31/2024 at 11:32 AM and stated that temperature checks must be performed for cold items, such as desserts, pies, milk, tuna/chicken salad, coleslaw, and mayonnaise-based foods. They further stated that there is no excuse for not taking the temperatures of the cold foods. 10 NYCRR 415.14(d)(1)(2)

Based on interviews and record review, during the Recertification Survey initiated on 8/24/2022 and completed on 8/30/2022, the facility failed to develop and implement policies and procedures to ensure a contingency plan for staff who are not fully vaccinated to mitigate the transmission and spread of COVID-19. This was identified for one [Licensed Practical Nurse (LPN) #1] of one unvaccinated, medically exempted, staff reviewed for COVID-19 vaccination. Specifically, the facility policy and procedure did not include a contingency plan for staff who are not fully vaccinated. Additionally, LPN #1's medical exemption form did not specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member. The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO 22-07-ALL Attachment A for Long Term Care and Skilled Nursing Facility dated 12/28/2021, and last updated 4/05/2022, requires facilities to ensure those staff who are not yet fully vaccinated, or who have a pending or been granted an exemption, or who have a temporary delay as recommended by the CDC, adhere to additional precautions that are intended to mitigate the spread of COVID-19. Accommodations of Unvaccinated Staff with a qualifying exception could include mandatory routine COVID-19 testing in accordance with Occupational Safety and Health Administration (OSHA) and CDC guidelines, physical distancing from co-workers and patients, re-assignment or modifications of duties, teleworking, or a combination of these actions. Accommodations can be addressed in the facility's policies and procedures. The facility's Policy and Procedure titled, COVID Vaccination Policy dated 8/26/2021, documented employees were required to be up to date with the COVID-19 vaccination as of September 27, 2021. The Policy and Procedure did not document additional precautions for those personnel with approved medical exemptions to prevent the spread of COVID -19 infection. A review of the COVID-19 staff vaccination matrix received on 8/29/2022 indicated there was one staff member, LPN #1, with a medical exemption for the COVID-19 vaccine. Review of the Request for Exemption from COVID-19 Vaccination Mandate Based on Medical Reasons form dated 9/8/2022 did not include which authorized or licensed COVID-19 vaccine is clinically contraindicated for LPN #1. LPN #1 was interviewed on 8/30/2022 at 10:21 AM and stated they (LPN#1) were medically exempt from the COVID-19 vaccination and were using a surgical mask when on the nursing units and providing resident care. LPN #1 stated they (LPN #1) are currently wearing an N95 mask because of the COVID -19 outbreak of two COVID-19 positive residents in the facility. The Director of Nursing Services (DNS), who is also the Infection Control Preventionist, was interviewed on 8/30/2022 at 11:45 AM. The DNS stated that the facility currently had two COVID-19 positive residents in the facility as of 8/26/2022. The DNS stated all staff are required to wear a surgical mask when in the facility unless the community rate increases. When the community rate for COVID-19 increases then all staff are required to wear an N95 mask covered by a surgical mask and must wear goggles. The Medical exempt staff are required to wear a surgical mask and eyeglasses (if needed) and are swabbed twice a week for COVID-19 infection. The DNS stated they were not aware that the facility policy should include contingency plans for staff who are not vaccinated. 10 NYCRR 415.19(a)(1-3)

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that each resident's care was supervised by a physician throughout the resident's stay for 1 ( Resident # 9 ) of 5 residents reviewed for Unnecessary Medications. Specifically, the physician discontinued an antidepressant ([MEDICATION NAME]) without providing instructions to staff to monitor for withdrawal symptoms. The finding is: Resident # 9 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. The resident did not exhibit any behavior symptoms. The resident received antidepressant medications 7 of 7 days of the assessment period. The Psychiatry physician progress notes [REDACTED]. The current physician order [REDACTED]. The physician's orders [REDACTED]. A pharmacy review dated 1/2/2020 documented Resident was recently started on [MEDICATION NAME] (antibiotic), also was noted on [MEDICATION NAME] ([MEDICATION NAME]- antidepressant). Concurrent use contraindicated due to risk for Serotoni[DIAGNOSES REDACTED]. Please evaluate and consider to discontinue the Selective Serotonin Re-uptake Inhibitor (SSRI) for the duration of the [MEDICATION NAME] therapy and monitor for signs of Central Nervous System (CNS) toxicity. The physician's orders [REDACTED]. The Physicians Desk Reference (PDR) 2020, documented to avoid abrupt discontinuation of any SSRI if possible. Gradual tapering is recommended during discontinuation of [MEDICATION NAME] to decrease or prevent the occurrence of potential discontinuation symptoms. Stopping [MEDICATION NAME] abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paresthesias (prickling, tingling sensation on the skin). The medical record lacked documented evidence of instructions to monitor the resident for withdrawal symptoms after [MEDICATION NAME] was discontinued. The Nurse Practitioner (NP) evaluation dated 1/20/2020 at 12:34 PM did not include evaluation of withdrawal signs and symptoms related to abrupt discontinuation of [MEDICATION NAME]. There were no subsequent physician evaluations of the resident's status related to discontinuation of [MEDICATION NAME]. The NP was interviewed on 2/12/20 at 11:53 AM and stated when an antidepressant is discontinued, nursing staff should have monitored the resident for symptoms to ensure the resident had not relapsed into Depression. The Pharmacy consultant was interviewed on 2/12/20 at 2:21 PM and stated the resident should not be on [MEDICATION NAME] and [MEDICATION NAME] concurrently even when they are administered at a different time. She further stated that she recommended to discontinue the [MEDICATION NAME] and to restart [MEDICATION NAME] after 24 hours of the last dose of the [MEDICATION NAME]. When [MEDICATION NAME] was discontinued by the physician, the resident should have been monitored for symptoms of headaches, nausea/vomiting, irritability, and dizziness. These withdrawal symptoms are caused by abrupt discontinuation of the medication ([MEDICATION NAME]). The Physician was interviewed on 2/13/20 at 11:45 AM and stated he discontinued [MEDICATION NAME] based on the Pharmacy Consultant's recommendations. He expected the nursing staff to monitor the residents for signs and symptoms of Depression. He further stated he did not provide specific instructions to monitor the resident for withdrawal symptoms when [MEDICATION NAME] was discontinued. The resident should have had a Psychiatry consult completed with a documented evaluation following the discontinuation of an Antidepressant. The Physician was unable to state why he did not order the Psychiatry consult after [MEDICATION NAME] was discontinued. 415.15(b)(1)(i)(ii)

Based on record review and interview during the Recertification survey, the facility did not ensure that residents were free from significant medication errors for 1 (Resident # 9) of 5 residents reviewed for Unnecessary medications. Specifically, Resident# 9 received two medications ([MEDICATION NAME] -an Antibiotic and [MEDICATION NAME] - an Antidepressant) concurrently for a total of 4 doses. The consultant pharmacist indicated concurrent use of these medications could result in Serotoni[DIAGNOSES REDACTED] (symptoms include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea. Body temperature can increase to greater than 41.1 °C). The finding is: Resident # 9 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. The resident did not exhibit behaviors and was on an antidepressant for 7 of 7 days of the assessment period. The physician order [REDACTED]. The physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. A pharmacy review dated 1/2/2020 documented Resident was recently started on [MEDICATION NAME] (antibiotic), also was noted on [MEDICATION NAME] ([MEDICATION NAME]- antidepressant). Concurrent use contraindicated due to risk for Serotoni[DIAGNOSES REDACTED]. Please evaluate and consider discontinue the SSRI for duration of the [MEDICATION NAME] therapy and monitor for signs of Central Nervous System (CNS) toxicity. The physician's orders [REDACTED]. The Pharmacy Consultant was interviewed on 2/12/20 at 2:21 PM and stated the resident should not be on [MEDICATION NAME] and [MEDICATION NAME] concurrently as the concurrent use can cause the Serotoni[DIAGNOSES REDACTED]. She gave recommendations to discontinue [MEDICATION NAME]. The Pharmacy Consultant further stated the [MEDICATION NAME] could be restarted after 24 hours from the last dose of the [MEDICATION NAME]. If [MEDICATION NAME] was to be given within 24 hours, two weeks of monitoring for the Serotoni[DIAGNOSES REDACTED] would have been expected. The dispensing Pharmacist #1 was interviewed on 2/13/20 at 10:24 AM and stated prior to dispensing [MEDICATION NAME], the pharmacy received an electronic prescription that identified an alert (identifying that there is contraindication using [MEDICATION NAME] with [MEDICATION NAME]); however, the facility acknowledged the alert and ordered the [MEDICATION NAME] medication. RN # 1 was interviewed on 2/13/20 at 11:33 AM and stated she could not recall what had occurred when she ordered the resident's [MEDICATION NAME] medication. RN #1 stated when an alert for any reason, including the medication interaction was received, she would call the physician to override the alert and would document her conversation with the Physician in the medical record. The Physician was interviewed on 2/13/20 at 11:45 AM and stated he did not enter the medication order for [MEDICATION NAME] in the computer and could not recall being called for a possible drug interaction prior to the medication being ordered. He recalled the Pharmacy Consultant's recommendation dated 1/2/2020 to discontinue [MEDICATION NAME] due to interaction with the antibiotic ([MEDICATION NAME]). The nursing staff called him and he discontinued the [MEDICATION NAME] on 1/3/2020. Pharmacist # 2 was interviewed on 2/13/20 at 12:30 PM and stated [MEDICATION NAME] was dispensed on 1/1/20. The Pharmacy received the prescription on 12/31/19 at 7:43 PM, which was entered by the Registered Nurse (RN) #1 via the computer that generated an alert indicating contraindication for using [MEDICATION NAME] and [MEDICATION NAME]. The alert was acknowledged, however, the pharmacy could not identify who had acknowledged the alert. 415.12(m)(2)

Based on observation, record review, and interviews during a Recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. Specifically, one (Resident #44) of five residents reviewed for unnecessary medications, who was on an Anticoagulant injection ([MEDICATION NAME]), had no care plan developed for the Anticoagulant injection. The finding is: The 10/01/10 policy and procedure for Comprehensive Care Planning (CCP) documented that the CCP reflects the current status of the resident. The CCP is reviewed and revised on an ongoing basis and is evaluated by the team. Resident # 44 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The resident had received 7 days of injection of anticoagulant during the MDS review period. The physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the medical record on 11/29/18 revealed there was no CCP developed to address the use of anticoagulant injection medication [MEDICATION NAME]. The charge Licensed Practical Nurse (LPN) was interviewed on 11/29/18 at 11 AM and stated that a CCP should be in place for the Anticoagulant injection. The Director of Nursing Services (DNS) was interviewed on 11/30/18 at 11:45 AM and stated the CCP should have been resident centered to address the resident's Anticoagulant injection use. The CCP should have included care, including to rotate sites and how nurses were to monitor for bleeding. 415.11(c)(1)

Based on record review and staff interviews during the recertification survey, the facility did not accurately assess the resident's functional capacity as part of the Minimum Data Set (MDS) Assessment process. This was evident for one of three residents reviewed for Activities of Daily Living (ADL) in a total sample of 25 Stage 2 residents. Specifically, Resident #16 had not been assessed accurately for wheelchair locomotion function in Section G on the MDS Assessment. The resident was assessed as being totally dependent on staff for locomotion, however, the resident independently propelled the wheelchair. The finding is: Resident #16 was had [DIAGNOSES REDACTED]. A Nursing Progress Note dated 2/18/17 documented that the resident self propels her wheelchair throughout the nursing unit. The Comprehensive Care Plan (CCP) dated 2/22/17 documented that the resident propels throughout the nursing unit. A Therapy Annual Assessment Form dated 2/23/17 documented that the resident uses her bilateral lower extremities to self propel her wheelchair on the unit. The MDS assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS also documented in section G that the resident was totally dependent on staff for locomotion on the unit. An interview was held with the resident's Certified Nursing Assistant (CNA) on 5/2/17 at 10:30 AM. The CNA stated that the resident moves by herself all around the unit, and that she moves in the wheelchair by moving her feet. The CNA stated that she very rarely pushes the resident in the wheelchair. An observation was made of Resident #16 on 5/2/17 at 11:15 AM. The Resident was in the hallway propelling her wheelchair by herself using her feet. Additionally, a staff member was observed to call the resident's name and use a hand gesture (wave) to have the resident follow her, which the resident did. The MDS Coordinator/Registered Nurse (RN) was interviewed on 5/3/17 at 10:00 AM. The RN stated after reviewing Section G, that the resident's locomotion on the unit was documented as totally dependent. The RN also stated that she did not assess the resident and that the information was documented on the CNA ADL sheet. 415.11(a)(2)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that each resident's medical records were maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident in 1 of 25 resident's medical records reviewed. Specifically, Resident #113 had an inaccurate [DIAGNOSES REDACTED]. The finding is: Resident #113 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented that the resident has an indwelling Foley Catheter. The MDS also documented that the resident had a [DIAGNOSES REDACTED]. A Physician History and Physical Form dated 4/21/17 documented that the resident has [MEDICAL CONDITION], that a probable cause is [MEDICAL CONDITION] and that the resident needs additional work up. The Physician History and Physical Form also documented an intervention of a Urology consult. A CCP titled Indwelling Foley Catheter dated 4/21/17 documented that the Foley catheter was for a [DIAGNOSES REDACTED]. Review of the Hospital discharge records dated 4/21/17 had no documented evidence that the resident had a [DIAGNOSES REDACTED]. An interview was held with the Registered Nurse (RN) on 5/3/17 at 8:30 AM. The RN reviewed the CCP and stated that she could not explain where the [DIAGNOSES REDACTED]. 415.22(a)(1-4)

Based on resident and staff interview during the quality indicator refortification survey, the facility did not ensure that each resident was allowed to choose their schedule for 1 (Resident #92) of 26 residents reviewed for resident rights. Specifically, the facility did not address the resident's request to change her morning medication time from 6:00 AM to later in the morning. There was no documented evidence that the staff made any attempt to resolve or honor her request. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. (Resident #92) The finding is: Resident #92 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Resident Capacity to Understand and Make Medical Decisions form dated 3/12/15, and signed by the physician, documented that the resident could understand her medical condition and had the capacity to make medical decisions. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was cognitively intact, was able to make herself understood and was able to understand others. Physician order [REDACTED]. The Medication Administration Record [REDACTED]. During an interview on 3/26/15 at 10:16 am, this resident stated that staff woke her at 6:00 am to give her medications. She stated that she complained every morning that they should not and did not need to wake her at 6:00 am just for that. The resident also stated that she had [MEDICAL CONDITION], and waking her up that early in the morning was, wearing me out. She stated that she was very tired every day. During an interview on 3/26/15 at 10:59 am, the Social Worker (SW) stated that this resident had trouble sleeping at night, and that the resident had been assessed as being cognitively intact. The SW reviewed the initial SW Assessment and stated that asking residents about their personal preferences were not part of the SW assessment. During an interview on 3/26/15 at 11:08 am, the Registered Nurse Manager (RNM) stated that this resident complained sometime last week that she did not want to be awakened for medication administration at 6:00 am every day. The RNM reviewed the resident's orders and stated that the resident received blood pressure and heartburn medication at 6:00 am. The RNM also stated that she had not yet spoken to the physicians to attempt to change the resident's medication times. 415.5(b)(1-3)

Based on observation, record review, resident and staff interviews, during the recertification survey, the facility did not ensure that each Resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This was evident for one of two residents in a total sample of 26 Stage 2 residents reviewed for Activities of Daily Living (ADL). Specifically, for Resident #11 the facility did not ensure the resident ambulated as ordered, subsequently the resident's ambulation diminished from requiring minimal assistance to requiring total assistance. Additionally, the facility did not ensure a neurologist's recommendation for gait therapy was followed-up on in a timely manner. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #11 has [DIAGNOSES REDACTED]. Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented that the resident was cognitively intact, and required the extensive assistance of one person for transfers and ambulation. The Comprehensive Care Plan (CCP) for Assistance with Bed Mobility, Transfers, Toileting Ambulation and Mobility dated 1/2015, documented that the resident had diminished function to complete those task. Staff were to provide extensive assistance for transfers and mobility to destination as needed. The resident was discharged from the Physical Therapy program on 12/27/14. The Physical Therapy (PT) Discharge Summary dated 12/26/14, documented that on discharge from the program, the resident was able to ambulate 50 to 75 feet with a wheeled walker with minimal contact assistance from staff. PT recommended that the resident be on a floor ambulation program with the unit staff. The Resident Care Record (RCR), used by staff to know what care each resident required, documented in January, February and March 2015 that the resident was to ambulate 50 to 60 feet daily with a rolling walker and one staff assist. The RCR for January 2015 documented that the resident met the distance goal on January 2015 only. The RCR for February 2015 documented no days that the resident met the ambulation distance goal. The RCR for March 2015 documented that the resident ambulated zero feet on four days, 30 feet on one day, and the remainder of the days from March 1 2015 through March 27 2015, the resident walked less than 30 feet. Additionally, for the month of March 2015 the resident refused to ambulate on 6 of 79 available shifts. During an interview on 3/27/15 at 1:42 PM, the Regional Manager for the PT department reviewed this resident's record and stated that the resident was discharged from PT on 12/26/14 because he had reached his goals and plateaued. Upon discharge from the program, the resident was able to walk 60 feet with a rolling walker and staff in light physical contact with the resident. During an interview on 3/27/15 1:58 PM, a Licensed Practical Nurse (LPN) who provided care to this resident and was familiar with him, stated that the resident required extensive assistance with toileting, and that he rarely ambulated with staff. During an interview on 3/27/15 2:15 PM, the resident's wife stated that she visited the resident every day, and that the staff no longer walked the resident since he was discharged from PT in 12/2015. The wife also stated that the staff ambulated the resident occasionally from his wheelchair and to the bathroom. During an interview on 3/27/15 2:18 PM, the Registered Nurse Manager (RNM) reviewed the resident's record and stated that staff were supposed to walk the resident up to 50 to 60 feet daily, although that goal had not been met in January, February and March 2015. The RNM also stated that on 3/12/15, the Neurologist Consult had recommended that the resident have an ambulatory referral to Occupational Therapy and PT. She also stated that she had sent the recommendation to PT, but had not yet heard back from them. The RNM also stated that staff had not reported to her that the resident had consistently not met his ambulation goals, and occasionally refused to ambulate. During an observation on 3/31/15 at 8:38 am, two Certified Nursing Assistants (CNA) ambulated the resident ambulated in the hallway. The resident was able to walk 20 feet before tiring and sitting in his wheelchair. During an interview on 3/31/15 at 8:42 am, a CNA (who had assisted the resident during the observation of ambulation) stated that she did not know how far the resident was supposed to walk every day, and that the resident was to be walked until he got too tired. She stated that the resident had walked 50 feet during the observation. She also stated that if the resident could not walk the required distance, staff were supposed to notify the supervisor. During an interview on 3/31/15 at 8:42 am, another CNA (who had also assisted the resident during the observation of ambulation) stated that the resident was supposed to be walked 20 feet every day, and that the resident had walked 8 feet during the observation. She also stated that if the resident could not walk the required distance, staff were supposed to notify the supervisor. During an interview on 3/31/15 at 8:51, the RNM reviewed the spot where the ambulation observation started and stopped and stated that the resident had walked twenty feet. She stated that staff were supposed to know how far a resident ambulated because the ceiling tiles were 2 feet long and 2 feet wide. The RNM counted the ceiling tiles and stated that the resident had walked 20 feet. 10NYCRR 415.12(a)(1)(i-v)

Based on record review and staff interviews during the standard and abbreviated (NY 211) survey the facility did not ensure that services were provided to meet professional standards of quality. Specifically, the nursing staff did not remove and bring discontinued controlled substance medications to the Director of Nursing (DNS) for destruction in a timely manner (Resident # 36, # 38, # 91, and # 84); 2) the DNS did not initiate an investigation of missing controlled substance medication ([MEDICATION NAME]) in a timely manner (Resident # 22, Complaint- NY 211) in December 2013 when brought to the DNS's attention; and 3) a Licensed Practical Nurse (LPN) did not follow standards of practice by writing a physician's order to discontinue [MEDICATION NAME] on an interim physician's orders [REDACTED].# 22 - Complaint NY 211). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) A) A physician's orders [REDACTED].# 36 dated 9/16/13 documented Tylenol#3 one tablet every four hours when necessary (PRN) for mild pain and Tylenol#3 two tablets for moderate pain. A POF dated 2/01/14 documented to discontinue Tylenol #3 one tablet every four hours when necessary (PRN) for mild pain and Tylenol#3 two tablets for moderate pain. B) A POF for Resident # 38 dated 1/14/14 documented Florinal (for headache) one tablet every 12 hours PRN. The resident was discharged home on[DATE] all medications were discontinued. C) A POF for Resident #91 dated 2/01/14 documented [MEDICATION NAME] 5/325 milligrams (mg) every 6 hours PRN. The resident was discharged home and all medications were discontinued. D) A POF for Resident # 84 dated 1/13/14 documented [MEDICATION NAME] (a controlled substance) 5 millimeters (ml) three times a day. A POF for Resident #84 dated 2/05/14 documented to discontinue [MEDICATION NAME] 5 ml three times a day. Observations were completed on 3/03/14 at 10:25 AM and 3/04/14 at 10:30 AM of the 2 East medication room. The observation revealed that there were 4 blister packs and one bottle of discontinued controlled substance medications. A Facility Controlled Substance Policy dated 2/28/14 documented that when a controlled substance medication has been discontinued, the controlled medications are given to the DNS for destruction. An interview was held on 3/03/14 at 10:30 AM with the Licensed Practical Nurse (LPN) medication nurse #1. The LPN observed the discontinued controlled substance medications and stated that any nurse could bring the discontinued controlled substance medications to the DNS, and that usually on a weekly basis the medication room is checked for discontinued medications. The LPN could not explain why the discontinued medication was still in the room. An interview was held with the Registered Nurse (RN) Charge Nurse on 3/03/14 at 10:35 AM. The RN stated that the discontinued controlled substance medication should be brought to the DNS's office after the DNS is called and informed that a medication was discontinued. The RN stated that the medication nurses would be responsible on a weekly basis to check the medication rooms. An interview was held on 3/03/14 at 11:00 AM with LPN #2 medication nurse who stated that when a controlled substance is discontinued it goes on the top self of the narcotic box in the medication room and that usually once a week the discontinued medication would be given to the DNS. The LPN stated that any nurse could do the task. An interview was held with the acting DNS on 3/03/14. The DNS stated that the policy is to bring the discontinued controlled medications to the DNS weekly and the nurse and the DNS would sign that it was given to and received by the DNS. The LPN further stated that if a medication was discontinued on the weekend it would be given to the DNS on Monday morning. An interview was held with the acting DNS on 3/05/14 at 12:00 PM. The acting DNS stated that the discontinued controlled substance medications should have been removed from the narcotic box and given to the DNS when the medications were discontinued. 2) On 2/27/14 the facility reported to the Department of Health (DOH) that they began an investigation due to a concern regarding the missing controlled substance medications for Resident #22. A Loss of Control Substance Report (LOCSR) dated 2/28/14 documented that on 6/16/13 that 90 [MEDICATION NAME] 10 Milligram (mg) tablets were delivered to the facility for Resident #22 and the controlled substance record could not be found. The information was reported to the former Director of Nursing Services (DNS) and the DNS documented that she felt that the drugs were never delivered. Subsequently, an investigation was initiated on 2/27/14 and revealed that 90 tablets were delivered to the facility on [DATE] and approximately 18 doses were administered to the resident with 72 tablets missing. The investigation is ongoing by the Acting DNS. On 2/27/14 a statement was provided to the facility by the former DNS. The statement documented that approximately 6 to 8 weeks ago the LPN approached her and questioned her about Resident #22's controlled substance pain medication. The former DNS's statement also documented that she believed the paper work was missing for the controlled substance medication. There is no documented evidence that an investigation was initiated in December 2013, at the time the DNS was made aware of the missing medications. An interview was held with the the Acting DNS (ADNS) on 3/03/14 at 8:30 AM. The ADNS stated that she was investigating a concern on missing controlled substance medication for Resident #22. The ADNS stated she was informed by the Chief Executive Director (CEO) of the facility on 2/27/14 of the concern. The ADNS also stated that the CEO was informed by an LPN staff member during a meeting that the missing medication was reported to the former DNS in December 2013 and that there is no documented evidence that an investigation was initiated. An interview was held on 3/04/14 at 9:00 AM. The administrator stated that he was not aware of any missing controlled substance medication for Resident #22 until 2/27/14 when the CEO informed him. An interview was held with the facility CEO on 3/04/14 at 9:20 AM. The CEO stated that she was informed on 2/27/14 by a licensed nurse that controlled substance medications were missing for Resident #22 and that the missing medication had been reported to the former DNS but that the former DNS in December 2013. The CEO stated that the LPN stated that the former DNS did not address the concern. The CEO also stated that a private investigation is being conducted. An interview was held with the Pharmacy Consultant on 3/04/14 at 1:00 PM. The Pharmacy Consultant stated that she had no knowledge of any missing controlled substance medications. An interview was held on 3/04/14 at 2:00 PM with the LPN #1. The LPN stated that Resident #22 requested pain medication sometime in December 2013. The LPN also stated that she looked for the [MEDICATION NAME] 10 mg to give the resident and remembered that there were 2 blister packs of [MEDICATION NAME]. The LPN further stated that she could not locate the medication or the controlled substance sign out sheet and that she immediately reported the concern to the former DNS. The LPN also stated that the DNS did not investigate her concern about the missing medication and told her to stop talking about it. 3) A review of the medical record for Resident #22 revealed an IPOF dated 12/28/13 documented [MEDICATION NAME] 5/325 1 tab every 3 to 4 hours when needed. This physician's orders [REDACTED]. The IPOF also documented to discontinue [MEDICATION NAME] which was written in a different handwriting. A faxed copy of the IPOF sent to the pharmacy dated 12/28/13 had no documented evidence of the discontinued [MEDICATION NAME]. An interview was held with the Acting Director of Nursing Services (ADNS) on 3/07/14 at 11:00 AM. The ADNS stated that she spoke with the RN who documented the IPOF for the [MEDICATION NAME] and that she did not document the the handwritten order to discontinue [MEDICATION NAME]. An interview was held with the ADNS on 3/07/14 at 3:00 PM. The ADNS stated that she interviewed the Licensed Practical Nurse (LPN) who documented the discontinued [MEDICATION NAME] on the IPOF. The ADNS stated that the LPN stated to her that she made a mistake, that she was in a hurry and should not have documented on the IPOF written by the RN. The LPN also stated that she should have written a new IPOF for the discontinued [MEDICATION NAME] including the complete order. 415.11(c)(3)(i)

Based on record review and staff interviews during the recertification and abbreviated survey (NY 211), the facility did not ensure that the Pharmacy Consultant reported that there were discontinued controlled substances medications on the 2 East unit. This was evident for 1 of 2 units observed. Specifically, an observation on 3/03/14 at 10:25 AM and 3/04/14 at 10:30 AM on the 2 East unit revealed that there were 2 blister packs (Resident #36) of discontinued controlled substance medications (Tylenol #3). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: A physician's orders [REDACTED].# 36 dated 9/16/13 documented Tylenol #3 one tablet every four hours when necessary (PRN) for mild pain and Tylenol #3 two tablets for moderate pain. A POF dated 2/01/14 documented to discontinue Tylenol #3 one tablet every four hours when necessary (PRN) for mild pain and Tylenol #3 two tablets for moderate pain. A Pharmacy Consultant Nursing Audit Form dated 2/03/14 documented that there were no discontinued medications in the 2 East medication room narcotic box. An observation was completed on 3/03/14 and at 10:25 AM and 3/04/14 at 10:30 AM of the 2 East medication room. The observation revealed that there were 2 blister packs of discontinued controlled substance medications. An interview was held with the acting DNS on 3/03/14. The DNS stated that the policy is to bring the discontinued controlled medications to the DNS weekly and the Nurse and the DNS would sign that it was given and received, except on weekends then it would be a Monday morning. An interview was held with the Pharmacy Consultant on 3/04/14 at 1:00 PM. The Pharmacy Consultant stated that she conducted the the Pharmacy nursing audit and that she can not remember if there were discontinued medications, but she would have documented the observation of discontinued medications on the audit form had she found discontinued medications. 415.18(c)(1)

Based on record review and staff interviews during the recertification and abbreviated survey (NY 211) the facility did not ensure that a system was in place to consistently monitor for accurate reconciliation and accounting of all controlled substance medications; and the Identification of loss or the diversion of controlled medications to minimize the time between actual loss and the detection and determination of the extent of loss. Specifically,there is no documented evidence that the facility completed an investigation of missing controlled substance medications (Oxycodone) used for pain for a fractured left femur for one resident (Resident # 22, complaint NY 211) in a timely manner. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: On 2/27/14 the facility reported to the Department of Health (DOH) that they began an investigation due to a concern regarding missing controlled substance medications for Resident #22. A loss of Control Substance Report (LOCSR) dated 2/28/14 documented that on 6/16/13 90 tablets of Oxycodone 10 Milligram (mg) tablets were delivered to the facility for Resident #22. The controlled substance record could not be found. The information was reported to the former Director of Nursing Services (DNS) by an LPN and the former DNS documented that she believed that the drugs were never delivered. Subsequently an investigation initiated on 2/27/14 revealed that 90 tablets were delivered to the facility on [DATE] and approximately 18 doses were administered to the resident between 6/16/13 through December 2013 and that 72 tablets are missing. The investigation is ongoing by the Acting DNS. A physician's orders [REDACTED]. The MAR indicated [REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A POF dated 12/28/13 documented to discontinue Oxycodone. On 2/27/14 a statement was provided to the facility by the former DNS. The statement documented that approximately 6 to 8 weeks ago a LPN approached her and questioned her about Resident # 22's controlled substance pain medication. The DNS's statement also documented that she believed the paper work was missing for the controlled substance medication. An interview was held with the the Acting Director of Nursing Services (ADNS) on 3/3/14 at 8:30 AM. The ADNS stated that she was investigating a concern on missing controlled substance medication for Resident #22. The ADNS stated she was informed by the Chief Executive Director (CEO) of the facility on 2/27/14 of the concern. The ADNS also stated that the CEO was informed by a nursing staff member during a meeting that the missing medication was reported to the former DNS in December 2013 and she was in the process of initiating an investigation. An interview was held with the Administrator on 3/4/14 at 9:00 AM. The Administrator stated that he received a phone call from the CEO on 2/21/14 that the DNS was put on administrator leave. The Administrator stated that he did not ask why. The administrator further stated that he was not aware of any missing controlled substance medication for Resident #22 until 2/27/14, when he was informed by the CEO. An interview was held with the facility CEO on 3/04/14 at 9:20 AM. The CEO stated that she was informed on 2/27/14 by a licensed nurse that controlled substance medications were missing for Resident #22 in December of 2013 and that the missing medications had been reported to the former DNS, however, the former DNS did not address the concern. The CEO also stated that a private investigation is being conducted. An interview was held with the Pharmacy Consultant on 3/04/14 at 1:00 PM. The Pharmacy Consultant stated that she had no knowledge of any missing controlled substance medications. An interview was held on 3/04/14 at 2:00 PM with the LPN who reported the missing medication to the DNS in December 2013. The LPN stated that Resident #22 requested pain medication sometime in December 2013. The LPN also stated that she looked for the Oxycodone 10 mg to give the resident. The LPN further stated that she could not locate the medication or the controlled substance sign out sheet and that she immediately reported the concern to the former DNS. The LPN also stated that the former DNS did not address her concerns and that the former DNS informed the LPN to stop talking about it. 415.18(d)

Based on record review and staff interviews during the recertification and abbreviated survey (NY 211) the facility did not ensure that clinical records were maintained for each resident in accordance with accepted professional standards and practices. This requires that clinical records are complete and accurately documented. This was evident for 2 of 27 Stage 2 sampled residents. Specifically, 1) Resident #22's (Complaint NY 211) Interim physician's orders [REDACTED]. The same IPOF also documented to discontinue [MEDICATION NAME] written in a different handwriting. 2) For Resident #46, the facility documentation for administration of Tylenol with [MEDICATION NAME] #3 was inconsistent for two dates (9/03/13 and 9/07/13). The Controlled Substance Record documented that Tylenol with [MEDICATION NAME] #3 was used on 9/03/13 and 9/07/13 with no other documented evidence that it was actually administered to the resident. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) A review of the medical record for Resident #22 revealed a IPOF dated 12/28/13 that documented [MEDICATION NAME] 5/325 1 tab every 3 to 4 hours when needed. This physician's orders [REDACTED]. The same IPOF also documented to discontinue [MEDICATION NAME]. This was written in a different handwriting. A faxed copy of the IPOF sent to the pharmacy dated 12/28/13 had no documented evidence of the discontinued [MEDICATION NAME]. An interview was held with the Acting Director of Nursing Services (ADNS ) on 3/07/14 at 11:00 AM. The ADNS stated that she spoke with the RN who documented the IPOF for the [MEDICATION NAME] and that the RN stated that she did not document the order to discontinue [MEDICATION NAME]. An interview was held with the ADNS on 3/07/14 at 3:00 PM. The ADNS stated that she interviewed the Licensed Practical Nurse (LPN) who documented the discontinued [MEDICATION NAME] on the IPOF. The ADNS stated that the LPN stated to her that she (the LPN) made a mistake and was in a hurry and should not have documented on the IPOF written by the RN. The LPN also stated that she should have written a new IPOF for the discontinued [MEDICATION NAME]. 2) Resident #46 has [DIAGNOSES REDACTED]. physician's orders [REDACTED].#3 ([MEDICATION NAME]- COD #3, 300 mg-30 mg Tablet), 1 Tablet by mouth every 8 hours as needed for pain. A Controlled Substance Record documented that Tylenol with [MEDICATION NAME] #3 was used on 9/03/13 and 9/07/13. A review of the September 2013 Medication Sheet (MS, sheet used to document the medications administered), the Medication Exception and Hold Notes, Pain Management Flow Record and the Integrated Progress Notes revealed no documented evidence of the medication administration. During an interview with the unit Licensed Practical Nurse (LPN) Charge nurse on 3/04/14 at 10:00 AM, she stated that the nurses should have documented the medication administration accurately, including the resident's response to the effectiveness of the pain medication. 415.22(a)(1-4)

Based on resident and staff interviews and record review during the Standard Recertification Survey it was determined that the facility did not ensure that each resident was provided with medically related social services to attain his/her highest practicable, physical, mental and psychosocial well-being. Specifically, one (Resident #11) of three residents in a sample of 14 reviewed for Do Not Resuscitate (DNR) requested a DNR status; there was no documented evidence to indicate that the resident's request has been addressed. This resulted no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The finding is: Resident #11 is [AGE] years old and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 dated [DATE] and [DATE] documented that the resident is cognitively intact. The Policy and Procedure for Advanced Directives (PPAD) documented that all residents will be offered information about Advanced Directives and the opportunity to develop the Advanced Directive of his/her choice. The PPAD further documented that the social worker provides each resident and/or designated representative, upon admission, with information on DNR orders and Health Care Proxy, informing the nursing staff. The Initial Admissions Nursing Assessment Sheet (IANAS) dated [DATE] documented that the resident has a health care proxy and states that he has a DNR (not in chart) under certain circumstances. The DNR directives decision documented was to "discuss with social worker." The Comprehensive History, Physical Exam and Medical Assessment (CHPEMA) dated [DATE], [DATE] and [DATE] documented that the resident is able to participate in medical decision-making and care planning. However, the section entitled, "Existing DNR order?," was left blank. The Psychosocial assessment dated [DATE] documented that the resident has no Advanced Directives. The Interdisciplinary Progress Notes (IPN) documented that the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The IANAS dated [DATE] documented the DNR decision was to "discuss with social worker." The Social Worker's Progress Notes (SWPN) dated [DATE] documented that the resident was readmitted on [DATE] from the hospital. There was no further documented evidence regarding Advanced Directives. There was documented evidence of a physician's orders [REDACTED]. An interview was conducted with Resident #11 on [DATE] at 10:27 AM. Resident #11 stated that he has had a health care proxy and had been asked by the social worker regarding a DNR. The resident stated that he wanted to be a DNR and told same to the social worker. The resident further stated, "I don ' t want them (staff) to resuscitate me only to come back like a vegetable." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse (RN) on [DATE] at 10:38 AM. The RN stated that Resident #11 is not a DNR and the RN had never been told of the resident being a DNR. An interview was conducted with the Social Worker (SW) on [DATE] at 11:48 AM. The SW stated that Resident #11 was admitted with a health care proxy but did not want to sign anything related to a DNR. The resident went out to the hospital and returned late last week but he has not wanted to sign regarding a DNR even though the SW has discussed same with the resident. The SW stated that the resident's living will documents that the resident would not want to be resuscitated but the resident has never actually said that he wants to be a DNR. The SW further stated that she has not documented same in the medical record. An interview was conducted with the Director of Nursing (DON) on [DATE] at 1:02 PM. The DON went through the resident's medical record at the nursing desk, explaining that the resident did not want to be a DNR. The DON stated that she was looking for a form which states that the resident either chooses to be a DNR or to have CPR (Cardiopulmonary Resuscitation) performed. The DON was unable to locate this form on the medical record. 415.5(g) (1) (i-xv)

Based on record review and staff interviews during a recertification survey, the facility did not ensure that services provided or arranged for each resident met professional standards of quality. Specifically, 1 (Resident # 12) of 14 residents' physician orders [REDACTED]. This resulted in no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy. The finding is: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician's admission orders [REDACTED]. Resident #12's medical record lacked documented evidence (lab results) of CMP, CBC, T3, T4, TSH, BNP, LFT, and HgBAIC to indicate that physician's orders [REDACTED]. During an interview with the RN unit coordinator on 3/16/13 at 10:55 AM, she stated that the lab orders were not picked up and drawn by the lab for 3/4/13. 415.11(c) (3) (I)

Based on record review and staff interviews during a recertification survey, the facility did not ensure that each resident was provided care in accordance with his or her written plan of care. Specifically, 2 (Resident #1 and Resident # 8) of 14 residents who consented to a Do Not Resuscitate (DNR) Status lacked documented evidence of a physician's orders [REDACTED]. This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings are: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Do Not Resuscitate order-Resident with Capacity Form documented a physician's signature dated 3/15/05. The form read resident expressed orally, in presence of physician, the decision to consent to a DNR order with risks and benefits of cardio [MEDICAL CONDITION] resuscitation explained to resident. The Resuscitation Consent Form dated 1/2/13 documented that the resident chose Do Not Resuscitate. The Social Services Initial Assessment Form dated 1/2/13 documented Resident #1's DNR status. The Minimum Data Set (MDS-assessment tool) dated 1/14/13 documented the resident's cognition status as independent. The physician's orders [REDACTED]. During an interview with the Registered Nurse Coordinator on 3/5/13 at 11:40 AM, she stated that the resident is a DNR and should have a physician's orders [REDACTED]. The Registered Nurse Coordinator added that the forms (physician monthly orders) are prepared by pharmacy and DNR was dropped off. Two nurses are to review the form for accuracy but this was missed. 2) Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Do Not Resuscitate order-Resident with Capacity Form documented a physician's signature dated 2/18/11. The form read resident expressed orally, in presence of physician, the decision to consent to a DNR order with risks and benefits of cardio [MEDICAL CONDITION] resuscitation explained to resident. The Resuscitation Consent Form dated 1/16/13 documented that Resident #8 chose Do Not Resuscitate. The Social Services Initial Assessment Form dated 1/16/12 (13) documented Resident #8's DNR status. The Minimum Data Set (MDS-assessment tool) dated 1/23/13 documented the resident's cognition status as modified independence. The physician's orders [REDACTED]. During an interview with the RN unit coordinator on 3/6/13 at 8:40 AM, the RN stated that she did not see the physician's orders [REDACTED]. 415.11 (c)(3)(ii)

Based on record review and staff interview during the recertification survey the facility did not ensure that a Comprehensive Care Plan (CCP) was developed, reviewed and revised for one of eleven stage two sampled residents. Specifically Resident #46 was seen by the Dentist seven times from 10/11-12/11 and there was no Dental CCP developed related to the resident's dental care needs. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #46 has [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident ' s cognition was moderately impaired and required total assist of one staff for personal hygiene. A CCP initiated 2/11 developed for broken teeth documented the care plan was discontinued 8/9/11. A Dental Orders and Progress Note form dated 10/11/11 through 12/13/11 documented that the resident was seen by the Dentist seven times for follow up visits with recommendations for dental care, which included application of adhesive to increase comfort and the use of a soft liner. A review of the medical record revealed no documented evidence that a Dental CCP was developed for this time frame related to the resident's dental care needs. Review of the resident's Patients Care Record (PCR) 8/2011-12/20/11 revealed no documented evidence that the resident had dentures. In addition, the PCR lacked documented evidence of instructions for oral care and application of the adhesive to the dentures. A review of the Nurses Notes dated 10/20/11 through 12/20/11 revealed no documented evidence of follow up dental consults. An interview was conducted with the resident on 1/30/12 at 10:47 AM. The resident stated that half the time he applied the adhesive to his dentures but there was always a problem with too much or too little adhesive. The resident stated the other times he ask the staff for assistance. During an interview on 1/30/12 at 11:18 AM the resident's Certified Nursing Assistant (CNA) stated that the resident was an extensive assist for care however he was able do his own mouth care. The CNA stated that the resident is capable of brushing his lower teeth and his dentures, she applies the adhesive to the denture and the resident puts the denture in his mouth. An interview was conducted with the Registered Nurse (RN) Unit Coordinator on 1/30/12 at 11:40 AM. The RN stated that a Dental CCP should have been developed with documented evidence of the resident's follow up care. The RN further stated that there should have been written instruction for the use of dental adhesive on the Patient Care Record (PCR). 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that for one of eleven sampled residents that there was a documented physician's orders [REDACTED]. There was no documented physician's orders [REDACTED]. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #42, with [DIAGNOSES REDACTED]. The hospital discharge orders included: Assisted (with feeding) with Aspiration Precautions. The readmission physician orders [REDACTED]. In addition, Aspiration Precautions were hand written on the order sheet. There was no documented orders for the nectar thickened liquids. The medical record contained a Dietary Communication Form dated 12/28/11 and signed by the Supervising Registered Nurse. The communication form documented the following: Pureed (food) and Nectar thickened liquids. In addition, the diet form documented the diet as CCD and NAS. Review of the interdisciplinary progress notes following the readmission date of [DATE] revealed that nurses were documenting that the resident was receiving and tolerating nectar thickened liquids. Nursing progress note dated 12/30/11 at 2 PM documented the resident's appetite was fair and that thickened fluids (were) encouraged. In addition, other interdisciplinary progress notes dated 12/30/11 at 10:00 PM, 12/31/11 at 5:00 PM, 1/1/12 at 9 PM, 1/2/12 at 11:00 AM, and 1/2/12 at 10:00 PM documented that thickened liquids were being offered. The readmission nutrition note dated 1/4/12 documented that Glucerna (supplement) cold refrigerator temperature appropriate and acceptable for nectar consistency. An interview with the Medication LPN on 1/30/12 at 2:25 PM revealed that the resident was receiving crushed meds in applesauce and Nectar thickened liquids with meals and medications. A telephone interview with the Supervising Registered Nurse on 1/30/12 at 2:10 PM revealed that she had documented the dietary communication form dated 12/28/11 upon readmission. She also explained that the form is in duplicate; one is sent to Dietary and the other copy is kept in the medical record. In addition, she stated that (upon readmission from the hospital on [DATE]), the resident was on Aspiration Precautions and that she presumed the resident was on the Nectar thickened liquids secondary to her decreased level of consciousness. She further stated that there should have been a physician's orders [REDACTED]. An interview with Charge Licensed Practical Nurse (LPN) on 1/30/12 at 2:15 PM revealed that although she reviewed the Physician orders, she could not find an order for [REDACTED]. An interview with the medication LPN on 1/30/12 at 2:25 PM revealed that the resident was receiving crushed meds in applesauce and nectar thickened liquids with her meals and the medications. A second interview with the Charge LPN on 1/30/12 at 3:00 PM revealed that the Physician was called and that an order for [REDACTED]. 415.11(c)(3)(ii)