Every finding on record at Latta Road Nursing Home West

Based on observations, interviews, and record review conducted during the Recertification Survey from 01/14/2025 to 01/21/2025, for one (Resident #13) of two residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were two medication errors for 26 opportunities resulting in a medication error rate of 7.7 percent. Specifically, during an observation of medication administration Resident #13's physician's orders were not followed for the administration of one medication and a second medication was administered without a prescribed dose included in the physician's order. This is evidenced by the following: The Medication Error Protocol, dated February 2020, documented in part that the nursing staff and medical provider shall try to prevent medication errors and adverse consequences and shall strive to identify and manage them appropriately when they occur. An example of a medication error includes orders received from a medical provider not transcribed promptly or accurately. 1. Resident #13 had diagnoses that included Parkinson's disease, atrial fibrillation (irregular, rapid heart rate that can cause poor blood flow), and type two diabetes. The Minimum Data Set Resident Assessment, dated 12/16/2024, documented the resident was cognitively intact. Review of current physician's orders as of 01/16/2025 revealed midodrine five milligrams one time daily for orthostatic blood pressure (blood pressure that changes from sitting to standing) with parameters to hold the medication for a systolic blood pressure greater than 90 and a Vitamin B12 tablet in the morning. There was no dose listed for the Vitamin B12. During an observation of medication administration on 01/16/2025 at 9:37 AM, Licensed Practical Nurse #2 obtained and documented Resident #13's blood pressure of 124/82. Licensed Practical Nurse #2 then administered the midodrine five milligrams and the Vitamin B12 at a dose of 1000 micrograms. During an interview on 01/16/2025 at 11:37 AM, Licensed Practical Nurse #2 stated the midodrine five milligrams should be held if Resident #13's systolic blood pressure was greater than 90. When Resident #13's blood pressure was reviewed at this time, Licensed Practical Nurse #2 stated they should not have given the medication. Additionally, Licensed Practical Nurse #2 stated if a physician's order did not include a dose, a note should be entered in the medical provider's log making them aware that the order was incomplete, and the medication should not be given until the medical provider verified the order. Licensed Practical Nurse #2 generated the list of medications that had been administered revealing the Vitamin B12 medication had been given without a dose ordered by the medical provider. During an interview on 01/16/2025 at 11:49 AM, Nurse Practitioner #1 stated the nurse should check the parameters and if the parameters indicated to hold the medication for a systolic blood pressure greater than 90, and the resident's blood pressure was 124/82, the medication should not have been given. The Nurse Practitioner stated if documentation showed that the medication had been held enough times, they would reach out to the family and discuss the possibility of discontinuing it. Nurse Practitioner #1 stated all physician's orders should have a dose included and nursing staff should not proceed without a dose. Nurse Practitioner #1 stated it was an error on their end, and the nurse administering the medication should have brought it to their attention. During an interview on 01/16/2025 at 3:25 PM, the Director of Nursing stated the nurse should check the resident's blood pressure, read the physician's order, and follow the ordered parameters. The Director of Nursing stated they were not aware there were physician's orders that did not have a dose included because upon entering an order, the system should not allow you to save the documentation if the order was incomplete. The Director of Nursing stated the nurse should have called the medical provider to verify the order prior to giving the medication. 10 NYCRR 415.12(m)(1)

Based on observations, interview, and record review conducted during the Recertification Survey from 01/14/2025 to 01/21/2025, the facility did not maintain the kitchen in accordance with professional standards for food service safety. Specifically, an exhaust hood and filters were dirty, and a dishwashing machine was not functioning properly to sanitize dishware. The findings are: Record review of the undated daily cleaning lists revealed there was no documented cleaning of the kitchen exhaust hood and filters. During observations on 1/14/2025 at 8:55 AM and again on 1/15/2025 at 12:00 PM, the exhaust hood and filters above the cooking range in the main kitchen had visible accumulation of grease and dust. During an interview at this time, the Kitchen Supervisor stated their vendor comes in to clean the hood once a year in September, and staff should clean the hood as well when it needs it. During observations on 01/14/2025 at 8:47 AM, a low temperature dishwashing machine in the main kitchen was not functioning as designed. The label on the machine read wash at 120 degrees Fahrenheit and rinse at 120 degrees Fahrenheit with chlorine sanitization. Further observations included the chlorine sanitizer did not inject into the dish machine while in operation and the Kitchen Supervisor had to manually depress the dispenser button to introduce sanitizer into the machine. During an interview at this time, the Kitchen Supervisor stated they just noticed the sanitizer was not automatically dispensing during a cycle and needed to manually activate the dispensing unit to add sanitizer. During observations on 01/15/2025 at 12:06 PM, the low temperature dishwashing machine in the main kitchen was not functioning properly. The chlorine sanitizer did not automatically dispense during a cycle and the dispensing line was observed to be leaking sanitizer when activated manually. During an interview at this time, the Kitchen Supervisor stated the dish washer was still not functioning properly and the vendor had yet to get back to them. The Kitchen Supervisor also stated that when manually operating the sanitizing dispenser, they noticed the hose was leaking sanitizer so that would need to be addressed, and may be why sanitizer measurements were erratic. The Kitchen Supervisor also stated that instead of having to manually use the dispenser and measure sanitizer levels each time, it was decided to use disposable utensils and plates and wash with the three-bay sink until the dish machine could be addressed. 10NYCRR: 415.14(h), 14-1.95, 14-1.96(c), 14-110(d), 14-113(a), 14-1.175(b)

Based on observations, interview, and record review conducted during the Recertification Survey completed 6/2/23 to 6/7/23, it was determined that for one of one kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, dish machine sanitizer levels were inadequate, and temperature controlled for safety (TCS) foods were not held at proper temperatures. The findings are: 1. Observations and interviews during the initial tour of the main kitchen on 6/2/23 between 8:30 a.m. and 10:00 a.m. included a [NAME] brand low-temperature mechanical dish washing machine. When tested after running, the sanitizer (chlorine based) level was zero. In an interview at this time the food service director (FSD) stated that the dish machine is checked every day but not this morning and they keep a log but could not readily locate them. The FSD also stated that they would call their vendor. 2. Observations and interviews during the follow-up visit to the main kitchen on 6/5/23 between 11:50 a.m. and 1:30 p.m. included a 'Nor-Lake' refrigeration unit full of beverages, including: a gallon of milk (a TCS food) at 50 degrees ( ) Fahrenheit (F) and a half-gallon of chocolate milk (a TCS food) at 47 F, both of which were located on the bottom shelf of the cooler. During an interview at this time the FSD stated that the milk was placed into the cooler at 11:00 a.m. The surveyor verified that the ThermoWorks Thermapen One digital thermometer was accurate using the ice-point method. The thermometer read 32 F after being placed in a cup of ice water. 3. On 6/7/23 at 12:15 p.m., monthly records of the dish machine were provided for review via email. The logs for January through June of 2023 included that before each meal dietary aides should check the dish machine using test strips, and chlorine should read 50-100ppm (parts per million). The dish machine logs on 6/1/23 included: 'isn't coming out' and 'not working', and the logs for breakfast on 6/2-6/4/23 did not include a check mark or any other indication that the sanitizer level was between 50 and 100ppm. 10NYCRR: 415.14(h), 14-1.31(c), 14-1.40(a), 14-1.44, 14-1.112, 14-1.113

Based on interviews, and record review conducted during the Recertification Survey, completed on 12/22/21, it was determined that for one (wing one) of two wings reviewed for medication storage, the facility did not ensure that an accurate reconciliation of all controlled substances was maintained. Specifically, the Controlled Substance Record sheets which included reconciliation of narcotic medications and the signatures of staff members for each shift-to-shift narcotic count were not completed to validate the correct controlled substance count. This is evidenced by the following: The facility policy and procedure for Accounting for Narcotic Medications dated July 2011 documented that the facility will ensure that narcotic medications are properly accounted for in compliance with regulatory requirements and standard of practice. At each shift change or change of incoming nurse responsible for passing medications, all narcotics are counted by the incoming and outgoing licensed nurses and the correct count attested to on the Narcotic Count Verification form. The outgoing and incoming nurses must visualize the Index prior to beginning the count, as well as during the count to assure that each resident has the appropriate medications. If a discrepancy is found at any time during a count with the Resident Index form and the Narcotic Count Sheet, the supervisor will be notified, and an investigation will begin. During medication storage review on 12/22/21 at 9:33 a.m., the wing one shift-to- shift narcotic count sheets revealed multiple missing signatures to verify that the narcotic counts were properly completed by two nurses. From 10/3/21 to 10/29/21 there were 19 missing signatures, from 11/1/21 to 11/30/21, there were 18 missing signatures and from 12/1/21 to 12/22/21, there were 4 missing signatures. During an interview on 12/22/21 at 9:40 a.m., the Licensed Practical Nurse (LPN) said staff are expected to sign off the narcotic count at each shift to ensure the narcotic count is correct. The LPN said there should be no unsigned areas on the narcotic sheets. During an interview on 12/22/21 at 9:53 a.m., with the Director of Nursing (DON) and the Administrator, both stated that they were not aware the narcotic count sheets were not always signed off by both oncoming and outgoing staff. The DON said that they have not done audits of the narcotics sheets since they had started working at the facility several months prior. The Administrator stated that it is the policy of the facility for staff to sign off the narcotic sheets for each shift. 10NYCRR 415.18(b)(1)(2)(3)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #63) of two residents reviewed for choices, the facility did not allow each resident the right to make choices about aspects of life that were significant to them. Specifically, the resident was not given the choice of bathing opportunities. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/7/19, revealed that the resident had moderately impaired cognition, clear speech, was understood by others and usually understands others, was frequently incontinent of bowel and bladder, and required the extensive assist of staff for personal hygiene and bathing. The annual MDS Assessment (the assessment that interviews the resident and/or representative regarding their preferences for their daily routine, including bathing), dated 9/19/18, included that neither the resident or her representative were interviewed regarding the resident's preferences as the resident was coded as 'rarely or never understood' and the representative was not available. In an interview on 6/17/19 at 10:00 a.m., the resident who was alert and oriented to name and place, stated she gets one shower a week at the facility and at home she took several showers a week. The resident's representative stated that the resident used to take several showers a week at home, but resident's only get one shower a week at the facility. The resident and resident representative both said that it would be preferable to get more showers a week especially due to the resident's recent bout with diarrhea. They both said no one has ever asked them about it. The resident's representative stated that he visits daily and has since admission. He said that he does not remember going to a meeting with all of the resident's caregivers to discuss the resident's care or being asked about preferences related to daily routines. Review of the resident's 'Continuity of Care' plan, dated 4/25/19, revealed that the resident requires extensive assist of staff and showers one day weekly. Review of the 'Resident's Personal Habits Preference Review, dated 5/6/19, revealed that neither the resident or the representative were interviewed regarding the resident's preferences for her daily routine including bathing. The documentation included that per staff assessment the resident prefers one shower per week and was signed by the Licensed Practical Nurse (LPN). Review of the resident's annual care plan meeting, dated 5/21/19, revealed that neither the resident or her representative were present. Interviews conducted on 6/20/19 included the following: a. At 9:29 a.m., the Social Worker stated that she invites residents and representatives to the care plan meeting via mail. She said that she did not have an annual meeting with the resident and/or representative because she thought the resident was in the hospital at the time. She said the team did not have a care conference when she returned. When asked if she could find documentation that a care plan meeting was held with the resident and/or her representative and the interdisciplinary team in the past year, none was provided. b. At 10:57 a.m., the LPN stated that she completed the preference review for the resident. She said she did not ask the resident or her representative because sometimes the resident was confused. The LPN said the resident's representative visits daily but she did not ask him about her preferences. c. At 11:14 a.m., the Activity Director stated that she completes the annual interview for resident preferences. She said that she thought she probably coded the resident as rarely or never understood because the resident may have been confused that day and her representative was not available. After review of the MDS instructions for preferences for daily routines, she stated that she completed that section wrong. d. At 1:06 p.m., the Registered Nurse Manager stated that the preference review for daily routines should not have been done with staff because this resident can tell you what she likes and does not like. She said preference reviews are completed quarterly. After review of the medical record, no other preference sheets were provided. (10 NYCRR 415.5(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #4) of three residents reviewed for non-pressure related skin conditions, the facility did not investigate a skin injury to rule out abuse, neglect or mistreatment. This is evidenced by the following: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/14/19, revealed the resident had moderately impaired cognition, and required the extensive assistance of two staff for activities of daily living. The Comprehensive Care Plan (CCP), dated 3/8/19, and the Continuity of Care Card, dated 6/11/19, revealed that the resident had the potential for bruising and or bleeding related to the use of an anticoagulant. Interventions on the CCP included to observe the skin daily and report new bruising. Review of the integrated progress notes and Incident and Accident Reports, from 6/1/19 through 6/20/19, revealed there was no documentation of skin injuries or bruises. During an observation on 6/17/19 at 1:47 p.m., the resident had a dark purple bruise on the left hand at the base of the thumb, that was the approximate size of a half dollar. At that time, the resident stated she did not know how it happened. When interviewed on 6/19/19 at 10:24 a.m., the Registered Nurse (RN) stated the resident did not have any skin issues. She stated she was unaware of the resident having any bruises. The RN said if a bruise was reported an Incident and Accident Report should be completed to try to determine how the bruise occurred. At that time, the resident's left hand was observed by the RN and surveyor. The RN said that she was aware of the bruise and believed an Incident and Accident Report had been completed. The RN reviewed the resident's medical record and then stated she was unable to provide documentation of the bruise. During an interview on 6/20/19 at 11:35 a.m., the Registered Nurse Manager stated that the RN reported the bruise and was currently completing an Incident and Accident Report. She stated that there should be documentation of the bruise in the medical record. (10 NYCRR 415.4(b)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's care plan was reviewed and revised to reflect the resident's current condition. Specifically, Residents #4 and #34's care plans were not revised to reflect the use of an antipsychotic medication, and Resident #4's care plan was not revised to reflect that the resident's dentures are missing or misplaced frequently. This is evidenced by the following: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/14/19, revealed the resident had moderately impaired cognition, no behaviors, no antipsychotic medications, and required the extensive assistance of two staff for activities of daily living. Physician orders, dated 5/15/19, included [MEDICATION NAME] (an antipsychotic) for depression with cognitive impairment, anxiety and agitation. Review of the current Comprehensive Care Plan (CCP) revealed the resident received an antidepressant for a [DIAGNOSES REDACTED]. Additionally, the resident had full upper and lower dentures, and required exstensive assistance for grooming. Review of the Continuity of Care Card, dated 6/11/19, revealed the resident had full upper dentures and a partial lower denture and was limited assistance with grooming. Review of the progress notes, dated, 5/2/19, 5/25/19, and 6/12/19, revealed that the resident's dentures were missing and or the resident was removing her dentures. When interviewed on 6/17/19 at 1:42 p.m., the resident stated that she was missing her top and bottom dentures. During an interview on 6/19/19 at 10:24 a.m., Registered Nurse (RN)#1 stated the resident does not always wear her dentures and had been missing one of them for at least three weeks. RN #1 stated the resident did not have a care plan addressing the resident's removal and/or misplacement of the dentures. When interviewed on 6/20/19 at 11:35 a.m., the Registered Nurse Manager (RNM) stated she was aware the resident removed the dentures and misplaced them. She said that the informatiom should be addressed on the CCP and Continuity of Care Card. 2. Resident #34 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/10/19, revealed the resident had severely impaired cognition, exhibited physical and verbal behaviors four to six days in the look back period, and no [MEDICAL CONDITION] medications. Review of the Nurse Practitioner progress note, dated 5/23/19, revealed that the resident was being seen for increased anxiety and agitation as evidenced by the inability to sit still, attempting to self-ambulate and falling, increased yelling and hitting other residents, calling out, tormented behavior, up all night, removing clothes, and unable to be redirected. Physician orders, dated 5/23/19, included [MEDICATION NAME] (antipsychotic)12.5 milligrams (mg) twice a day for dementia with behaviors, anxiety and agitation. On 5/30/19, [MEDICATION NAME] was increased to 25 mg twice a day and on 6/6/19, the evening dose of [MEDICATION NAME] was increased to 50 mg. Review of the CCP revealed the resident had behavioral symptoms (5/14/19) but did not include the use of an antipsychotic medication. Review of the Continuity of Care Card, dated 6/18/19, revealed there were no special instructions related to behaviors. When interviewed on 6/20/19 at 11:09 a.m., a Certified Nursing Assistant stated she would check the Care Card for information related to a resident's behaviors and approaches. She said the resident would stand up when she was agitated. During an interview on 6/21/19 at 7:19 a.m., RN #2 stated she was responsible for the development and revision of the CCP. RN #2 stated she worked the night shift, and when she developed a CCP she read the chart and included the care areas triggered by the MDS Assessment. She stated if a resident started a new [MEDICAL CONDITION] medication she would be informed either through report or the Director of Nursing. (10 NYCRR 415.11(2)(iii))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #17) of three residents reviewed for a decline in Activities of Daily Living (ADL), the facility did not ensure that each resident received the appropriate treatment and services to improve and/or maintain ambulation. Specifically, the resident was not being ambulated as recommended by therapy. This is evidenced by the following: Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/2/19, revealed that the resident had severely impaired of cognition, and required limited assist of staff to ambulate in her room and in the corridor. The Physical Therapy discharge summary, dated 5/21/19, included recommendations that the resident requires limited assist of one staff with a rolling walker for ambulation and to ambulate up to 100 feet to and from the bathroom. Review of the Certified Nursing Assistant (CNA) Continuity of Care (care plan used by the CNA's) form, dated 5/23/19, revealed that the resident required limited assist of one staff for ambulation up to 100 feet and to encourage the resident to ambulate to the bathroom, meals, and activities to maintain her ambulation status. The care plan did not include that the resident refuses care. Review of the ADL history report (electronic health record of daily care documented by the CNA's) revealed that for the past 17 days the resident ambulated in her room on 9 of the 17 days and in the corridor on 2 occasions. In an interview on 6/18/19 at 1:29 p.m., CNA #1 (day shift) stated that the resident's ambulation has declined. She said she ambulated the resident about a month ago. She said the resident no longer ambulates, so she transfers her to the toilet. Observations made periodically during the day and evening shifts from 6/17/19 to 6/19/19 revealed the resident being pushed in her wheelchair to and from her room, to the dining area, and to activities. At no time was the resident observed to ambulate or encouraged to ambulate. During an observation of toileting on 6/18/19 at 3:25 p.m., the resident was wheeled into the bathroom and with the assist of a grab bar was instructed to stand by the toilet, pivot and sit down on the toilet which the resident did without difficulty, and repeated following toileting. When interviewed at that time, CNA #2 (evening shift) stated that the resident used to ambulate but was no longer able to. Interviews conducted on 6/19/19 included the following: a. At 10:07 a.m., the Rehabilitation Aide stated that the CNA ambulate the residents, and it should be on her care card. b. At 1:36 p.m., the Physical Therapist stated that when the resident was discharged from therapy she could ambulate up to100 feet. She said that the resident should be encouraged to ambulate daily and to at least walk to and from the bathroom. She said if the aides are unable to ambulate the resident or if she refuses, staff should inform therapy, so the resident can be reassessed. When interviewed on 6/20/19 at 1:47p.m., the Registered Nurse Manager stated that the resident will not always ambulate but she will ambulate for some people, including herself with encouragement. She said that the CNA should at least attempt to ambulate the resident, if she refuses, staff should notify the nurse. (10 NYCRR 415.12(e)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #25) of one resident reviewed for bladder/bowel incontinence, the facility did not provide services in accordance with the resident's written plan of care. Specifically, the resident was not toileted per the plan of care. This is evidenced by the following: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/8/19, revealed that, the resident had an indwelling urinary catheter, was always continent of bowels and required extensive assist of staff for toileting. The MDS Assessment, dated 5/6/19, revealed that the resident was cognitively intact and was now frequently incontinent of bowels. Review of the 'Continuity of Care' form (care plan used by nursing assistants), dated 6/11/19, revealed that for toileting the resident was total assist of two staff at bed level, uses a bed pan and wears a brief. Incontinent was not checked. Review of the Occupational Therapy progress note, dated 5/16/19 (most recent in the medical record), revealed that the resident was touch down weight bearing of the lower extremity in therapy, non-ambulatory and continued to require assist of staff at bed level for toileting. Review of the Certified Nursing Assistant (CNA) bowel history, for the past five weeks revealed that the resident was incontinent of bowels daily. In an interview on 6/17/19 at 8:54 a.m., the resident stated that he must go to the bathroom in a brief and that he cannot wait till he can get up and use the bathroom. The resident said when he first arrived at the facility, staff tried a bedpan, but it was too small. The resident said he must use a lift to get up, so he has had to go in the brief ever since. When interviewed on 6/18/19 at 2:16 p.m., the primary CNA stated that the resident was incontinent of bowels and wears a brief. The CNA said that the resident has not gone on a bedpan since he arrived at the facility. In an interview on 6/19/19 at 12:32 p.m., the Registered Nurse Manager said that the resident was in a lot of pain when he was admitted to the facility and could not tolerate sitting on a commode or a bedpan. She said that it had been several months and that they should try again as he has improved. When interviewed on 6/19/19 at 1:10 p.m., the Occupational Therapist (OT) stated that she thought the resident was using a bedpan and if not, she expects staff to talk to therapy. The OT said they could use a larger bedpan or a padded commode but that the resident should not be made to go in a brief. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews and record review conducted during the Recertification Survey, it was determined that for one (Resident #7) of one resident reviewed for pain management, the facility did not ensure pain management was provided to a resident who required such services consistent with professional standards of practice. The issues involved the lack of a consistent pain assessment at the time of administration of a pain medication, the lack of monitoring of the effectiveness of the pain management plan of care, and notification of the medical provider of routine use of an as needed pain medication. This is evidenced by: Review of the facility policy, Pain Management revealed a pain assessment flow sheet to be utilized to measure and assess the frequency and intensity of the signs and symptoms of pain and to monitor the response to the intervention. The policy recommended to utilize the pain flow sheet when a resident is frequently using an as needed medication or complains of pain regardless of when routine medication is given. The policy included pain scales for both cognitively intact and impaired residents. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set MDS) Assessment, dated 4/10/19, revealed the resident was moderately cognitively impaired and was understood by others. The staff interview for pain revealed the resident vocalized complaints of pain and pain was observed on three to four of seven days. The Comprehensive Care Plan, dated 7/10/18, revealed the resident has chronic pain. Interventions included to evaluate the effectiveness of pain management interventions, to monitor and record complaints of pain, location, frequency, effect on function, intensity, alleviating and aggravating factors. Physician orders, dated 4/25/19, included [MEDICATION NAME] (narcotics) immediate release 5 milligram (mg) tablet by mouth twice a day and every four hours as needed for moderate to severe pain, extra strength Tylenol 1,000 mg twice a day for [MEDICAL CONDITIONS] and Tylenol 650 mg every 24 hours as needed for pain. A physician progress notes [REDACTED]. Pain management included Tylenol and [MEDICATION NAME]. The physician's plan of care included that her pain was being managed. Review of the (MONTH) 2019 and (MONTH) 2019 Medication Administration Records (MAR) revealed in (MONTH) the [MEDICATION NAME], as needed, was administered at least once a day 21 out of 30 days and in May, 27 of 31 days in addition to the routine doses of [MEDICATION NAME] and Tylenol twice daily. The MAR indicated [REDACTED]. Review of the nursing progress notes, 4/1/19 through 6/7/19, revealed notes documenting the resident requested and received the as needed [MEDICATION NAME] for leg pain 7 days in (MONTH) and 16 days in May. No other documentation of the administration of the as needed pain medication was available. During an interview on 6/17/19 at 9:27 a.m., the resident stated she was aching and needed pain medication. At 10:27 a.m., the resident stated her pain was mostly in her legs but kind of all over. Interviews conducted on 6/19/19 included the following: a. At 8:44 a.m., the RN Manager (RNM) stated if a resident was requesting pain medication often we would notify the Nurse Practioner (NP). The RNM stated the NP was aware the resident used of pain medication but could not provide documentation of the notification. b. At 9:04 a.m., the NP stated there should be an assessment completed prior to administering as needed pain medication and that the resident did not want to increase the routine dose of [MEDICATION NAME]. The NP could not provide documentation of his review of the resident's pain management plan with the resident. c. At 10:14 a.m., a Registered Nurse (RN) stated it would depend on the resident whether she would ask them the location of pain or to rate the pain from zero to ten. She stated Resident #7 usually stated the pain was a ten and that she did not document the resident's non verbal indications of pain as her pain was constant. The RN said the resident would not accept anything but the [MEDICATION NAME] for pain. She said pain assessments are done routinely by the nurse completing the MDS. During an observation on 6/20/19 at 8:42 a.m., the resident was sitting up in bed after eating breakfast and stated she was aching, and her pain level was at least an eight out of ten. The resident stated she had not had pain medication yet that morning and that was what was wrong. During an interview 6/20/19 at 11:16 a.m., a Certified Nursing Assistant stated the resident woke up every morning yelling her legs were in pain because she had not had her medications yet. (10NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #19) of three residents reviewed for nutrition, the facility did not ensure the medical care of each resident was supervised by a physician. Specifically, the physician did not evaluate the resident's significant weight loss. This is evidenced by the following: Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/4/19, revealed that the resident's cognitive skills for daily decision making were severely impaired and the resident weighed 122 pounds, and had a weight loss of 5 percent in the last month or 10 percent in the last six months, and was not on a physician prescribed weight loss program. The resident's weight record revealed that she weighed 139.2 pounds in (MONTH) 2019 and 121.4 pounds in (MONTH) 2019 (12.7 percent weight loss over six months). There was no documentation in the medical record that the physician was notified of the resident's significant weight loss. Interviews conducted on 6/18/19 included the following: a. At 1:53 p.m., the Registered Dietician (RD) said that either she or the Nurse Manager notify medical of a significant weight loss. b. At 1:39 p.m., the Nurse Manager said that she discussed the resident's weight loss with the RD and asked the Nurse Practitioner to increase the resident's Resource ( nutritional supplement) the previous day. When interviewed on 6/19/19 at 9:07 a.m., the Nurse Practitioner said he has no documentation that he was notified of the resident's weight loss. He said if he was notified of the resident's weight loss he may have generated a note or an order. He said he would have also talked to the resident's family as she was comfort care. (10 NYCRR 415.15(b)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #17) of one resident observed for incontinence care and one of one unit observed for dining, the facility did not provide care using appropriate infection control practices. Specifically, a staff member did not provide incontinence care following toileting and a second staff member was observed handling resident's food with their bare hands (Resident #25). This is evidenced by the following: 1. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/2/19, revealed that the resident had severely impaired cognition, required extensive assist of staff for toileting and was frequently incontinent of bladder. Review of the Continuity of Care form (care plan used by the Certified Nursing Assistant-CNA) revealed that the resident was incontinent of bowel and bladder, used the toilet and required extensive assist of staff. The form did not include that the resident refused care. During an observation of toileting on 6/18/19 at 3:25 p.m., the resident was transferred to the toilet, and the brief she was wearing was soiled with urine. The resident's buttocks were reddened but no open areas present. The resident voided again wiped her front peri area and stood while the CNA#1 applied a new brief. At no time was the resident's buttocks cleansed. When interviewed at that time the CNA #1 stated that yes, the resident's brief was wet, but she did not do incontinence care because the resident does not let them. CNA #1 said that she should have attempted to clean the resident's bottom and wash her hands, but she did not. In an interview on 6/20/19 at 1:45 p.m., the Registered Nurse Manager and the acting Infection Control Nurse stated that if the resident's brief was wet they would expect the CNA to clean both the resident's buttocks and peri area with peri-wash (cleanser they use for skin care) or soap and water. 2. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/6/19, revealed that the resident was cognitively intact and required extensive assist of staff for eating. The Continuity of Care form, dated 6/11/17, included that the resident was independent with eating after setting up and to cut food small. During an observation of lunch on 6/17/19 at 12:30 p.m., CNA #2 was setting up a lunch tray for the resident in his room. While setting up the meal tray the CNA #2, without sanitizing, cleaning his hands or donning gloves moved the resident's sausage and roll, cut it and eventually handed it to the resident, touching the roll on three different occasions with bare hands. When interviewed on 6/19/19 at 11:57 a.m., CNA #2 stated that he thought he was supposed to wear gloves when setting up the tray. CNA #2 said he was told at facility that he did not have to wear gloves when passing trays, just sanitize his hands. In an interview on 6/20/19 at 1:45 p.m., the acting Infection Control Nurse stated that it was not acceptable to pick up a resident's food without gloves on. She later stated that while CNA #2 was fairly new, he had been trained in safe food handling. (10 NYCRR 415.19)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #5) of one resident reviewed for grievances, the facility did not make prompt efforts to resolve a grievance. Specifically, a family member voiced concerns regarding food consistency that were not investigated in a timely manner. This is evidenced by the following: Review of the facility's, Grievance Policy, dated (MONTH) (YEAR), revealed that the facility had appointed a Grievance Officer to facilitate the prompt resolution of all grievances regarding resident rights. Review of the facility's grievance log revealed no documented grievances for the past six months. Resident #5 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/13/17, revealed the resident had severely impaired cognition, was totally dependent on staff for eating, and required a mechanically altered diet. Physician orders, dated 2/5/18, included a regular diet, consistency as tolerated. The current Comprehensive Care Plan identified the resident with a decreased ability to process chewing and swallowing. Interventions included a pureed diet. During an observation on 3/7/18 at 8:38 a.m., the resident was being fed by staff pureed pancakes and at 1:48 p.m., pureed meatloaf. During an interview on 3/6/18 at 12:59 p.m., the resident's family member stated that on 1/1/18, she was feeding the resident and observed three pieces of bone and four pieces of cartilage in the pureed chicken. The family member said she contacted Administration that week and met with the Administrator on 1/16/18. She stated she did not receive any follow up, and on 2/25/18, she again observed cartilage in the resident's pureed food. Interviews conducted on 3/7/18 included the following: a. At 10:47 a.m., the Food Service Director (FSD) stated the resident was on a blended/pureed diet. The FSD stated on 1/1/18 baked chicken was served and on 2/25/18 it was sweet and sour chicken. The FSD stated she had sent the family a response on 3/6/18 after the Administrator brought the issues to her attention on 3/2/18. The FSD stated she would respond to a concern within 24 hours unless it occurred on the weekend. b. At 1:49 p.m., the Licensed Practical Nurse (LPN) stated that a while ago the family mentioned the chicken was lumpy and there was cartilage in it. The LPN stated the family reported it. c. At 3:22 p.m., the Administrator stated grievances are handled by Social Work. The Administrator stated he had received a complaint regarding food consistency and discussed the issue with the FSD, without identifying the resident, and asked the FSD to address the issue with the dietary staff. He stated last week the family had a second complaint regarding the food consistency and he again addressed the concern with the FSD. He stated he had shared the resident's name and the facility owed the family a response. The Administrator stated the FSD did respond to the family. He stated he attempts to respond to complaints as quick as possible. He stated he did not document the conversations and follow up with the FSD and/or family. The Administrator stated he had apologized to the family for not being prompt. (10 NYCRR 415.3(c)(1)(i))

Based on observations, interviews and record reviews conducted during a Recertification Survey, it was determined that for 2 (Residents #10 and #35) of 12 residents reviewed for Comprehensive Care Plan (CCP), the facility did not implement the CCP for each resident. Specifically, Resident #10 was not positioned per the CCP and Prevalon Boots (foam booties to prevent skin breakdown) were not consistently applied, and Resident #35's call bell was not within reach. This is evidenced by the following: 1. Resident #10 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/1/18, revealed the resident had severely impaired cognition and was totally dependent on staff for bed mobility and transfers. Physician orders, dated 2/12/18, included to off load coccyx (position off buttocks to relieve pressure) in bed, turn and reposition every 1.5 to 2 hours, and Prevalon Boots to both feet and legs when in bed. The current CCP and Continuity of Care Sheet included that the resident had an open area on the coccyx, to wear Prevalon Boots when in bed, free float the heels and to off load the coccyx when in bed. During an observation on 3/7/18 at 2:12 p.m., the resident was in bed with a wedge cushion placed on her left side, slippers were in place to both feet and her feet were lying directly against the mattress. Observations conducted on 3/8/18 included the following: a. At 10:08 a.m., the resident was lying in bed on her back. There was a wedge cushion behind her on the pillow, her feet were bare and lying directly on the mattress. b. At 11:39 a.m., the resident had been repositioned in bed with a wedge cushion in place. She had socks on both feet, but no Prevalon Boots were in place. c. At 2:18 p.m., the resident was lying flat on her back. Again, no Prevalon Boots were in place on her feet. During an interview on 3/7/18 at 9:23 a.m., Certified Nursing Assistant (CNA) #1 stated the resident had a wedge cushion when in bed for positioning. Interviews conducted on 3/8/18 included the following: a. At 2:20 p.m., CNA #2 stated the Prevalon Boots should be on when the resident is in bed. b. At 2:35 p.m., Registered Nurse (RN) #1 stated the resident is to have Prevalon Boots in place when she is in bed and the wedge cushion should be used to position her from side to side. The RN stated the resident should not be lying flat on her back when in bed. c. At 2:36 p.m., CNA #3 stated that she was unaware that Prevalon Boots were to be worn by the resident when she was in bed or that a wedge cushion was to be used for positioning. She stated the Nurse Manager had recently informed her. 2. Resident #35 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident's primary language is Italian. The MDS Assessment, dated 2/16/18, revealed the resident had severely impaired cognition and required the extensive assistance of two staff members for bed mobility and transfers. The CCP for Activities of Daily Living, dated 2/2/18, included under interventions to ensure the call light is within reach. When observed on 3/6/18 at 11:45 a.m., the resident was in bed. When asked to speak to her, she said, No capeche. But when her roommate spoke to her, in Italian, the resident clearly answered that she wanted her back scratched/rubbed. She was unable to reach the call bell which was on the floor. The surveyor activated the call bell and CNA #4 responded. The CNA said the resident can use her call bell. Observations and interviews conducted on 3/8/18 included the following: a. At 10:30 a.m., the resident was lying on the bed and the call bell was on the floor. She motioned to the surveyor to come closer and asked for something to eat. RN #2 went in with the surveyor and saw the call bell lying on the floor. RN #2 said it should not be there, picked it up and then stated there was no clip on it. RN #2 put the call bell within the resident's reach on the bed. b. At 11:13 a.m., the resident was in bed and the call bell was on the floor, still with no clip on it. c. At 1:39 p.m., the resident was lying in bed and her family was visiting. The family said when they arrived, the call bell was not within the resident's reach so they gave it to her. The family spoke to the resident in Italian and the resident picked up the call bell and demonstrated that she could activate it. Interviews conducted on 3/9/18 included the following: a. At 11:05 a.m., RN #2 said the call bell needs a clip to keep it secured on the bed. She said there was no clip in place for the call bell and she would add it to the maintenance book. b. At 11:28 a.m., the Director of Maintenance said there is a box of clips at the nursing station and anyone can replace the clip. She said they monitor call bells monthly and when terminally cleaning a room. She said that should be taken care of right away. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #29) of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. The issue involved the lack of documentation of the resident's behaviors, non-pharmacological interventions attempted prior to the administration of a one time dose of an antipsychotic medication, and the lack of a [DIAGNOSES REDACTED]. This is evidenced by the following: The facility policy, [MEDICAL CONDITION] Drugs, dated (MONTH) (YEAR), directs that each resident will receive a Comprehensive Assessment and the facility will ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record. Residents who use [MEDICAL CONDITION] drugs will receive behavioral interventions in accordance with their care plan. Resident #29 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/8/18, revealed that the resident's cognitive skills for daily decision making were moderately impaired with inattention and altered levels of consciousness that fluctuate. Physician orders, dated 2/6/18, instruct [MEDICATION NAME] (an antipsychotic medication that can be used to treat acute [MEDICAL CONDITION], agitation and [MEDICAL CONDITION]) to be given now for elopement attempts x 2. The Comprehensive Care Plan for Elopement and Intervention Plan, dated (MONTH) (YEAR), revealed the resident was at high risk for elopement with approaches to redirect as needed, engage in activity, attempt to determine cause of trying to leave and address accordingly, calmly approach and offer to assist the resident back into the building, tell him what the weather is like outside, and if weather is nice offer to go for a walk. In a Nursing Progress Note, dated 2/6/18, the Licensed Practical Nurse Manager (LPNM) documented that at approximately 4:00 p.m., the door alarm was heard and the resident was observed exiting the building. He was promptly returned and his family was notified. In a second Nursing Note, the LPNM documented that at 4:20 p.m., the resident was again observed exiting the building with alarms sounding, and was promptly returned. The family was again notified. The Nurse Practitioner (NP) ordered [MEDICATION NAME] to be given now. The [MEDICATION NAME] was documented as being administered at 4:20 p.m. There was no documentation of of a specific [DIAGNOSES REDACTED]. The facility Incident/Accident Report, dated 2/6/18, included that the resident was observed exiting the building twice and returned promptly, both times with no injuries noted, and the NP ordered [MEDICATION NAME] to be given. The resident was observed on 3/7/18 at 10:18 a.m. walking slowly in the hall. Interviews conducted on 3/9/18 included the following: a. At 10:08 a.m., the Licensed Practical Nurse Manager said the resident tried to get outside twice and was agitated. After reviewing the Nursing Notes and the 24-Hour Report Sheet, she said the resident's behavior should have been documented by the nurse who administered the [MEDICATION NAME], but it was not. b. At 10:08 a.m. and 11:01 a.m., the NP said the resident was agitated, pacing, his voice became loud, and he did not want to be in his room with his wife. The NP said the resident was not able to be redirected. He said the whole event should have been documented in the Progress Notes. The NP said he will document a specific [DIAGNOSES REDACTED]. c. At 11:05 a.m., the Registered Nurse said the resident had nonchalantly walked out of the door that day and she never saw him agitated. She said staff were able to bring him right back in without a problem. She said the resident responds well to 1:1 and talking to him. d. At 1:07 p m., the Certified Nursing Assistant said sometimes the resident does yell, but she can usually talk to him and redirect him. She said the resident has never hurt himself or another resident. (10 NYCRR 415.12(1)(2)(i))

Based on observations and interviews, it was determined that for one of one main kitchens, the facility did not prepare food in a sanitary manner. Specifically, the sinks were backing up onto the floor, the dish machine sanitizer levels were too low, and resident plates were dried with a cloth. This is evidenced by the following: Observations conducted on 12/16/16 between 12:45 p.m. and 1:12 p.m. revealed the following: a. There was a clear plastic bin under the first bay of the three bay sink where the indirect drain was located. The bin contained approximately 1½ inches of light brown colored liquid. The plumbing appeared to pitch backwards so that the water would flow towards the indirect drain rather than the sewer system. In an interview at that time, Cook #1 stated that the sink is clogged and overflows. He said it had been that way since he started to work at the facility, approximately one year ago. b. The chlorine disinfectant level in the dish machine was tested by Cook #1 and was found to be approximately 10 parts per million (ppm). Dietary Aide (DA) #1 then tested the sanitizer level and found it to be approximately 10 ppm as well. In an interview at that time, DA #1 stated that the sanitizer levels should be between 50 ppm and 100 ppm and showed the surveyor on the test strip color chart what color the strip should be. DA #1 stated that she checks the sanitizer level at the beginning of every shift but does not document the checks. She said the sanitizer level was fine when she checked it at the beginning of her shift. c. Cook #1 was observed drying a white plastic plate with a blue disposable cloth. Cook #1 stated at that time, that when the dishes are wet, they dry them with a blue cloth. In an interview on 12/16/16 at approximately 1:40 p.m., the Kitchen Manager stated that the plastic bin under the sink catches the water that backs up from the sinks and comes out the indirect drain. The Kitchen Manager also stated that dishes should be air drying, not dried with a towel. (10 NYCRR 14-1.112, 14-1.113, 14-1.116, 14-1.130)

Based on observations and staff and resident interviews, it was determined that for 10 (Rooms #4, #5, #6, #7, #9, #10, #12, #15, #18, and #19) of 22 resident rooms, the facility did not provide adequate lighting in all areas. Specifically, resident rooms did not have reading lights for each resident. This is evidenced by the following: 1. Observations and interview on 5/18/16 from 8:55 a.m. to 10:05 a.m. revealed the following: a) There was only one lamp for reading in double occupancy resident rooms #4, #5 (near the B-bed), #6 (near the A-bed), #7 (near the A-bed), #15 (between the A and B-beds), #18 (near the A-bed), and #19 (between the A and B-beds). b) There was no reading lamp or additional lighting present in single occupancy resident rooms #9, #10, and #12. c) A resident in room [ROOM NUMBER] stated that there is not enough light and she would like a floor lamp. 2. During an interview on 5/18/16 at 9:55 a.m., the Director of Maintenance revealed he was not aware that each resident was required to have a reading light and thought that since there are lamps near the A-beds, then the overhead light closer to the windows/B-beds were enough. (10 NYCRR 415.29; 713-1.10(b))

Based on observations, interviews, and record reviews, it was determined that for 2 of 17 Comprehensive Assessments reviewed, the facility did not code the Minimum Data Set (MDS) Assessment accurately. Issues included inaccurate coding of dental status (Resident #26) and nutritional status (Resident #45). This is evidenced by the following: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Dental Consult, dated 6/12/12, revealed the resident had all her remaining teeth extracted. The Nursing Admission Summary, dated 7/28/14, included that the resident had no upper or lower teeth. The Annual MDS Assessment, dated 6/30/15, under Oral/Dental Section L was none of the above are present, which includes edentulous (toothless). The Comprehensive Care Plan, dated October 2015, included that the resident had no natural teeth or tooth fragments. When observed on 10/15/15 at 10:01 a.m., there were no visible natural teeth or dentures in the resident's mouth. The resident said she had full dentures but did not care to wear the lower ones. Interviews conducted on 10/20/15 include the following: a. At 12:58 p.m., the MDS Coordinator said if a resident has no natural teeth the annual MDS Assessment should be coded that way. She said that she does not look inside the resident's mouth but will use dental consults and/or nursing notes to determine how to code the MDS Assessment. At that time, the MDS Coordinator reviewed the previous annual MDS Assessments on the computer and said they have been coded incorrectly since 7/1/12. b. At 1:03 p.m., a Certified Nursing Assistant said the resident has no teeth. 2. Resident #45 has [DIAGNOSES REDACTED]. The MDS Assessments, dated 6/17/15 and 9/15/15, Section K 0310, are both coded for a weight gain of 5 percent or more in the last month or loss of 10 percent or more in the last six months. Review of 6/14/15 and 9/10/15 MDS worksheets completed by a Registered Dietitian (RD), revealed the June 2015 MDS Section K0300 should be coded 2 for weight loss, and the September 2015 MDS Section K0300 and K0310 should both be coded 0 for no weight loss or gain. During interviews on 10/20/15 at 10:03 a.m. and 10:13 a.m., the Registered Nurse (RN)/MDS Coordinator said she uses the MDS worksheets, completed by the RD, to code Section K of the MDS. The RN/MDS Coordinator reviewed the data and weights and said both these MDSs had been coded incorrectly. (10 NYCRR 415.11(a)(1))

Based on interviews and record reviews, it was determined that for one (Resident #7) of six residents reviewed for Unnecessary Medications, the facility did not provide services in accordance with physician orders [REDACTED]. Specifically, the resident did not consistently receive an oral antidiabetic agent, aspirin, and blood glucose checks as ordered. This is evidenced by the following: Resident #7 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 7/20/15, revealed that the resident was cognitively intact and received daily insulin injections. A Comprehensive Care Plan, reviewed August 2015, for diabetes includes approaches to monitor blood glucose per physician orders [REDACTED]. Review of August 2015, September 2015, and October 2015 Medication Administration Records (MARs), Sliding Scale Insulin Diabetic Flow Sheets, 24-Hour Nursing Report Sheets, and Progress Notes revealed the following: 8/1/15 to 8/31/15, missed four doses of [MEDICATION NAME] coated aspirin, two doses of Glimepiride, and three blood glucose checks; 9/1/15 to 9/30/15, missed one dose of [MEDICATION NAME] coated aspirin, three doses of Glimepiride, and three blood glucose checks; October 2015, missed three doses of [MEDICATION NAME] coated aspirin and two blood glucose checks. Physician orders, dated 10/19/15, direct nursing staff to check blood glucose before meals and at bedtime; to give Humalog insulin injections four times daily (before meals and at bedtime) per sliding scale; Glimepiride (antidiabetic) twice daily by mouth 30 minutes before a meal, [MEDICATION NAME] coated aspirin daily (status [REDACTED]. In an interview on 10/19/15 at 8:17 a.m., the resident said, When I go out, I make sure to take my pills ahead of time. I was not on insulin at home, only pills. I never go out for longer than three hours, except at night. I don't take my blood glucose by myself. Interviews conducted on 10/20/15 included the following: a. At 1:39 p.m., a Licensed Practical Nurse/Nurse Manager (LPN/NM) said that nurses try to give medications before the resident leaves of after they return to the facility. The LPN/NM said if notified ahead of time, pharmacy is contacted and will prepackage medications. She also said that nursing has discussed changing orders for other residents with the Nurse Practitioner (NP) to accommodate going out of the facility but was not sure if the NP or any other provider had been notified concerning this resident. b. At 2:00 p.m. and 2:26 p.m., the NP said he had not been told that the resident had been missing medications and blood glucoses when going out of the facility. He said this certainly should be discussed with the family who might be willing to give medications. The NP added that he could reassess the frequency of checking blood glucoses. Additionally, the resident has frequent UTIs and he needs to stay on top of her diabetic management. He said the resident is to take her antidiabetic agent 30 minutes prior to eating. c. At 3:44 p.m., a RN/Medication Nurse/Days said the resident goes out of the building with family and could take her pills with her. The RN/Medication Nurse said the resident is alert and oriented. d. At 4:42 p.m., a LPN/Medication Nurse/Evenings said she would give the resident the medication she missed once she returns to the facility. She said the procedure is to circle the medication not given on the MAR, and write a progress note. A physician order, dated 10/20/15, directs nursing staff to give the evening dose of Glimepiride to the resident to take herself when she goes on family outings to avoid missing doses. During an interview on 10/21/15 at 10:57 a.m., the LPN/NM and RN/Medication Nurse/Days reviewed the October 2015 MAR and said, for example, on 10/14/15, the 5:30 p.m. blood glucose check was not done because the resident was out of the building, but the 5:30 p.m. Glimepiride was given. Both nurses said they were not sure what actually had occurred and would be addressing this with the involved evening nurse. On 10/21/15 at 12:02 p.m., LPN/Medication Nurse/Days said if a resident misses a medication for two days, she writes that information on the 24-Hour Report Sheet, speaks to the next shift, and puts a note in the Physician Communication Book. A review of the Physician Communication Book, dated 9/9/15 to 10/20/15, revealed that there were no notes to the physician regarding this resident. Review of a Medication Policy, dated March 2015, revealed that medications from the facility supply may be sent with residents on temporary leave or when attending an activity outside of the facility. Medications for residents out of the facility for more than 24 hours will be prepared by the pharmacy. (10 NYCRR 415.11(c)(3)(ii))

Based on interviews and record reviews, it was determined that for one (Resident #7) of six residents reviewed for unnecessary medications, the facility's pharmacist did not identify or report irregularities or omissions in medication administration and blood glucose checks affecting Resident #7. This is evidenced by the following: Resident #7 has [DIAGNOSES REDACTED]. Pharmacy Reviews, dated 1/1/15 to 9/3/15, do not identify any medications or blood glucose check omissions for this resident. Physician orders, dated 10/19/15, direct nursing staff to check blood glucose before meals and at bedtime, to give Humalog (insulin) injections four times daily (before meals and at bedtime) per sliding scale, Glimepiride (antidiabetic) twice daily by mouth 30 minutes before a meal, enteric coated aspirin daily (status [REDACTED]. Review of the August 2015, September 2015, and October 2015 Medication Administration Records (MARs), Sliding Scale Insulin Diabetic Flow Sheets, 24-Hour Nursing Report Sheets, and Progress Notes revealed the following: 8/1/15 to 8/31/15, missed four doses of enteric coated aspirin, two doses of Glimepiride, and three blood glucose checks; 9/1/15 to 9/30/15, missed one dose of enteric coated aspirin, three doses of Glimepiride, and three blood glucoses; October 2015, missed three doses of enteric coated aspirin and two blood glucoses. During an interview on 10/20/15 at 2:00 p.m., the Nurse Practitioner (NP) said he had not been told about the resident missing blood glucose checks and medications. Interviews conducted on 10/21/15 included the following: a. At 10:40 a.m., the consulting pharmacist said he completes monthly medication reviews, including screening the MARs for omissions. He said he was not aware that the resident had not received some medications. He said he had not seen that on the MARs and nobody told him about it. b. At 10:57 a.m., a Licensed Practical Nurse/Nurse Manager said the consulting pharmacist is responsible for reviewing the MARs and reporting medication omissions. (10 NYCRR 415.18(c)(2))

Based on observations, interviews and record reviews it was determined that the facility failed to keep 3 of 24 residents (Residents 44,45,and 46) free of physical restraints imposed for the purpose of discipline or convenience and not required to treat a medical symptom . The findings include: 1. A review of the face sheet dated 3/11/14 revealed Resident # 46 had [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #46 was cognitively impaired and did not use a restraint. A review of the Continuity of Care dated 3/18/14 revealed Resident #46 was full weight bearing and used a walker for ambulation. A review of the admit Physician Orders dated 3/11/14 revealed Resident #46 had no orders for a positioning device or restraint use. A review of the Nursing Admission Summary Form dated 3/11/14 revealed Resident #46 was full weight bearing and used a walker for ambulation with a two person assist prior to Resident 46 ' s Physical Therapy (PT) evaluation. A review of the Nursing Notes dated 3/1/14-3/18/14 did not document the use of a physical restraint for Resident #46. A review of the Braden Scale dated 3/11/14 revealed Resident #46 had a slightly limited ability to change and control her body position, made frequent though slight changes in her body or extremity, position independently and walked occasionally during the day for very short distances, with or without assistance. A review of the Fall Risk assessment dated [DATE] revealed Resident #46 was ambulatory. The Siderail/Restraint Use assessment dated [DATE] did not include the use of Resident #46 ' s reclined Geri Chair with an elevated leg rest. A review of the Physical Therapy Evaluation dated 3/13/14 revealed Resident #46 had extensive stand-pivot transfer with SW (standing walker) with gt. (gait) Belt. On 3/18/2014 at 10:12 a.m., Resident #46 was observed sitting in the hallway next to her room in a reclined Geri chair with her legs up and a chair alarm in placed. On 3/19/14 at 9:10 a.m., Resident #46 was observed awake, sitting in a Geri chair in a reclined position and the legs elevated. Resident #46 was positioned leaning to the left side. On 3/19/14 at 10:52 a.m., Resident #46 was observed awake, sitting in a Geri chair with in a reclined position and legs elevated. On 3/19/14 at 10:51 a.m., Resident #46 was interviewed. When asked if she was able to walk she stated " A little bit. " On 3/19/14 at 10:51 a.m., Employee # 1 (E1) was interviewed. When asked if Resident #46 was able to walk, he stated " They (staff) walk her down the hall with the walker. " On 3/19/14 at 12:20 p.m., Resident #46 was observed awake, sitting in a Geri chair in a reclined position with her legs elevated. On 3/19/14 at 1:17 p.m., an interview was conducted with the Physical Therapist (PT). When she was asked if Resident #46 could ambulate she stated " Yes, she walked 28 feet today. " When asked if Resident #46 could get out of her Geri chair she stated Resident #46 " ...could get out of the chair but she would fall. " When asked if Resident #46 could get out of the reclined Geri chair she stated, " If the feet were up she could not get out of it but if the feet were down she could probably get out of it. " On 3/20/14 at 8:55 a.m., Resident #46 was observed sitting in the hallway next to her room in a reclined Geri chair with the legs in the elevated position. On 3/20/14 at 10:07 a.m., Resident #46 was observed sitting in the hallway next to her room asleep in a Geri chair with an attached chair alarm leaning to the left side with legs in the elevated position. On 3/20/14 at 10:29 a.m., Nursing Assistant # 29 was observed providing a bed bath to Resident #46 while Resident #46 remained seated in the Geri chair in the doorway of the bathroom. At 3:00 p.m., an interview was conducted with Nursing Assistant #29. When Nursing Assistant #29 was asked why she administered a sponge bath to Resident #46 while she remained seated in the Geri chair in the doorway she stated, " There are two aides on the hall, the other aide was on break. I can ' t transfer her by myself because she is a two person transfer. Keeping her in the Geri chair would help me do her upper half (body). " Nursing Assistant #29 continued " Morning time is very busy; we only have 5 aides here. ' Nursing Assistant # 29 added, " I don ' t have a lot of leisure time. I try to get the ones who have to lie down in bed. " When asked why the residents are line up in the hallway during the day she stated, " To keep eye sight on them to make sure they are not trying to get up. " When asked if Resident #46 could get up from the reclined Geri chair when the legs were elevated, she stated, " It ' s a possibility that with the legs up the resident would not be able to get up. " When Nursing Assistatgn #29 was asked how long she had been employed at the facility and she stated about a year. On 3/20/14 at 4:45 p.m. an interview was conducted with the Certified Occupation Therapist Assistant (COTA). When asked if Resident #46 was ambulatory she stated " Yes, she is ambulatory in therapy. She is making progress. She would not even stand before she came here. She is staring to get over the fear of walking. " When further questioned regarding Resident #46 spending large amounts of time in her Geri chair relative to Resident #46 ' s therapy goal, the COTA stated, " She (Resdient #46) has been spending a lot of time sleeping in her Geri chair. " When asked if Resident #46 could get out of the reclined Geri chair with the legs elevated she stated, " The leg up position would stop her from getting up if she wanted to. " On 3/21/14 at 9:07 a.m., an interview was conducted with the COTA who notified the surveyor of the following: " We feel the Geri chair is appropriate for her. Obviously she should be positioned correctly. " She added " I agree that the information in the chart is contradictory. " A review of the medical record for Resdient #46 was completed. A medical symptom, evaluation for use, documentation explaining the risks, benefits and alternatives, and re-evaluation for Resident #46 ' s use of the reclined Geri chair was not located in the medical record. On 3/21/14 at approximately 9:30 a.m., an interview was conducted with the Director of Nursing (DON). When the above observations were discussed with the DON, she stated the facility did not consider the use of the reclined Geri chair as restraint for Resdient #46. The DON was asked if she could provide documentation regarding a medical symptom for use, evaluation for use, documentation explaining the risks, benefits and alternatives, and re-evaluation for Resident #46 use of the reclined Geri chair and stated she did not have that documentation. A review of the Policy On Side Rail/Physical Restraints, undated revealed the following: " ...The facility will provide each resident with considerate respective care designed to promote independence and dignity in a least restrictive environment. A physical restraint is used only to protect the health and safety of the resident, and used only after all previous innovations or approaches to avoid restraints have been considered and tried ...Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident ' s body that restricts freedom of movement or normal access to his/her body. 2. Resident #45 was admitted to the facility 2/19/14 with a [DIAGNOSES REDACTED].M., Resident #45 was observed sitting in a Geri-chair in the hallway. The resident was unable to maintain an upright position. The resident's upper body was leaning to the right side of the chair and his right arm was tightly compressed against the chair arm. His legs were elevated. Both legs were observed completely wrapped with bandages. The resident was sleeping. When approached, the resident was found unable to interview. Resident #45 was observed again at 12:30 P.M. on 3/17/2014 as he was being pushed into the dining room by a CNA. The resident was positioned in a Geri-chair with his legs elevated. The CNA was observed to wheel the resident close to, but not directly at one of the dining room tables. The resident ' s legs remained in an elevated position. Several other residents were observed engaged in a table bowling activity several feet away from where the resident ' s chair had been placed. Due to the distance away from the table activity and the postion of the Geri-Chair with legs elevated, the resident was not included in the activity until a staff member pushed his chair closer to the activity table, lowered his legs and encouraged the resident to participate. He was then able to do so. On 3/17/2014 at approximately 2:40 P.M., the resident was observed sitting in a semi-reclined position in the Geri-chair in the hallway outside of his room. His legs were elevated. The resident was sleeping, his head was falling onto his chest and his right arm was compressed tightly against the right side of the chair. Various staff was observed to periodically walk past the resident. None stopped to re-position, speak to, or to remove the resident from the hallway. At approximately 3:30 P.M. on 3/17/ 2014, Resident #45 was seen seated in his Geri-chair with legs elevated in the hallway perpendicular to the dining room and unit corridors. The resident was in a partially reclined position and his legs were elevated. The resident was leaning to the right side of the chair, with his right arm compressed against the right side of the chair. The resident was sleeping. Staff was observed to pass by the resident going to and fro. None stopped to reposition or to relocate the resident. The resident was observed at various times of the day on each day 3/17/2014, 3/18/2014, 3/19/2014, 3/20/14 and 3/21/2014. On each occasion for observation, except on 3/19/2014, when staff was observed to assist the resident to ambulate a few feet in the hallway, the resident was always seated, partially reclined in his Geri-chair. The resident was frequently leaning to the right side with his body compressed against the right side of the chair. He was periodically observed sleeping with his head dropped on his chest, and his legs were elevated throughout each day. When observed on 3/18/2014, at 8:55 A.M., the resident was seen sleeping in his Geri-chair in the hallway outside of his room. His legs were elevated. At 10.00 A.M. Resident # 45 was observed sitting in the Geri-chair in the same location. His legs were elevated. On 3/18/14 at 11:28 A.M., the resident was seen sitting with legs elevated in the Geri-chair in the hallway outside of his room. At 11:40 A.M., the resident was observed being pushed in his Geri-chair into the Dining room. His legs were elevated. At 12:45 P.M., on 3/18/14, he was observed seated in the Geri-chair in the dining room, and at 4:30 P.M. was again observed sitting in the hallway in the Geri-chair with legs elevated. MDS OBRA Assessments dated 2/26/14 indicate the resident is cognitively impaired, has clear speech, minimal difficulty with hearing, is capable of sometimes understanding others, and responds adequately to simple, direct communication. Documentation on the MDS section (G0110) indicates the resident has no psychomotor [MEDICAL CONDITION], no functional impairment and no behaviors, but requires one person for assistance with bed mobility, transfers, and for walking in his room or corridors. Documentation in Section G also indicates the resident requires the assistance of one person for feeding, and is capable of using the toilet with a two person assist. In MDS Section G 0300 for Balance, the resident is checked for the ability to stabilize himself with human assistance or with a mobility device (i.e. walker or wheelchair). Section G 0900 is checked yes for Direct Care staff believes resident capable of Increased independence in at least some activities of daily living. During a Family interview conducted 3/18/14 at 11:51 A.M., the family member stated that prior to the resident ' s placement in the nursing home, Resident #45 was capable of ambulating around the house, in his bedroom, and able to toilet without assistance. The family stated the resident did not require an assistive device and had no falls prior to admission. Staff interviews were conducted on 3/18/2014 and 3/19/2014 with the Unit Charge Nurse, an LPN, CNA and the Director of Physical Therapy. During the interview conducted with the Charge Nurse, when asked about the bandages on the resident ' s legs, the Nurse stated " he developed dependent [MEDICAL CONDITION] from sitting in the chair for so long, so we had to wrap his legs and we keep his legs elevated. " CNA #1 was interviewed 3/18/2014 and stated Resident #45 generally spends most of the day in his Geri-chair with his legs raised because he has [MEDICAL CONDITION].in his legs, the CNA stated she provides his A.M. care and then along with another staff, positions him in the chair and he is wheeled into the dining room for breakfast and again for lunch. She stated he spends most of the day in the Geri-chair unless he gets put into bed for a nap. The CNA states, the resident can walk, but he ' s a little unsteady on his feet. She states, we walk him into the bathroom for toileting. " An interview was conducted with LPN #1 on 3/18/2014 at 9:15 A.M. When the LPN was asked about the level of activity of Resident #45, the LPN stated " the CNAs are responsible for getting Resident # 45 out of bed. They provide his A.M. care and toilet him, after that, he ' s put in his Geri-chair and taken into the dining room. Usually he stays in the chair until lunch or if there is an activity he ' s taken into the activity. In response to questions regarding the resident ' s ability to ambulate, " the LPN stated, " the only time I ' ve seen him walk is with a physical therapist. " He can ' t get out of the chair with the legs up. " A Nurse Practitioner's SOAP note dated 3/19/14 was found to include in the #3 section corresponding to weakness, a statement that reads: multifactorial, no recent falls, mobility as tolerated, fall precautions, chair/bed alarms. Found OOB recently, no recent falls. During interview with an Occupational Therapist conducted 3/20/14, the therapist stated the resident receives all of his meals in the dining room in a Geri-chair. She stated we do push him as close to the table as possible so that he can feed himself. Documentation on a Physical Therapy evaluation dated 2/19/14 reveals resident #45 " had a prior level of functioning in a multi-level house with one person ' s assistance and a rolling walker. " The evaluation indicates the resident is capable of actual ambulation when relaxed. The Physical Therapy Assessment Evaluation dated 2/24/14 lists the following recommendations for nursing: 1. Bed mobility 1 (A) (Assist) extensive. 2. Transfers RW (Rolling Walker) 1 (A) (Assist) extensive. 3. Ambulate (A) (Assist) extensive RW (Rolling Walker) 60 ' (feet) or better to meals, Bathroom, activities, follow with wheelchair. Nursing recommendations documented on Physical Therapy Progress Notes dated 2/27/14 are transfers 1(A) (Assist) extensive, Ambulation 1 (A) (Assist) extensive RW (Rolling Walker) 100 ' (feet) or better to bathroom, meals, activities; follow with WC (wheelchair). The resident ' s rehabilitation potential is documented as Good. Review of a Plan of Care /Treatment Plan documented on the Maintenance Nursing/Rehabilitation Aide Referral Form dated 3/7/14 for ambulation, indicates the resident requires a one person extensive assist with a rolling walker for ambulation and should be followed with a Geri-chair. Nursing Notes reviewed for the months of February 2014 and March 2014 reveal the resident's capability for ambulating: A Nursing Note dated 2/21/14 and timed 2250, documents the resident has " no C/O (complaint of) this evening. After being put to bed, resident attempted to get OOB (out of bed) and was brought out to the nurses ' station in a W/C (wheelchair); a few minutes later, resident attempting to get out of W/C. Currently sitting in T.V. area in Geri-chair. On 2/18/14, nursing documentation at 2330 reveals " resident attempting to get out of W/C several times before dinner. Resident was asked if he needed to go to the bathroom and he said " that would help. " Resident was toileted but continued to stand up and try to get out of W/C (wheel chair.) Staff sat with resident but continued to try and get up. Resident was transferred to Geri-chair. Resident did not attempt to get up and out of Geri-chair, but went to sleep. " On 2/24/14 a note written for 0615 reads: Awake 50% of shift as of this writing. Got himself up out of bed X 3., making his bed. Easy to re-direct once oriented to time. On 3/1/14, a Nurse documents the following on an Interdisciplinary Progress Record note at 0740 A.M.: " Responding to bed alarm. Resident was discovered standing next to bed. Very unsteady R/T (related to) wearing Prevalon boots. Resident thought it was later in the morning and wanted to make his bed. (Time 2445). Assisted back to bed. Explained that he was wearing a special boot not made for ambulation and showed him how to use call light to let staff know if he wanted to get up. Resident has a DX (diagnosis) of Dementia and rarely understands or processes what is said to him. Staff again responded to bed alarm at 0230 and again discovered resident out of bed attempting to ambulate with Prevalon boots in place. Resident has a HX (history) of falls and the falls risk assessment on 2/14/14 = (equals) a risk of 16 which is a high risk for falls. Writer felt that the risk of falls, confusion with cognitive deficits rendered wearing the boots as an unsafe option at this time. Prevalon boots were removed. Resident OOB (out of bed) twice more during this shift without difficulty in relation to ambulation. " Nursing documentation on an Interdisciplinary Progress record for 3/4/14 at 0525 A.M. reveals the resident removed the Prevlon boots to get OOB to go to the bathroom. The nurse writes " did not re-apply them for resident ' s safety. " A telephone interview was conducted 3/31/14 with the Nurse Practitioner identified as the Primary Practitioner responsible for the resident ' s medical care and treatment plan. The Nurse Practitioner admitted that if a resident was able to ambulate and was positioned in a Geri-chair with legs elevated, preventing him from standing, the Geri-chair has to be considered a restraint. The Nurse Practitioner stated he did not write an order for [REDACTED]. The facility ' s Medical Director was interviewed by telephone on 3/21/14 and stated during the interview she would have to consider the Geri-chair a restraint if it prevented a resident from standing at will. The Director of Physical Therapy was interviewed 3/20/14 and stated she was not very familiar with Resident #45 as she had just recently started working in the facility, but would take a look at his therapy records. In response to questions regarding the use of a Geri-chair as a restraint, the Director stated, " the Geri-chair must be considered a restraint if the resident was positioned in a manner that restricted the resident from standing if the resident has the ability to stand independently. After reviewing the resident ' s Physical Therapy and Occupation Therapy records, the Director stated she would arrange to have the resident re-assessed for Rehab. (rehabilitation) potential. During an interview held with LPN #2, on 3/20/14 at approximately 4:35 P.M., the LPN stated she worked mostly on the evening shift and was very familiar with Resident #45. The nurse said Resident #45 was always in the Geri-chair when she arrived to start her shift. She stated the resident could walk and sometimes got out of bed at night. The Nurse said he was kept in the Geri-chair now so he would not get up. She stated, he used to be in a wheel chair, but he was always standing up. Facility ' s Policy for Physical Restraints, sections #5, 6, and 8 reads: " A physical restraint is used only to protect the health and safety of the resident, and used only after all previous innovations or approaches to avoid restraints have been considered and tried. ..... When restraints are applied in an emergency situation, the Physician must be notified within 24 hours for an order ... ... The Physician determines the presence of a specific medical symptom that would require the use of restraints. The MD then writes or gives a verbal order for the physical safety device stating the reason and medical symptom, type of safety device, and length of time safety device is to be used ... ... Restraints are released as necessary to meet the residents care needs (at least every two hours)." The resident ' s Medical Record was found to not contain a Physician ' s order for Physical restraint use, did not contain an indication for restraint use on a Restraint Risk Assessment, and did not contain a care plan for the use of restraints. Restraints are defined in the Facility ' s Policy on Side Rail/Physical Restraints as " any manual method or physical device, material or equipment attached to, or adjacent to the resident ' s body, that the resident cannot easily remove and that restricts freedom of movement or normal access to his /her body." On the last survey day, 3/21/14, the Director of Physical Therapy provided the survey team with a Physical Therapy Evaluation dated 3/21/14 indicating Resident #45 was " re-evaluated to determine appropriateness for on-going P.T. (Physical therapy). This evaluation indicates the resident will benefit from skilled P.T. to improve functional mobility including independence with transfers, ambulation and bed mobility and reach (max) maximal independence. Recommendations documented for ambulation, include " limited assist 1(A) with rolling walker in room, to /from meals, activities up to 100 ' (feet) with W/C (wheelchair} to follow. 3. Observations throughout the survey from 3/17/14 until 3/21/14 revealed Resident #44 sitting in a Geri-chair in the hallway in front of his room or the nurse's station. He was observed unsuccessfully trying to get out of the Geri-chair on several occasions. Observation on 3/19/14 at 9:41 a.m. revealed Resident #44 walking down the hallway using a walker during his physical therapy. The Physical Therapist was supervising the resident but was providing no assistance. Observation on 3/19/14 at 2:33 p.m. revealed staff wheeling Resident #44 down the hallway in a Geri-chair. Observation on 3/20/14 at 5 p.m. revealed six residents including Resident #44 all lined up along the wall of the hallway in Geri-chairs with their feet elevated. Interview on 3/19/14 at approximately 11 a.m. with Licensed Practical Nurse #8 (LPN8) revealed that Resident # 44's two falls were from the Geri-chair. Interview on 3/19/14 at 1:13 p.m. with the Physical Therapist revealed that Resident #44 can walk at least 140 feet. She stated that "they use the Geri-chair to stop him from getting up and falling." Review of Resident #44's medical record revealed no physician orders for restraints or Geri-chair use. Further review of Resident #44's medical record revealed no analysis of risk versus benefit for the medical need of the Geri-chair versus restraining the resident in the Geri-chair. The medical record revealed no care planning for Resident #44's Geri-chair use. Interview on 3/20/14 at 10:25 p.m. with the Director of Nursing (DON) confirmed that there was no physician order to elevate Resident #44's legs or to restrain him. The DON confirmed that elevating R44's legs in the Geri-chair restricts his movement. Review of Resident #44's medical record revealed that he developed a stage 2 pressure ulcer on his right buttock.